This issue of the ASA Monitor is devoted to the prevention of surgical site infections (SSIs). The Centers for Disease Control and Prevention (CDC) defines SSI as “an infection that occurs after surgery in the part of the body where the surgery took place.” In 2015, the CDC estimated that 110,800 patients suffered from SSIs (asamonitor.pub/3O8UOXi). Such statistics resulted in the Surgical Care Improvement Project (SCIP), which was created to help reduce the rate of SSIs (JAMA Surg 2017;152:784-91). Hospitals are required to report SSIs (asamonitor.pub/3xtGTUM). Treating patients with SSIs is expensive – the average cost for SSIs ranges from $10,443 to $25,546 (JAMA Surg 2017;152:784-91).
The role of anesthesiologists in reducing SSIs has increased over the past decade, as summarized in the following articles in this issue of the Monitor.
Drs. Ural, Rajan, Metry, and Rafique provide indications, doses, and dosing intervals for commonly used perioperative antibiotics. Dr. Richard Beers reviews safe injection practices to reduce the risk of transmitting pathogens to patients. Drs. Jain and Sundararaman review methods by which health care facilities reduce perioperative infections. Drs. Long, Makarewicz, Bryson-Cahn, and Dagal discuss how anesthesiologists need to partner with hospital infection prevention and control teams. Drs. Swerdlow and Hopf offer practical tips for anesthesiologists to reduce the risk of spreading pathogens. Finally, Barbara Rogers, MD, MBOE, FASA, emphasizes that fomites are a source of many infections, including MRSA and VRE (but not SARS-CoV-2). (Are you reading this issue of the ASA Monitor in the OR? If so, don’t put it down in your contaminated zone!)
Reducing SSIs follows common sense throughout the perioperative period. The first step is preoperative antimicrobial bathing with 4% chlorhexidine soap and nasal decolonization for S aureus using an antibiotic ointment. On the day of surgery, patients are usually evaluated for MRSA and MSSA infection for the possible need for vancomycin.
The next step is to ensure appropriate timing of prophylactic parenteral antibiotics. At my institution, antibiotics are started in the preoperative area to ensure the infusion is completed before the incision is made. Confirmation of antibiotic prophylaxis is part of the routine timeout process before the surgery begins.
The table outlines steps throughout surgery to reduce the risk of infection. For example, patients are kept normothermic by wearing a special gown connected to a warming device. This has been welcomed by most patients and minimizes the heat-redistribution associated with anesthesia induction. A relatively recent Cochrane review concluded that active surface warming does improve patient comfort, reduces postoperative cardiovascular complications, and reduces SSIs (Cochrane Database Syst Rev 2016;4:CD009016).
S aureus is the most common bacterium in SSIs. As much as 30% of the population is colonized with methicillin-sensitive S aureus, and up to 3% of the population is colonized with methicillin-resistant S aureus. S aureus is particularly troublesome in orthopedic, obstetric, gynecologic, and cardiac SSIs (Infect Dis Clin North Am 2021;35:107-33). A surveillance swab can be easily obtained to evaluate susceptible patients, and the results are available in a few hours. Strategies for decolonization include showers using an antiseptic, as already discussed, and by using nasal agents such as mupirocin, retapamulin, or povidone-iodine.
As anesthesiologists and perioperative caregivers, we need to pay close attention to each step required to reduce SSIs. Prevention is always the best strategy!