THE LANDSCAPE OF SURGICAL SITE INFECTIONS
Surgical site infections (SSIs) are devastating; they worsen patient outcomes by adding new morbidities and increasing mortality risk, and add significant direct and indirect financial costs to facilities and patients.1 SSIs are among the most frequent hospital acquired infection.2 The most common microbial cause of SSIs in community hospitals is methicillin-resistant Staphylococcus aureus (MRSA).3 SSIs caused by MRSA are indicative of the larger trend of drug resistant pathogens causing SSIs, as one study found that 60% of infected surgical wounds contained microorganisms demonstrating antibiotic resistant patterns.4 Despite the above data, SSIs are considered largely preventable when following a holistic approach to infection control.5 The practice of pre-operative decolonization has been demonstrated to play a critical role in an overarching SSI prevention protocol.6
COLONIZATION AND INFECTION RISK
Bacteria have inhabited humans for millennia, such that each person carries a rich microflora containing trillions of microorganisms, almost all of which are beneficial or at least harmless. However, pathogenic microorganisms, such as S. aureus, can colonize a patient without causing any symptoms of an infection. Nonetheless, patients who are carriers of pathogenic bacteria are more likely to develop an SSI, since the bacteria are already present in the patient and can more easily migrate to the incision, causing an SSI.7
Pre-operative application of broad spectrum antiseptic agents can reduce the potential for a patient to develop an SSI.6 Moreover, since patients can be cocolonized – the state of multiple pathogenic bacteria colonizing a patient simultaneously – the application of a horizontal approach that kills numerous species of microorganisms can be beneficial. This preventative approach is also positioned well to counter the incidence of multi-drug resistant organism (MDRO) colonization, since antiseptic agents such as chlorhexidine gluconate (CHG) and povidone-iodine (PVP-I) demonstrate antiseptic activity against several MDROs.6,8 As part of a holistic SSI reduction program, the application of broad-spectrum antiseptics can be applied to targeted areas that are most likely to be colonized.
NASAL DECOLONIZATION WITH POVIDONE IODINE NASAL SWABS
Gram-positive organisms, such as S. aureus, frequently colonize the skin and nasal mucosal membranes.7 Historically, the antibacterial agent mupirocin has been the standard method of decolonizing the nares prior to surgery, but the possibility of resistance, along with barriers to patient compliance, have led to a search for alternative solutions; in that search, PVP-I antiseptic nasal swabs have emerged as a potential alternative. PVP-I demonstrates activity against gram-positive and gram-negative bacteria, including MRSA,6 and does not appear likely to lead to resistance.9 Additionally, two studies report no difference in SSI rates when comparing mupirocin treated patients to those treated with PVP-I.10,11 Finally, data suggest that decolonization with PVP-I costs less than mupirocin treatment, and patients preferred nasal decolonization with PVP-I compared to mupirocin.11,12
ORAL AND SKIN DECOLONIZATION WITH CHLORHEXIDINE GLUCONATE
CHG is likely the most widely used antiseptic in health care, largely due to its long history of use, broad-spectrum activity, and low incidence of adverse events.13 Preoperative decolonization protocols often include bioburden reduction of the skin with CHG bathing, especially at the surgical site, as it is well established that the skin is frequently colonized with numerous pathogenic bacteria. Indeed, pre-operative skin decolonization with CHG, often along with nasal decolonization, has been shown to significantly reduce SSIs.6 In addition to the skin and nares, the oral cavity harbors significant amounts of bacteria, and therefore represents a preoperative target for decolonization. Given the broad-spectrum antimicrobial activity of CHG, use of a CHG oral rinse can reduce the bioburden in the oral cavity, thereby minimizing transmission of oral bacteria to the surgical site. Lastly there is little evidence to suggest CHG usage leads to resistance, providing an advantage over antibiotic prophylaxis.6
A BROAD-SPECTRUM, TARGETED, BUNDLE FOR DECOLONIZATION
The implementation of a pre-operative bundle consisting of nasal decolonization with PVP-I swabs, oral decolonization with an oral CHG rinse, and skin decolonization with CHG bathing, has been associated with a significant reduction in SSIs.14 Moreover, the authors of this study report that compliance with the preoperative protocol was 100%.
Medline Industries, Inc. provides the necessary components to implement an evidence-based, preoperative decolonization protocol. Medline’s 2% CHG Skin Cleansing Kit provides four fluid ounces of a 2% CHG solution along with six dry wipes for application. In addition, Medline offers a Nasal & Oral Antiseptic Cleansing Kit containing four PVP-I antiseptic nasal swabs, and 0.51 fluid ounces of a 0.12% CHG oral rinse, complete with several devices allowing for multiple modes of administration. These products represent a convenient, yet multi-faceted, approach to preoperative decolonization in an effort to help prevent SSIs.
For more information, visit www.medline.com.
- Leaper D, Ousey K. Evidence update on prevention of surgical site infection. Curr Opin Infect Dis. 2015;28(2):158-163.
- Sievert DM, Ricks P, Edwards JR, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention,2009-2010. Infect Control Hosp Epidemiol. 2013 Jan;34(1):1-14.
- Anderson DJ, Sexton DJ, Kanafani ZA, Auten G, Kaye KS. Severe surgical site infection in community hospitals: Epidemiology, key procedures, and the changing prevalence of Methicillin-Resistant Staphylococcus aureus. Infect Control Hosp Epidemiol. 2007; 28(9): 1047-1053.
- Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014; 370: 1198–208.
- Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011; 32: 101–114.
- Septimus EJ & Schweizer ML. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev. 2016; 29:201-222.
- Wertheim HF, Melles DC, Vos MC, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005; 5: 751–762.
- Hill RL, Casewell MW. The in-vitro activity of povidone-iodine cream against Staphylococcus aureus and its bioavailability in nasal secretions. J Hosp Infect. 2000; 45: 198–205.
- Lanker Klossner B, Widmer HR, Frey F. Nondevelopment of resistance by bacteria during hospital use of povidone-iodine. Dermatology. 1997; 195 Suppl2: 10-13.
- Phillips M, Rosenberg A, Shopsin B et al. Preventing Surgical Site Infections: A Randomized, Open-label Trial of Nasal Mupirocin Ointment and Nasal Povidone Iodine Solution. Infect Control Hosp Epidemiol. 2014; 35(7): 826-832.
- Torres EG, Lindmair-Snell JM. Is preoperative nasal povidone-iodine as efficient and cost-effective as standard methicillin-resistant Staphylococcus aureus screening protocol in total joint arthroplasty? J Arthoplasty. 2016; 31: 215-218.
- Maslow J, Hutzler L, Cuff G, Rosenberg A, Phillips M, Bosco J. Patient experience with mupirocin or povidone-iodine nasal decolonization. Orthopedics. 2014 Jun;37(6):e576-81.
- McDonnell G & Russell AD. Antiseptics and disinfectants: Activity, Action, and Resistance. Clin Microbiol Rev. 1999; 12(1): 147-179.
- Bebko SP, Green DM, Awad SS. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surgery. 2015; 150(5): 390-395.