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Innovations in patient care: infection control
clots in the wound space and prevention of third spaces by tissue
re-approximation.
Prevention of SSIs
Prevention is always better than a cure, and thus a careful
assessment of risks related to SSIs is paramount. The goal of SSI
management is to prevent or minimise the risk through careful
planning.
The following factors or methods external to the patient are
critical to preventing SSIs: a) Theatre environment and care of
instruments; maintenance of positive pressure ventilation of
operating theatre, laminar airflow in high risk areas, and
sterilisation of surgical instruments, sutures etc. according to
guidelines, and b) Surgical team members educated in aseptic
technique; staff with infections excluded from duty and scrubbing
up followed by appropriate sterile attire.
The following section outlines the evidence regarding hair
removal, preparation of the sterile field, and wound closure
technique. Prophylactic antibiotic use is discussed in section 6.
Decisions regarding hair removal
Hair removal is commonly performed prior to surgery, yet both the
Centers for Disease Control and Prevention (CDC) and the
Norwegian Centre for Health Technology Assessment recommend
against hair removal 14 . The CDC recommends that, if performed,
hair removal should be done by clipping or use of a depilatory
cream, rather than by razor. A recent Cochrane Database of
Systematic Reviews identified 11 studies that met criteria for
inclusion in a meta-analysis of hair removal and infections; 3 of
these studies compared shaving with clipping and found that
shaving increased surgical site infections (relative risk 2.02, 95%
confidence interval 1.21 to 3.36). Furthermore, shaving versus
clipping leads to more skin trauma even under ideal conditions,
providing further evidence that shaving should be avoided 15 .
There were no studies meeting inclusion criteria that compared
clipping of hair to no hair removal. Two studies compared shaving
with no hair removal, and found that shaving increased infection
(relative risk 1.59). However there were relatively few subjects in
these two studies and hence the conclusion did not reach
statistical significance.
Evidence from within Africa supports the CDC recommendation
against hair removal. Adeleye et al. recently reported their
experience with 17 cranial procedures on black Africans, in which
all of the fields were non-shaved, and reported no serious
complications over a 2 to 6 month follow-up 16 .
In conclusion, if hair is to be removed at all, it should be done by
clipping and not by shaving. Furthermore, hair should not routinely
be removed except in cases where the presence of hair interferes
with the technical aspects of the surgery, which is a judgment that
is best left to the operating surgeon within the context of these
recommendations.
Preparation of the surgical field
Two factors relate to the surgical field – the choice of skin
preparation, and the method of draping. In developing countries,
the choice of drapes has been limited due to cost constraints,
whereas in developed countries, sterile, adhesive iodineimpregnated
drapes (commonly known as Ioban) are available.
These adhesive drapes are placed over the skin after preparation
and application of standard side drapes. However, this practice
has demonstrated no benefit in randomized controlled trials.
Furthermore, adhesive drapes without iodine increase SSI rates
(relative risk 1.23, p=0.03) 17 . Thus the avoidance of adhesive
drapes as an adjunct to standard cloth drapes is best avoided.
Several methods of skin preparation are available, including
chlorhexidine, iodine, spirit, and over-the-counter soap. Bibbo et
al. compared chlorhexidine and isopropyl alcohol to povidoneiodine
in a randomized of 127 patients undergoing foot surgery
and found that chlorhexidine preparation resulted in a lower rate of
culture-positive skin swabs (38% versus 79%) 18 . Chlorhexidine, an
antiseptic solution that has been used worldwide since the 1950s,
is a safe and effective product with broad antiseptic activity.
Chlorhexidine gluconate is a water soluble, cationic biguanide that
binds to the negatively charged bacterial cell wall, altering the
bacterial cell osmotic equilibrium and is available in a variety of
concentrations (0.5%–4%) and formulations (with and without
isopropyl alcohol or ethanol). Chlorhexidine (0.05% solution) has
broad activity against gram-positive and gram negative bacteria,
facultative anaerobes and aerobes, yeasts, and some lipidenveloped
viruses, including HIV. Chlorhexidine is not sporicidal 19 .
Meier et al., recognizing the scarcity at times of conventional
skin preparation solutions, compared the use of over-the-counter
soap followed by methylated spirit, to the use of iodine 20 . The
study randomized 200 patients undergoing elective inguinal hernia
repair in Nigeria. In group 1, the subject’s skin was prepared by
scrubbing with soap and water, blotting with a sterile towel, and
applying spirit. In group 2, skin was prepared by scrubbing with
povidone-iodine then blotting with a sterile towel and applying
povidone-iodine paint. There was no difference in surgical site
infections between groups 1 and 2 (5.1% versus 5.9%,
respectively).
To this date, no studies have compared using soap and spirit
versus chlorhexidine. Thus the current evidence supports the use
of chlorhexidine for preparation of the surgical site. If chlorhexidine
is not available, scrubbing with soap followed by painting with
spirit (70% alcohol/30% water) appears equally efficacious as
scrubbing and painting with povidone-iodine.
Wound closure techniques and use of drains
There is little disagreement that clean wounds should be closed
primarily. However, the choice of whether to close primarily or
leave open, contaminated and clean-contaminated wounds is not
as straightforward. If a wound is not closed primarily (closed at the
time of surgery), it can be left open to heal by secondary intent, or
evaluated for closure at a later date (delayed primary closure, or
DPC). DPC of a surgical wound involves placing sterile dressing
over the wound at the conclusion of the case, and then removing
the dressing usually several days later. If the wound bed appears
clean and without devitalized tissue, the wound is then closed with
sutures.
One prospective randomized study from Tanzania found that the
rate of infection was higher when clean-contaminated or
contaminated wounds were left open, as opposed to closed
(30.2% versus 2.1%) 1 . It must be noted that those subjects in the
group whose wounds were left open were heterogeneous, and
included a combination of delayed primary closure (DPC) and
secondary healing techniques. Marion et al. conducted a metaanalysis
of primary versus DPC in complicated appendicitis, and
122 Hospital and Healthcare Innovation Book 2009/2010