Abstract

Peri-prosthetic joint infection (PJI) is a severe complication of total joint arthroplasty that appears to be increasing as more of these procedures are performed. Numerous risk factors for incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSIs) have been identified. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional SSI and PJI. The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recently updated the national Guideline for Prevention of Surgical Site Infection. The updated guideline applies evidence-based methodology, presents recommendations for potential strategies to reduce the risk of SSI, and includes an arthroplasty-specific section. This article serves to introduce the guideline development process and to complement the Prosthetic Joint Arthroplasty section with background information on PJI-specific economic burden, epidemiology, pathogenesis and microbiology, and risk factor information.

Abstract

Guidelines regarding the prevention, detection, and management of surgical site infections (SSIs) have been published previously by a variety of organizations. The American College of Surgeons (ACS)/Surgical Infection Society (SIS) Surgical Site Infection (SSI) Guidelines 2016 Update is intended to update these guidelines based on the current literature and to provide a concise summary of relevant topics.

Abstract

Background: Surgical site infections (SSI) remain a significant problem to both the patients and the healthcare system. Value care and standardized quality measures continue to promote improvement in surgical asepsis, but certain debates remain unresolved in the field of surgical hand antisepsis.

Methods: Review of relevant accounts and literature.

Results: Controversy has existed regarding the U.S. Food and Drug Administration (FDA)’s 1994 Tentative Final Monograph (TFM), which defined how surgical hand antisepsis products are assessed. Issues involving neutralizers and demonstration of a cumulative effect were addressed in the FDA’s Proposed Rule in 2015. Few studies have used SSI as a primary outcome and instead have used a surrogate marker (colony-forming units [CFU]). Quantitative microbiology studies suggest a minimum bacterial inoculum of 10⁵–10⁷ CFU/mL is necessary to cause a clinical infection. Outcomes of antisepsis likely are driven by both active ingredient(s) and overall product formulation. Povidone–iodine aqueous scrubs are inferior to chlorhexidine gluconate (CHG) 4% aqueous scrubs and alcohol-based rubs (ABR). The SSI and CFU outcomes studies support the equivalence or superiority of ABR over CHG.

Conclusions: Both ABRs and CHG 4% are preferred to povidone–iodine for surgical hand antisepsis. Well-powered randomized controlled trials measuring SSI as a primary outcome, as well as those designed according to either TFM or European methodology, with appropriate controls and neutralizers, are warranted. These trials should incorporate different ABR formulations and CHG 4%, as well as skin tolerance assessments and a cost analysis.

Abstract

Background: Intra-operative surgical site irrigation (lavage) is common practice in surgical procedures in general, with all disciplines advocating some form of irrigation before incision closure. This practice, however, has been neither standardized nor is there compelling evidence that it effectively reduces the risk of surgical site infection (SSI). This narrative review addresses the laboratory and clinical evidence that is available to support the practice of irrigation of the abdominal cavity and superficial/deep incisional tissues, using specific irrigation solutions at the end of an operative procedure to reduce the microbial burden at wound closure.

Methods: Review of PubMed and OVID for pertinent, scientific, and clinical publications in the English language was performed.

Results: Incision irrigation was found to afford a three-fold benefit: First, to hydrate the bed; second, to assist in allowing better examination of the area immediately before closure; and finally, by removing superficial and deep incisional contamination and lowering the bioburden, expedite the healing process. The clinical practice of intra-operative peritoneal lavage is highly variable and is dependent solely on surgeon preference. By contrast, intra-operative irrigation after device-related procedures has become a standard of care for the prophylaxis of acute peri-prosthetic infection. The clinical evidence that supports the use of antibiotic irrigation is limited and based on retrospective analysis and few acceptable randomized controlled trials. The results of laboratory and animal studies using aqueous 0.05% chlorhexidine gluconate are favorable, suggesting that further studies are justified to determine its clinical efficacy.

Conclusion: The adoption of appropriate and standardized intra-operative irrigation practices into peri-operative care bundles, which include other evidence-based strategies (weight-based antimicrobial prophylaxis, antimicrobial sutures, maintenance of normothermia, and glycemic control), offers an inexpensive and effective method to reduce the risk of post-operative SSI and deserves further evaluation.

Abstract

Background: Surgical site infection (SSI) is the most common type of healthcare-associated infection, contributing to substantial annual morbidity, costs, and deaths. In the United States it is the number one reason for hospital re-admission after surgery. Relatively little attention has been paid to the proportion of SSIs that occur after discharge. This paper systematically reviews two decades of publications to characterize better the proportion of SSIs that are identified after discharge and the need for better early detection and treatment.

Methods: A restricted systematic literature search was conducted in PubMed to identify English-language studies published after 1995 that include the occurrence of pre-discharge and post-discharge SSIs. The data abstracted were the date of publication, country of origin, procedure, study design, surveillance system, population size, follow-up rate, and SSI counts and proportions. Descriptive statistics and forest plots were used to characterize the data set, represent the overall proportion of SSIs occurring after discharge, and assess the heterogeneity of the studies.

Results: A total of 55 articles met the inclusion criteria, with data from 1,432,293 operations and 141,347 SSIs based on studies from 15 countries. The overall proportion of operations leading to SSI was 9.9%. Of the 141,347 infections, 84,984 (60.1%) appeared after discharge. The proportion of SSIs after discharge differed among studies, from 13.5 to 94.8, and was heterogeneous for all studies and for most individual surgery types.

Conclusion: Post-discharge SSIs constitute the majority of these infections and pose a substantial disease burden for surgical patients globally and for different surgery types. Further examination is warranted to determine the methodologic and clinical factors moderating the proportion of post-discharge SSIs.