The Surgical Site Infections: Clinical Practice Guidelines

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Introduction

New health problems are coming up today as time progresses and lifestyles of individuals in the society change. Before the end of the twentieth century, practitioners strictly relied on their knowledge and skills to solve medical related problems in their field. Due to increased complication of these conditions, clinicians find it hard to keep up with the emerging demand for new and improved skills (Melnyk & Fineout-Overholt, 2010, p. 167). As a result, practitioners around the world are adopting different methods to solve emerging problems. For example, most of them conduct randomized tests on patients. The development has raised concerns among stakeholders. Consequently, it has created the need for guidelines that would reduce the inappropriate variations in techniques used by these professionals. In addition, the guidelines are aimed at minimizing harm and optimizing health outcomes among patients receiving medical care (Melnyk & Fineout-Overholt, 2010, p. 186).

Surgical infection is not a major issue in medical practice if it is handled appropriately. It can be prevented using basic hygiene practices. However, it may become fatal when ignored. Research shows that about 5% of patients undergoing extra-abdominal surgery develop infections during recovery. The same happens to 20% of individuals undergoing intra-abdominal operations (Bratzler & Houck, 2005, p. 396).

The objective of this paper is to develop a detailed guideline for clinical practice in the context of surgical site infections. Students, physicians, nurses, patients, and management teams will find this paper beneficial to their practice and research.

Target Audience

The parties targeted by this guideline include:

Patients undergoing surgery from around the world
Clinicians involved in surgery
Caregivers dealing with surgery patients

Stakeholders

Following are the stakeholders:

Bratzler D. and Houck P.

The two are the authors of “Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project”.

Melnyk, B and Fineout-Overholt, E.

They are the authors of “Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice”.

Dellinger, E., Olsen, K, Perl, T., Auwaerter, P., Bolon, M., Fish, D., Napolitano, L., Sawyer, R., Slain, D., Steinberg, J., and Weinstein, R.

The scholars have authored an article titled “Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery”.

All stakeholders possess knowledge, skills, and experience in the medical field. In addition, they are recognized by their respective medical bodies in their regions.

Surgical Site Infections

The main function of the skin is to prevent entry of pathogens into human bodies. It is noted that chances of infection increase when the skin tears off or breaks. Surgical site infections (SSIs) refer to contamination of wounds obtained as a result of surgical procedure. According to Bratzler et al. (2013, p. 200), the infections are usually caused by bacteria. They result from contamination to the surgical wound. The pathogens that cause surgical site infections are usually from the body of the patient. When this happens, the resulting situation is referred to as endogenous infection. On its part, exogenous infections are rare. They occur as a result of contamination of the wound by pathogens from operating equipments. The pathogens may also access the wound during recovery (Berrios-Torres, 2009, p. 6). The major signs and symptoms associated with an infected surgical wound include fever, pain around the affected area, and pus. In addition, there is redness around the wound.

According to Melnyk and Fineout-Overholt (2010, p. 34), the risk for a site infection is determined by the type of surgical wound the patient has. In light of this, Berrios-Torres (2009, p. 5) notes that wounds are classified into different clusters.

Classification of Surgical Wounds

Clean wounds

They have a low risk of infection. The likelihood of an infection is usually 2% (Institute for Healthcare Improvement, 2012, p. 5). The wounds are strictly as a result of operation on the skin surface. They do not involve internal organs. In addition, they are not contaminated at the time of surgery. As a result, they do not get infected during recovery.

Clean-contaminated wounds

They are as a result of an operation conducted on an internal organ. In most cases, they do not display any contamination at the time of surgery. However, risk of getting infected during recovery stands at about 10% (Graham, Mancher, Wolman, Greenfield & Steinberg, 2011, p. 5).

Contaminated wounds

They result from an operation conducted on an internal organ. The secretions of this organ get into contact with the wound. The probability of obtaining a surgical site infection ranges from 13% to 20% (Graham et al., 2011, p. 4).

Dirty wounds

They are wounds that display a known infection during operation. They have a 40% risk of surgical site infection (Bratzler & Houck, 2005, p. 401).

Surgical Site Infections: Risk Factors

Smoking

Research shows that smokers are at a higher risk of developing surgical site infections compared to non-smokers. Smoke from the cigarette reduces the capacity of blood to carry oxygen. The situation leads to vasoconstrictive effects. Low concentration of oxygen interferes with the healing process of the wound (Bratzler & Houck, 2005, p. 399).

Obesity

After bleeding has been controlled in a wound, the inflammatory phase of the healing process begins. The process sets in with the movement of inflammatory cells into the wound area. It is followed by the infiltration of neutrophils, microphages, and lymphocytes (Graham et al., 2011, p. 9). The neutrophils act as clearing agents by removing microbes from the wound. As such, they are important in the wound healing process. The adipose tissue of obese persons is poorly vascularized. As a result, there is low blood supply. The situation means that there are few neutrophils in the wound. As a result, microbes accumulate, leading to infection.

Malnutrition

Human bodies require nutrients to build immunity against pathogens. Poor eating practices and lack of a proper diet deprives the body of these nutrients. The situation leads to a weak immune system. Ultimately, malnutrition increases the risk of wound infection (Bratzler et al., 2013, p. 204).

Recommendations to Avoid Surgical Site Infections

Patients and other stakeholders should take precautions to avert instances of surgical site infections. Preventive measures are broadly categorized into three phases. The three include preoperative, intraoperative, and postoperative phases.

Pre-Operative Measures

They include the precautions undertaken before the patient undergoes surgery. They include:

Shaving of hair

Hair on the operation site should not be shaved unless it interferes with surgery (Berrios-Torres, 2009, p. 14). If shaving occurs before surgery, it should be done using clippers and not a razor. Use of razors increases the risk of surgical site infections. The reason is that these tools can cause microscopic cuts and nicks on the skin (Institute for Healthcare Improvement, 2012, p. 7).

Administering antibacterial prophylaxis

The prophylaxis should not be administered during a clean wound surgery. The purpose of this intervention is to inhibit the accumulation of organisms during operation by manipulating levels of drugs in serum and tissues (Bratzler & Houck, 2005, p. 398). Prophylaxis should only be used during clean-contaminated and contaminated surgeries. It is used during clean surgeries only in cases of implants or operation on prosthesis (Bratzler et al., 2013, p. 203). It should be administered 1 hour before surgery and discontinued 24 hours after. However, at times, it extends to 48 hours, especially for heart patients (Institute for Healthcare Improvement, 2012, p. 6). The antibacterial should be administered 2 hours before operation in cases of fluoroquinolone or vancomycin (Berrios-Torres, 2009, p. 13).

Dressing

Both the patient and the operating team should be dressed in proper theater gear. They should not have any make-ups or jewelry (Graham et al., 2011, p. 5).

Intra-Operative Measures

Skin preparation

The skin should be disinfected just before the incision using an alcohol-based disinfectant. Povidone-iodine is commonly used by most practitioners.

Maintaining homeostasis

It is another important aspect of intra-operative procedures. The temperature of the patient should be stabilized during the operation (Bratzler & Houck, 2005, p. 401). Concentration of oxygen should also be maintained at 95% and above during surgery and recovery.

Closure methods

The method used in wound closure solely depends on the preferences of the surgeon. Research is still ongoing in relation to different closure strategies. In the past, materials used in the process included catgut and silk. However, modern surgeons prefer absorbable and non-absorbable polymers (Graham et al., 2011, p. 9). Some methods allow for faster closures compared to others. Regardless of the method used by the surgeon, efforts should be made to minimize risks of surgery site infection.

Post-Operative Measures

Wound Dressing

Surgical wounds should be dressed using sterile material for up to 48 hours after operation. When changing the dressing, an antiseptic should be used without directly touching the wound (Graham et al., 2011, p. 5).

Antibiotics

Administration of antibiotic prophylaxis should be discontinued 24 to 48 hours after surgery. In case surgical site infection occurs, tests should be done to determine the best antibiotic to use (Bratzler et al., 2013, p. 197).

Wounds Healing from Secondary Infection

A patient should consult a medical practitioner to get information on how to dress wounds that are healing from secondary infection. The patient should avoid using Eusol and gauze on such wounds.

Implementing the Guidelines

To effectively implement the recommendations, a fiduciary relationship should exist between a clinician and a patient. The clinician must take into consideration the patient’s best interests (Melnyk & Fineout-Overholt, 2010, p. 172). Consequently, a bond is established between the two parties. The link is strong enough for the clinician to mind the wellbeing of the patient.

Different jurisdictions adopt varying clinical practice guidelines. Some medical bodies would disapprove the recommendations outlined in this guideline. However, it is important to note that the recommendations are based the need for efficiency. In terms of cost, the suggestions mainly involve basic hygiene practices and care of surgical wounds. Most of the items needed are found in standard hospital stores. As such, no extra costs will be incurred in the process of adopting these guidelines. However, institutions should take into consideration implementation costs when working on these recommendations.

Conclusion

The early 1990s were characterized by variations in practice and failure to turn research evidence into practical applications. The situation led to the establishment of regulatory guidelines. The guidelines combine research with the need to observe patients’ values. Such interventions have changed the status of medical practice around the globe.

References

Berrios-Torres, S. (2009). Surgical site infection (SSI) toolkit: Activity C: ELC prevention collaboratives. Web.

Bratzler, D., & Houck, P. (2005). Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. American Journal of Surgery, 189(4), 395-404.

Bratzler, D., Dellinger, E., Olsen, K., Perl, T., Auwaerter, P., Bolon, M.,…Weinstein, R. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy, 70(3), 195-283.

Graham, R., Mancher, M., Wolman, D., Greenfield, S., & Steinberg, E. (2011). Clinical practice guidelines we can trust. Web.

Institute for Healthcare Improvement. (2012). How-to guide: Prevent surgical site infections. Web.

Melnyk, B., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins.

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