SSI in Focus: Assessment, Prevention, and Management

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Surgical site infections (SSI) are serious complications, accounting for 20 percent of all the healthcare-associated infections, and they are considered to be the second most frequent type of hospital-acquired infection (HAI) in Europe and the United States. Although SSIs are among the most preventable hospital acquired infection, they represent a significant burden in terms of morbidity, mortality, and additional costs to the health care system. 

In cardiac surgery, 3.6 percent of the patients who have heart operations experience an SSI. Although the mortality rate related to SSI is only about 1.6 percent, the mean additional hospital LOS can be up to twelve days, which results in extra hospital cost of £8548 (€9444) per SSI-infected patient (5). This does not include the indirect costs because of patients’ temporary or permanent incapacity to work, income lost by family members, forgone leisure time, travel, and home care costs, which can account for up to eight times the direct costs of SSI. Furthermore, patients with SSI may experience additional pain, delayed wound healing, and be more susceptible to secondary infections, such as bacteremia. It may also have a negative impact on patients’ mental health as a result of prolonged hospitalization.

Based on the Centre for Disease Control and Prevention’s (CDC), SSI is defined as any incisional (superficial and deep) and space or organ infection occurring within thirty days postoperatively after initial procedure or up to twelve months postoperatively if the procedure includes an implant. It should also include at least one of the following factors: pus discharge on incision; organisms isolated from an aseptically obtained culture; an abscess or other evidence of infection that is found by the surgeons at the time of reoperation, percutaneous drainage, or by histopathological or radiological; or diagnosis of an incisional or organ or space SSI by the clinician.

Infections after surgery are caused by germs that can be already on the patient’s skin and spread to the surgical wound, inside the body or from the organ on which the surgery was performed, or in the surrounding environment such as from infected surgical instruments or on the hands of the health care provider. However, some patients may have higher risks of developing SSI. Those who have poorly controlled diabetes; have problems with their immune systems or are taking corticosteroids; have high body mass index or are obese; are currently or recently smoking; or undergo surgery that lasts longer than two hours are particularly susceptible.

Assessment of an SSI includes looking for local signs and symptoms of infection—for example, heat, redness, pain, and swelling. In more serious cases, systemic signs of fever or a raised white blood cell count may be observed. Visually, infection in the surgical wound may prevent healing, causing the wound edges to separate, or it may cause an abscess to form in the deeper tissues. In addition, severity of SSIs may vary, and this should be taken into account when comparing reported rates of SSI.

In the United Kingdom, it is recommended that patients undergoing elective cardiac surgery have a preoperative assessment to stratify risk of SSI, which should be used to inform the consent process and reduce the risk of SSI. Although there are several risk stratification tools for cardiac patients, such as the Barts Surgical Infection Risk tool, the Brompton and Harefield Infection Score, and the Australian Clinical Risk Index, there is currently a lack of evidence as to which of these risk tools are the most valid and reliable to be used in clinical practice.

In terms of management, most SSIs can be treated with antibiotics. The patient must be given an antibiotic that covers the likely causative organisms. Remember to consider local resistance patterns and the results of microbiological tests in choosing an appropriate antibiotic. Sometimes additional surgery or procedures may be required to treat the SSI. During recovery, make sure that friends and family members wash their hands before and after they enter the patient’s room. Also ensure that doctors, nurses, and other caregivers wash their hands too. Other preventive strategies include preoperative showering, nasal decolonization, antibiotic prophylaxis, antiseptic skin preparation, and hand decontamination.

However, a recent national survey in the UK of SSI prevention strategies demonstrated significant variation in care in cardiac surgery centers, which is also reflected in this center. To address the issue, a cross-department network of SSI champions has been established at Barts Heart Centre in London. Nationally, ongoing research is also being conducted to standardize prevention practices. For example, the Cardiothoracic Interdisciplinary Research Network, which is a collaborative research group of healthcare professionals in cardiac and thoracic surgery, have developed a program of research that will establish a new way of working out each patient’s risk of developing an infection.

In summary, SSI is a serious complication after cardiac surgery. It can have a huge impact on patients’ recovery and experiences as well as on economic perspective. Given the high burden of SSI for the patient and the health care system, effective management and prevention strategies are essential.

References

1. National Institute for Health and Care Excellence (2019) Surgical site infections: prevention and guidelines. https://www.nice.org.uk/guidance/ng125
2. Figuerola-Tejerina A, Rodr ıguez-Caravaca G, Bustamante-Munguira J, et al. Epidemiological surveillance of surgical site infection and its risk factors in cardiac surgery: a prospective cohort study. Rev Esp Cardiol (Engl Ed) 2016;69(9):842e8.
3. Findeisen A, Arefian H, Doenst T, Hagel S, Pletz MW, Hartmann M, et al. Economic burden of surgical site infection in patients undergoingcardiac surgery. Eur J Cardiothorac Surg 2019;55(3):494e500.
4. Getting It Right First Time (2019) GIRFT SSI National Survey. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2017/08/SSI-Rep...
5. Centres for Disease Control and Prevention (2013) CDC/NHSN Surveillance definition of healthcare-associated infection and criteria for specific types of infection in the acute care setting. http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
6. Magboo R, Drey N, Cooper J, Byers H, Shipolini A and Sanders J (2020) Predicting cardiac surgical site infection: development and validation of the Barts Surgical Infection Risk tool. J Clin Epidemiol; 128: 57-65.
7. Raja SG, Rochon M, Jarman JWE. Brompton Harefield Infection Score (BHIS): Development and validation of a stratification tool for predicting risk of surgical site infection after coronary artery bypass grafting. Int J Surg. 2015 Apr ;16(Pt A):69–73.

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