Prevention of perioperative wound infections

Abstract

Surgical site infection (SSI) is the commonest hospital acquired infection that occurs in early postoperative period in surgical patients and accounts for 38% of infections in surgical patients and 31.1% of all infections in trauma patients. Ifs frequency increase parallels increase in number of risk factors. Prevention of peri-operative infection necessitates management directed at optimizing of patient factors like smoking, nutritional factors, immune-suppression, obesity and cardiovascular status. Use of principles like antibiotic prophylaxis, aseptic theatre conditions, respect of soft tissues during operation, local therapy and other modern patient safety practices is mandatory. Antibiotic prophylaxis should be started early pre-operatively at least 30-60 minutes before incision and antibiotic level exceeding minimal inhibitory concentration for infecting organism or before inflation of a tourniquet if applicable to closure of wound. Aiming at short preoperative stay in hospital, and pre-washing of the area concerned before cleaning with antiseptic are also imperative in reducing SSI. Preoperative skin preparation is an important element in prevention of infection, but removes only up to 80% of skin flora. Standard surgical antisepsis is an accepted method and involves scrubbing with antiseptic solutions. Chlorhexidine gluconate compared with povodine iodine showed a prolonged reduction in skin contamination and with less toxicity and skin irritation. Aqueous surgical hand scrubs are equivalent to traditional scrubs with regard to reduction of skin contamination, with higher surgeons protocol compliancy compared to traditional scrubs. The use of laminar flow and ultra-violet light in theatre is associated with decreased rates of postoperative skin infections and contamination. Respect of soft tissues during surgery through decrease in excessive use of diathermy, contusions and excessive tension is advised. Wound closure without tension and no dead space is encouraged. Issues of wound drainage have not been shown to reduce rates of infection. When used, closed suction drainage is better than open drain. SSI is a common complication and it is in the interest of the surgeon and the patient that it is prevented as it can be associated with morbidity, mortality and increased resource utilization. This article will deal with peri-operative management of the orthopaedic patient using evidence based benefits to the current practices available from recent updates, reviews and prospective randomized control trials, and some retrospective studies.