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Surgical site infection prevention: a global priority

  • M. Abbas
    Affiliations
    Infection Control Programme and WHO Collaborating Centre on Patient Safety, Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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  • D. Pittet
    Correspondence
    Corresponding author.
    Affiliations
    Infection Control Programme and WHO Collaborating Centre on Patient Safety, Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
    Search for articles by this author
      More than 300 million people undergo surgical procedures each year around the world.
      • Weiser T.G.
      • Haynes A.B.
      • Molina G.
      • et al.
      Size and distribution of the global volume of surgery in 2012.
      This represents twice the number of babies born every year! Thus, millions of individuals are at risk for complications resulting from surgery if correct actions and prevention strategies are not applied at appropriate times. Surgical site infection (SSI) is a leading cause of healthcare-associated infections; it is associated with high mortality, prolonged duration of hospital stay, and high use of additional resources.
      • European Centre for Disease Prevention and Control
      Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals.
      • Perencevich E.N.
      • Sands K.E.
      • Cosgrove S.E.
      • Guadagnoli E.
      • Meara E.
      • Platt R.
      Health and economic impact of surgical site infections diagnosed after hospital discharge.
      • Kirkland K.B.
      • Briggs J.P.
      • Trivette S.L.
      • Wilkinson W.E.
      • Sexton D.J.
      The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.
      Yet, with a solid infection prevention and control programme, many of these infections are preventable.
      • Haley R.W.
      • Culver D.H.
      • White J.W.
      • et al.
      The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.
      This issue of the Journal includes several papers that address SSI and SSI prevention; the work and investigations presented are those of clinicians and researchers from around the world, illustrating the universality of SSI prevention.
      • Choi H.J.
      • Adiyani L.
      • Sung J.
      • et al.
      Five-year decreased incidence of surgical site infections following gastrectomy and prosthetic joint replacement surgery through active surveillance by the Korean Nosocomial Infection Surveillance System.
      • Dawod J.
      • Tager A.
      • Darouiche R.O.
      • Al Mohajer M.
      Prevention and management of internal cerebrospinal fluid shunt infections.
      • De Nardo P.
      • Gentilotti E.
      • Nguhuni B.
      • et al.
      Post-caesarean section surgical site infections at a Tanzanian tertiary hospital: a prospective observational study.
      • Fukuda H.
      Patient-related risk factors for surgical site infection following eight types of gastrointestinal surgery.
      • Yang W.
      • Liu Y.
      • Zhang Y.
      • Zhao Q.H.
      • He S.F.
      Effect of intra-operative high inspired oxygen fraction on surgical site infection: a meta-analysis of randomized controlled trials.
      The global volume of surgery is increasing and is estimated to have increased by ∼38% in the past eight years.
      • Weiser T.G.
      • Haynes A.B.
      • Molina G.
      • et al.
      Size and distribution of the global volume of surgery in 2012.
      The largest increases in rates of surgery took place in very-low- and low-expenditure countries.
      • Weiser T.G.
      • Haynes A.B.
      • Molina G.
      • et al.
      Size and distribution of the global volume of surgery in 2012.
      The global burden of SSI is important worldwide, yet this burden seems to affect low-income countries disproportionately, with almost three-fold higher SSI rates than in high-income countries.
      • World Health Organization
      Report on the burden of endemic health care-associated infection worldwide.
      • Allegranzi B.
      • Bagheri Nejad S.
      • Combescure C.
      • et al.
      Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis.
      Intensifying infection prevention and control measures, especially in low-income countries, thus becomes paramount.
      Surveillance of SSI should be a priority for infection control programmes, even in resource-limited settings. The rate of Caesarean sections is ∼15% worldwide, but they comprise one-third of all operations in resource-limited settings.
      • Weiser T.G.
      • Haynes A.B.
      • Molina G.
      • et al.
      Size and distribution of the global volume of surgery in 2012.
      De Nardo and colleagues have conducted a prospective cohort study in a rural region of Tanzania with the aim of evaluating rates of post-Caesarean section SSI, as well as risk factors and microbiological characteristics.
      • De Nardo P.
      • Gentilotti E.
      • Nguhuni B.
      • et al.
      Post-caesarean section surgical site infections at a Tanzanian tertiary hospital: a prospective observational study.
      The study highlighted several issues, of which the most salient are the astonishingly high rates of SSI (48.2%), the extremely low rate of pre-incision prophylactic antibiotic use (2.1%), and the high rate of loss to follow-up (29.7%). This rate of loss to follow-up was higher than in similar studies in Tanzania and Kenya.
      • Nthumba P.M.
      • Stepita-Poenaru E.
      • Poenaru D.
      • et al.
      Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya.
      • Mpogoro F.J.
      • Mshana S.E.
      • Mirambo M.M.
      • Kidenya B.R.
      • Gumodoka B.
      • Imirzalioglu C.
      Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania.
      These findings illustrate the dire need to implement SSI prevention measures, and confirm that post-discharge surveillance in some settings is difficult, even in the context of a study, and may depend on regional factors.
      High-income countries from other regions of the world have realized that collecting data through centralized surveillance systems is an essential component of SSI prevention. Reports stemming from data collected by two such surveillance systems (Japan Nosocomial Infections Surveillance, JANIS, since 2000; Korean Nosocomial Infection Surveillance System, KONIS, since 2006) are presented.
      • Choi H.J.
      • Adiyani L.
      • Sung J.
      • et al.
      Five-year decreased incidence of surgical site infections following gastrectomy and prosthetic joint replacement surgery through active surveillance by the Korean Nosocomial Infection Surveillance System.
      • Fukuda H.
      Patient-related risk factors for surgical site infection following eight types of gastrointestinal surgery.
      In the paper by Fukuda, multi-level mixed-effects models were developed to identify patient-related risk factors for SSI following gastrointestinal surgery, to direct efforts to collect easily obtainable data for surveillance, and to further develop risk prediction models.
      • Fukuda H.
      Patient-related risk factors for surgical site infection following eight types of gastrointestinal surgery.
      Interestingly, intraoperative blood transfusion, diabetes, and use of steroids constituted risk factors for SSI following certain types of gastrointestinal surgery and, thus, could be included in data collection and risk evaluation. The article by Choi and colleagues reports trends in SSI rates following gastrectomy and following total hip and total knee arthroplasty after the introduction of KONIS.
      • Choi H.J.
      • Adiyani L.
      • Sung J.
      • et al.
      Five-year decreased incidence of surgical site infections following gastrectomy and prosthetic joint replacement surgery through active surveillance by the Korean Nosocomial Infection Surveillance System.
      There were encouraging results showing decreased crude SSI rates over five years; the observed reductions were, however, non-significant when risk-adjusted rates were analysed. This may be due to a ‘dilution effect’ that was taken into account in other analyses, by stratifying according to time since the beginning of surveillance.
      • Brandt C.
      • Sohr D.
      • Behnke M.
      • Daschner F.
      • Ruden H.
      • Gastmeier P.
      Reduction of surgical site infection rates associated with active surveillance.
      • Geubbels E.L.
      • Nagelkerke N.J.
      • Mintjes-De Groot A.J.
      • Vandenbroucke-Grauls C.M.
      • Grobbee D.E.
      • De Boer A.S.
      Reduced risk of surgical site infections through surveillance in a network.
      • Staszewicz W.
      • Eisenring M.C.
      • Bettschart V.
      • Harbarth S.
      • Troillet N.
      Thirteen years of surgical site infection surveillance in Swiss hospitals.
      This highlights once more the importance of considering multiple parameters in reports and analyses of surveillance time trends.
      The question of high fraction of inspired oxygen as a potential preventive intraoperative measure to reduce the incidence of SSI is controversial, with conflicting results in the literature. A recent Cochrane review had found that there was insufficient evidence to recommend routine use of perioperative high fraction of inspired oxygen.
      • Wetterslev J.
      • Meyhoff C.S.
      • Jorgensen L.N.
      • Gluud C.
      • Lindschou J.
      • Rasmussen L.S.
      The effects of high perioperative inspiratory oxygen fraction for adult surgical patients.
      In this issue, Yang and colleagues report results from a meta-analysis suggesting that there may be a reduction in SSI when using high fraction of inspired oxygen intraoperatively.
      • Yang W.
      • Liu Y.
      • Zhang Y.
      • Zhao Q.H.
      • He S.F.
      Effect of intra-operative high inspired oxygen fraction on surgical site infection: a meta-analysis of randomized controlled trials.
      We believe that the jury is still out, and that further high-quality studies are required. Additional studies are also needed to evaluate the question of the effect of postoperative hyperoxygenation on the incidence of SSI.
      It would not be possible to discuss infection prevention in surgery without mentioning hand hygiene. The World Health Organization's (WHO) ‘Save Lives: Clean Your Hands’ global May 5th, 2016 annual call to action for healthcare workers focused on ‘improving hand hygiene practices in all surgical services through the continuum of care, from surgical wards to operating theatres, to outpatient surgical services’.
      • World Health Organization
      Clean Care is Safer Care.
      This highlights not only the importance of hand hygiene when caring for surgical patients, both for surgical hand preparation and in the pre- and postoperative periods, but also puts these patients in the spotlight (Figure 1).
      • Nthumba P.M.
      • Stepita-Poenaru E.
      • Poenaru D.
      • et al.
      Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya.
      Surgical patients comprise a population that is vulnerable to infection.
      • Sax H.
      • Uçkay I.
      • Balmelli C.
      • et al.
      Overall burden of healthcare-associated infections among surgical patients. Results of a national study.
      This underscores the importance of SSI prevention, which is a field in its own right. SSI prevention is multi-modal, calls for multi-parametric and multi-disciplinary actions, and is also extremely challenging.
      Figure thumbnail gr1
      Figure 1Infographic produced by the World Health Organization for the ‘Save Lives: Clean Your Hands 5 May 2016’ annual call to action for healthcare workers, illustrating the surgical patient's journey through the healthcare system, as well as opportunities for infection prevention, including hand hygiene. Available at: http://www.who.int/gpsc/5may/EN_PSP_GPSC1_5May_2016/en/ [last accessed June 2016].
      Many guidelines exist on the issue of SSI prevention, and most are specifically tailored to meet the needs of the countries in which they were published.

      Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–278; quiz 79–80.

      • National Institute for Health and Clinical Excellence
      Surgical site infections: prevention and treatment.
      • Griffin F.A.
      Reducing surgical complications.
      • Joint Commission
      National patient safety goals effective January 1, 2016.
      • Bratzler D.W.
      • Hunt D.R.
      The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.
      Thus, there is a need for global guidelines, applicable to all settings, including low and middle-income countries. Guidelines must be based on evidence; when evidence is lacking, testing is required, ideally in large randomized clinical trials using SSI as an outcome measure.
      WHO has mandated an international group of experts and has conducted around 30 meta-analyses in order to produce global, evidence-based guidelines on SSI prevention.

      van Rijen M, Allegranzi B, Solomkin J, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers undergoing surgery: a systematic review. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #2207.

      de Vries F, Gans S, Solomkin J, et al. Targeting lower perioperative glucose levels to reduce surgical site infections without an increased risk of mortality or stroke – a systematic review and meta-analysis. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #1576.

      Bischoff P. Antimicrobial-coated sutures to decrease surgical site infections: a systematic review. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Oral Presentation #O338.

      de Jong S, Zayed B, Solomkin J, Dellinger P, Allegranzi B, Boermeester M. Optimal duration for antibiotic prophylaxis. A systematic review and meta-analysis. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #6194.

      Solomkin J, de Jong S, Zayed B, Egger M. It is all about the tube: a systematic review (SR) of hyperoxygenation in the prevention of surgical site infection. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #2342.

      Solomkin J, Zayed B, Gomes S, Egger M. Warm while asleep: a systematic review of the role of normothermia for the prevention of surgical site infections. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #6483.

      Solomkin J, Gomes S, Zayed B, Egger M. A systematic review of antiseptics in surgical site preparation. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #6511.

      de Jong S, Gans S, Jasper A, et al. Optimal timing for preoperative antibiotic prophylaxis. A systematic review and meta-analysis. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #4161.

      We look forward to the launch of these guidelines, which will be published in the second part of 2016. This effort is highly praiseworthy, as guidelines need to be constantly updated and adapted, not only to respond to production of new evidence, but also to take into account issues regarding implementation in all settings. This initiative will also stimulate a new research agenda and provide additional perspectives for improved patient care.
      Let's reduce SSI and make surgery safer for all patients worldwide.

      Funding source

      SSI surveillance and prevention studies by Dr Abbas leading to this editorial have received support from the Innovative Medicines Initiative Joint Undertaking under the Combatting Bacterial Resistance in Europe (COMBACTE-Net) grant agreement no. 115523 , resources of which are composed of financial contribution from the EU's Seventh Framework Programme ( FP7/2007–2013 ) and the European Federation of Pharmaceutical Industries and Associations (EFPIA) , grant agreement no. 115523 , companies' in-kind contribution.

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      1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250–278; quiz 79–80.

        • National Institute for Health and Clinical Excellence
        Surgical site infections: prevention and treatment.
        NICE, London2008
        • Griffin F.A.
        Reducing surgical complications.
        Jt Comm J Qual Patient Saf. 2007; 33: 660-665
        • Joint Commission
        National patient safety goals effective January 1, 2016.
        Joint Commission, Oakbrook Terrace, IL2015
        • Bratzler D.W.
        • Hunt D.R.
        The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery.
        Clin Infect Dis. 2006; 43: 322-330
      2. van Rijen M, Allegranzi B, Solomkin J, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers undergoing surgery: a systematic review. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #2207.

      3. de Vries F, Gans S, Solomkin J, et al. Targeting lower perioperative glucose levels to reduce surgical site infections without an increased risk of mortality or stroke – a systematic review and meta-analysis. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #1576.

      4. Bischoff P. Antimicrobial-coated sutures to decrease surgical site infections: a systematic review. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Oral Presentation #O338.

      5. de Jong S, Zayed B, Solomkin J, Dellinger P, Allegranzi B, Boermeester M. Optimal duration for antibiotic prophylaxis. A systematic review and meta-analysis. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #6194.

      6. Solomkin J, de Jong S, Zayed B, Egger M. It is all about the tube: a systematic review (SR) of hyperoxygenation in the prevention of surgical site infection. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #2342.

      7. Solomkin J, Zayed B, Gomes S, Egger M. Warm while asleep: a systematic review of the role of normothermia for the prevention of surgical site infections. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #6483.

      8. Solomkin J, Gomes S, Zayed B, Egger M. A systematic review of antiseptics in surgical site preparation. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #6511.

      9. de Jong S, Gans S, Jasper A, et al. Optimal timing for preoperative antibiotic prophylaxis. A systematic review and meta-analysis. European Congress of Clinical Microbiology and Infectious Diseases, Amsterdam, 2016. Abstract #4161.