Institute of Industrial Biotechnology, Government College University Lahore 54000, Pakistan
Department of Pharmacy, COMSATS University Islamabad, Lahore Campus, Pakistan
Department of Allied Health Sciences, Afro Asian Institute Lahore 54000, Pakistan
Published Date: 11/11/2021.
*Corresponding author: mar Farooq Gohar, Institute of Industrial Biotechnology, Government
College University Lahore 54000, Punjab, Pakistan
Introduction: Surgical site infections (SSIs) represent index of healthcare system and are third most commonly reported nosocomial infection. SSIs are responsible for high morbidity and mortality ratio and account round about 1/4 of hospital acquired infections which produce adverse impacts on patients. Moreover, they increase patient stay in hospital resultantly responsible for economical loss of patient and family.
Objective: The aim of present review is to assemble already known information regarding incidence of SSIs, pathological as well as microbiological risk factors and mitigation strategies (pre-operative, intraoperative and postoperative) for patients posted for any surgery in hospital. Additionally, importance of SSIs related preventive measures and prophylactic antibiotic therapy for better healthcare is also highlighted.
Methodology: Several research, review articles, clinical reports and survey-based reports were searched by using different databases to gather the information regarding SSIs.
Results: Complete ten published clinical studies were thorough reviewed to highlight importance of operation theater quality management to prevent SSIs. Data obtained showed that implementation of pre, intra and postoperative strategies can cut down mortality rate associated with SSIs around the world. Moreover, surveillance of SSIs risk factors and decline in them may also decrease nosocomial infections.
Conclusion: SSIs surveillance is a well-established and comprehensive approach to reduce incidence of SSIs. Along with, maintenance of operation theater quality is hallmark for reduction in SSIs. However, further studies are still required to improve standards for periodic surveillance and management of hospital acquired infections.
Keywords: SSIs, operation theater, pre-operative, nosocomial infection, surveillance programs
Surgical site infections (SSIs) represent major health care complications and account for 38% of hospital acquired infections. SSIs usually occur within one month of procedure execution or maximum in 1 year in patients who has received implants . These contaminations could be deep or superficial incisional infections and generally involve body organs/spaces. In particular, superficial diseases that affect skin only can be SSIs such as operative wounds (involvement of surface tissues, organs, or soft masses) . Extreme SSIs account for about half of all SSIs in deep incisions or organ gaps . One clinical study has reported that an estimated 11% of entire disease burden were associated with operating procedure . Moreover, 1 in 10 patients admitted to hospital face nosocomial infection. Among all on them, majority of in-hospital events are linked to surgical incisions and administration of medications . SSIs are responsible for high morbidity and mortality ratio as SSI patients remain 2-11 times more expected to die than non-SSI patients therefore, management of SSIs is a significant clinical concern globally. Moreover, surgical site infected patients stay in hospital for around 7-10 additional days which resultantly drop economic conditions of patients .
According to Centers for Disease Control National Nosocomial Infections Surveillance (CDCNNIS) system four major types of risk of injuries related to operating procedure are categorized as 1) clean wounds, an uninfected operational wound in which no inflammation is observed and alimentary, respiratory, genital, or uninfected urinary tract is not accessed; 2) operative incisional wounds that accompany blunt trauma; 3) clean-contaminated wounds, a surgical wound in which gastrointestinal, respiratory, genital, or urinary tracts are entered under sterile environments and without unusual contamination and 4) contaminated wounds including open, fresh or accidental wounds. For example, procedures with major disruptions due to leakage from GIT tract and the incisions in which non-purulent, acute inflammation is encountered mainly involve dirty-infected wounds, traumatic wounds and lacerated viscera [2,7,8] (Figure 1).
Figure 1: Surgical Site Infections (SSIs) classification according to CDCNNIS.
Besides this, risk of developing SSI differs considerably depending on procedure type and individual’s characteristics undertaking surgery . Different studies have reported both internal (related to patient i.e. dehydration, older age, co-existing disease and diabetes) and external (related to procedure i.e. length of procedure, working ethics of surgeon, stability of pre-operative skin preparation, adequacy of antimicrobial prophylaxis and addition of foreign objects) factors responsible for SSIs . A research conducted by Dominioni et al. has shown that serum albumin accumulation, older age and standard of operation theater can increase chances of SSIs . Various studies have been revealed prominent role of microorganisms in surgical site infections. Findings showed Staphylococcus aureus and methicillin-resistant staphylococcus aureus (MRSA) strains related medical complications which consequently increase post-operative medical stay and related hospital expenses . Likewise, occurrence of concomitant infections due to inevitable growth of bacterial species (e.g., S. aureus, coagulase-negative staphylococci (CoNS), Enterococcus and Escherichia coli) are accountable for SSIs in patients undergoing any implantation or other prosthesis. Hence, use of prophylaxis antibiotic may significantly reduce rate of nosocomial infections . Considering this all information, operating care has become an integral measure of global health care with approximately 234 million procedures per year.
Rarely, pathogenic microorganisms are originated from an exogenous source like operating theatre (OT) environment, surgical personnel or employees  and total tools including instruments as well as materials used during a surgery [10,14]. Giacometti et al. studied 676 patients of surgery with signs and symptoms suggestive of wound infections, who presented over course of six years. Findings showed bacterial pathogens in 614 victims and most of them were aerobic bacteria (S. aureus, P. aeruginosa, E. coli, S. epidermidis and Enterococcus faecalis) with percentages of 28.2, 25.2, 7.8, 7.1 and 5.6 respectively (Table 1) .
Table 1: Pathogens commonly linked with majorly performed surgical procedures.
Numerous numbers of research and review articles have been analyzed for acquisition of information about surgical site infections and their remedial measures especially concerning operation theater quality. Different databases have been investigated to find out the information about respective topic. Keywords used were “surgical site infection”, surgical site prevention”, “operation theater infections”, risk factors responsible for SSIs”, strategies to reduce SSIs”, “SSIs related complications”, “etiology of SSIs”, “intra-operative SSIs”, “post-surgical site infections”, “exposure time for surgical site treatment”, “nosocomial infection types” and so on. It was a qualitative type of review so no specific software was used for data analysis. Articles having supposititious and un-authentic information regarding SSIs were excluded from the review process.
For the avoidance of surgical site infections, few strategies are adopted including preoperative, intra-operative and post-operative strategies as summarized in Figure 2.
Figure 2: Strategies for surgical site infections (SSIs) prevention
For pre-operative preparation of skin, most commonly used agents are alcohol-containing products, iodophors, and chlorhexidine gluconate. According to FDA, alcohol is well-established agent having active constituents including ethyl alcohol (C2H5OH) 60-95% or isopropyl alcohol 50-91.3% by volume . Alcohol remains most effective, readily available, inexpensive, rapidly acting agent and have bactericidal, fungicidal and virucidal activity, but spores can show resistance . The technique for application of antiseptic is in concentric circle, starting from area of supposed incisional site to periphery . According to Center for Disease Control (CDC) guidelines maintenance of “hand hygiene” including trimming of nails, use of proper antiseptic agent for scrubbing and drying can help to reduce pathogen transfer from medical workers to patients . For removing hairs, shaving of surgical site causes a significant increase in SSI (5.6%) as compared to other hair removal agents (0.6%). Shaving causes microscopic traumas in skin that later act as a center for replication of bacteria .
OT workers may have interactions during medical procedures with individual skin and/or mucous membranes and there is a chance of sharp injury leads towards chronic infections. Sharp wounds placed employees at threat of exposure to blood-borne diseases as well . Proper educational programmers and policies must be developed among health sector personals in order to limit chances of pathogen transfer to patients which in turn decreases hospital acquired infections among post-surgery patients. Before surgery, administration of antimicrobial prophylaxis has been shown to significantly decrease severity of wound infections associated with surgical procedures. The usage of antibiotic drug prophylactically prior to surgery allow availability of appropriate concentration in tissue thus, reduce microbial concentration and occupancy at incisional site .
SSIs may result from bacteria surviving on surgical tools or penetrating directly into operational site . Ventilation and humidity in the OT are important factors to minimize chance of infection. In order to avoid getting potentially polluted air to reach surgical suite, surgical operation room (SOR) must be hold on to positive pressures in comparison to the hallways outside the room . As best practice, there must also be at least 15 air changes per hour (3 of fresh air). To stop development of molds and fungi, humidity should be conserved at a definite level . The Ventilation health care facility suggests that the OT must be managed at 20-24oC, with positive pressure and humidity of 20-60% . Flash sterilization is a procedure designed for instant use of instruments (e.g., for reprocessing of an accidentally dropped instrument). However, it is not recommended for implants because of a viable risk of infection . Various studies did not prefer this method as a routine sterilization for convenience, to save time and to minimize sterilization cycle factors (i.e., temperature and time)  (Table 2).
Table 3: Parameters for flash sterilization cycles.
Environmental surfaces are hardly concerned for expansion of SSIs. When surfaces get visibly soiled during a procedure, a hospital disinfectant approved by environmental protection agency (EPA) would be used before next procedure . According to Occupational Safety and Health Administration (OSHA) requirement, environmental surfaces should be disinfected after interaction with infectious material or blood . After the end of night or day, a disinfectant approved from environmental protection agency (EPA) is used on regular basis for wet-vacuuming of floor of operating room . The tacky mats have not been played significant role in reduction of microorganism present on stretcher wheels or shoes. So, there is no need to use them for controlling infection .
Microbiological sampling and counting can regularly be used to determine condition of air in OTs, but the relationship between two approaches has rarely been tested. A study indicated that there is no need to substitute microbiological sampling with particle counting in conventionally ventilated operating theatres for routine assessment of pathogenic organisms . Surgical attire is worn to minimize release of microbes into atmosphere of operation theater. Clean, freshly washed scrubs should be worn by each medical staff member  just to prevent spread of possible pathogens to the wounds. In addition, sterile drapes can also be used for the same purpose .
Strict obedience to codes of asepsis by scrubbed staff as well as by anesthesia personnel is base for controlling SSIs. Different surveys related to operation theater visits revealed that anesthesia personnel were involved as source of pathogen when placing intra-vascular devices, endotracheal tubes (ETT), and when administrating intravenous (IV) drugs . Improper implementation of aseptic-principles throughout performance is associated with outbreaks of post-operative infections. It is believed that risk of SSIs can be reduced through application of surgical technique in operation theatre . Presence of some type of foreign body like suture material, an implant, or drain, might stimulate inflammation at surgical site and may enhance chance of SSIs . Moreover, studies have been showed that risk of SSIs drop when closed suction drains are used instead of open drains  (Table 3).
After performing a surgery, the care of surgical site incision is mandatory depending upon the type of incision the patient had. There are three forms of incision sites including closed skin edges incision, open edges incision which is closed later and open incision site for healing purpose. Postoperative incision care in case of closed edges, the incision is covered with germ free bandage for up to 48 hours . In case of open edges incision, it must be packed with sterile dressing for minimizing the contamination of surgical site. When the incision site left open for healing purpose, it is also filled with germ free damped gauze and covered with bandage. The American College of Surgeons (ACS) and other authorities have suggested usage of germ-free gloves and tools while exchanging dressings of surgical incision  .
Presently, patients are discharged momentarily even afore surgical incisions have restored. Physician will provide specific instructions about when and how to adjust it. After a few days, most wounds do not require taking off the gauze but wrapping of area and change dressing on regular basis by maintaining proper hand hygiene it may help to protect cut from infection and it may heal more quickly. The discharge planning intent is to sustain reliability of restorative incision, let the patient to know almost signs and symptoms of infection and direct patient about whom to interact to account any issues . Previous studies which have worked to identify the risk factors responsible for surgical site infections and strategies for preventing them are summarized below (Table 4).
Table 4: Summary of clinical studies on maintenance of operation theater quality to reduce SSIs rate.
Data obtained exhibited that an area where all contaminating factors and micro-environmental changes are kept under controlled supervision is considered as a safe operating unit. By giving thorough attention, this task can be done by proper management and frequent inspections, as well as by adequate ongoing employee training . Indeed, OT is an extremely complex environment in which there are various risk factors, including not only infrastructure characteristics and its equipment but also the administration and actions of workers in healthcare system . Design of OT is one of the most important parameters to maintain quality of procedure. In specific description, it is essential to separate clean and dirty areas and maintain organized and logical movement of patients from their entrance to exit. For execution of medical procedures and for preparation of equipment separate rooms should be allocated. In these rooms, it is essential to limit the level of movement and activities of people as both factors can manipulate microbial contents and therefore can influence possibility of infections. The size of storage area should be determined according to workload and types of materials need to be placed in it. Windows of operating room (OR) should have a surface that are easy to clean and free from collecting dust . Design of operation room, furniture, floor finishing and its covering will influence cleaning condition of operation room. In order to assist infection control, surface of floor should be impermeable, easy to clean, anti-stain and suitable for moving equipment’s of operating room [45-55].
To summarize, surgical site infections can be avoided through implementation of well-planned pre-operative, intra-operative and post-operative strategies as well as by practicing infection management through execution of sterile technique while conducting procedures. It's important to remember that much of the morbidity and mortality ratio associated with SSIs can be reduced by modifying a variety of variables, including surgical environment, patient-related or procedure-related risk factors along with personnel behavior. Furthermore, SSIs surveillance is a well-documented and well-established method of reducing incidence of SSIs. Despite its usefulness, many hospitals continue to ignore this advice. The importance of good patient preparation, aseptic conditions and adherence to sterile surgical procedure are highlighted in the CDC guidelines for prevention of SSIs and antimicrobial prophylaxis is also guided in particular circumstances. Altogether, SSIs prevention necessitates a comprehensive approach and the contribution of all individuals involved, including those responsible for the design, layout, and management of operating rooms. However, further research into prevention strategies, as well as strict adherence to the implementation of established evidence-based methods to mitigate SSIs is still required to reduce infection even more.