Prevention of surgical site infections in orthopaedics

INTRODUCTION

Advances in medicine resulting from the improvement of surgical techniques and the introduction of more and more modern instruments have significantly improved the quality of life of patients treated for diseases of the musculoskeletal system. This progress, however, does not eliminate the risk of developing surgical site infections (SSI) [1].
Surgical site infections are healthcare-associated infections (HAI), and they are still some of the most severe complications emerging in contemporary surgery, which can be prevented or reduced to a minimum. Surgeries conducted on the bone tissue, which is sensitive to infection, require the operator to scrupulously follow the rules of the sanitary regime. The occurrence of a complication in the form of SSI changes the lives of patients completely, prolongs their hospital stay, lowers their quality of life, prolongs their inability to work, and can lead to disability and even death. The prestige of the institution also experiences a decline as a result of court claims. The negative effects of SSI also bring about increased costs due to prolonged hospitalization, performing additional diagnostic tests and operations, or administering antibiotic therapy [1-4].
In European studies, SSIs accounted for approximately 27% of all hospital-acquired infections [5]. In Poland, in one study, SSIs were in second position in the structure of hospital-acquired infections and accounted for 23% of all HAIs [6]. In another analysis from 2001-2004, SSIs amounted to 32% and took the first place among all HAIs detected in the facility under study [7]. Such a high percentage of SSIs in the general pool of hospital-acquired infections also results in increased costs of patient treatment [8, 9]. In the literature, a wide incidence rate of SSIs can be found in orthopaedic surgery, which ranges from 1% to 14% depending on the type of surgery and coexisting risk factors [10-17].
One of the most vital actions as regards the surveillance of SSIs is detecting the SSI itself and documenting it through the knowledge of the HAI criteria and definitions. Activities undertaken in order to prevent SSIs should include clear and consistent procedures, which will prepare the patient for surgery in the optimal way and reduce the risk of SSI at every stage of hospital care.
This study is a review of global guidelines concerning the prevention of surgical site infections, with particular emphasis on orthopaedics and traumatology. It is not a systematic review; the selection of literature was conducted with the use of PubMed and Google Scholar databases. The analysed literature concerned surgical site infections and recommendations for SSI prophylaxis, particularly pertaining to orthopaedic and traumatology procedures. While looking for the material, the following key words were used: surgical site infections (SSI), SSI risk factors, orthopaedics, fractures, SSI prevention, antibiotic prophylaxis.

CRITERIA FOR DIAGNOSING SURGICAL SITE INFECTIONS
Surgical site infections are diagnosed and categorized according to the definitions and criteria accepted by the European Centre for Disease Prevention and Control (ECDC), which constitute the guidelines for the countries forming the European Union (EU) [18, 19].
Surgical site infections can be categorized into superficial, deep, and organ/space infections. In order to classify SSI into a particular group, the following criteria need to be met:
• superficial incisional SSI (SSI-S) is an infection that develops within 30 days of surgery, affects only the skin and subcutaneous tissue at the site of the incision, and meets at least one of the following conditions:
– the presence of laboratory-confirmed or unconfirmed purulent discharge from the site of the superficial incision,
– a positive fluid or tissue culture from the superficial incision site, performed under aseptic conditions, – at least one of the local symptoms of inflammation: pain, swelling, tension, tenderness, redness, or local warmth,
– deliberate opening of the surgical wound by the surgeon, except when there are no microorganisms in the incision,
– diagnosis of SSI-S from a doctor;
• deep SSI (SSI-D) can be diagnosed when an infection appears within 30 days of an operation that did not involve implantation of artificial elements, and if an implant is implanted, it is up to 90 days following the operation. If the implant is kept, and the infection is associated with the surgery and affects deeply located soft tissues (muscles and fascia), at the incision site, and meets one of the following conditions:
– the presence of purulent discharge from deep layers around the incision (but not from the organs or body cavities),
– spontaneous wound dehiscence or its deliberate opening by the surgeon, if at least one of the following symptoms occurs: fever (> 38oC), local pain, or tenderness, unless a negative culture is obtained,
– the presence of an abscess or other symptoms of infection demonstrated during a physical examination, re-surgery, whether confirmed by the results of histopathological or radiological examinations,
– diagnosis of SSI-D from a doctor;
• organ/space SSI (SSI-O) appears within 30 days of the operation if an artificial implant was not implanted or within 90 days if a biomaterial was implanted during the operation and the infection may be associated with the surgery performed and includes any anatomical site other than the area of the incision of the integuments and the site that was opened or compromised during the operation, where at least one of the following circumstances is true:
– purulent discharge from the drain inserted through a puncture wound into an organ or body cavity,
– isolation of a microorganism from the culture of fluid or tissues from body cavities or an organ carried out under aseptic conditions,
– the presence of an abscess or other clinical signs of an organ/cavity infection, found in the course of a physical examination, re-surgery, or in histopathological or imaging examinations,
– diagnosis of SSI-O from a doctor.

HAND HYGIENE
One of the most important, and at the same time the simplest, SSI prevention procedures is hand hygiene. In 2009, the World Health Organization (WHO) [20] issued recommendations that include all the components of hygiene: preparation of hands, indications for washing and disinfection, proper decontamination techniques, proper selection of preparations for hand washing and disinfection, proper use of protective gloves as well as education and supervision of compliance with hand hygiene. It is recommended that hands are disinfected with an alcohol-based agent, which is held in higher regard than washing hands with soap and water, except for when there is visible contamination of hands that have been exposed to biological material, or after contact with a patient suspected of or diagnosed with the presence of spore-forming microorganisms, e.g. Clostridium difficile. The next significant element of hand hygiene is the bare below the elbow principle, which aims at preventing the transmission of microorganisms found on white coats, under jewellery, or on watches and bracelets. It is also recommended to have natural nails with length of up to 0.5 cm. The hand hygiene procedures recommended by the WHO involve 5 indications (moments) related to the provision of health services, and these are: before and after touching a patient, before clean procedure, after body fluid exposure (dirty procedure), and after touching patient surroundings. For proper hand decontamination, Ayliffe’s 6-step technique should be employed, in which the sequence of steps and the number of repetitions are of importance. The use of protective gloves is an important aspect. The WHO recommends their use in the situations when one expects to come into contact with blood or another biological material, damaged skin, or mucous membrane. Hands should be disinfected before putting on the gloves and after taking them off. Gloves should be changed or removed when moving from one dirty procedure to another [20].

PREVENTION OF SURGICAL SITE INFECTIONS IN ORTHOPAEDIC SURGERIES
For many years, attempts have been made to develop a single standard of care as regards the prevention of SSI. In the literature, there are many recommendations concerning this topic, and these have developed over the years, depending on the country, the facility, or the surgical procedure carried out. Even though there are still no clear international standards or recommendations and there is an ongoing discussion on this subject, the literature indicates comparable recommendations from WHO, Centres for Disease Control and Prevention (CDC), or the National Institute for Health and Care Excellence (NICE) and from other institutions, and these recommendations are constantly being updated.
Table 1 lists the recommendations of individual organizations regarding the prevention of SSI in orthopaedic surgery [21-33].

PERIOPERATIVE ANTIBIOTIC PROPHYLAXIS IN ORTHOPAEDIC SURGERY
Perioperative antibiotic prophylaxis (PAP) is one of the more significant elements of SSI prevention, which is generally applied in clean procedures with the insertion of an implant or in clean-contaminated procedures, which should not be confused with dirty procedures, in which antibiotic therapy is used. PAP consists of short-term administration of an antibiotic to the operated patient before the skin incision to reduce intraoperative microbial contamination to a level at which the body can fight the infection. The choice of antibiotic is dependent on the type of procedure and risk factors; the time of antibiotic administration depends on its half-life; and the duration of using it in PAP depends on the procedure type. In Table 2, recommendations concerning PAP in orthopaedic surgery from selected institutions are summarized. The individual recommendations do not vary as regards the recommendations to administer an additional intraoperative dose if the procedure time is extended or there is a significant blood loss, or if the procedure involves the implantation of joint prostheses [21, 22, 24, 25, 30, 34-39].
The literature review that was carried out points to the fact that due to the growing number of orthopaedic procedures requiring insertion of implants, an increased percentage of SSIs can be expected. These infections have a significant impact on the patients’ health. Although they cannot be completely eliminated, the use of SSI prophylaxis can substantially reduce the infection rate. Knowledge regarding the methods for SSI prevention should be popularized, and medical staff should be made aware of the consequences of developing infections. The recommendations mentioned in this study may become a vital factor in reducing the number of infections and their complications. An attempt was made to collect recommendations concerning the prevention of SSI from several medical institutions. It is necessary to put greater focus on SSI because perioperative antibiotic prophylaxis, asepsis, and antiseptics do not solve the problem of infections. The recommendations presented in this study will allow to the patient to be reliably prepared for surgery and the course of the procedure to be optimized, improving patient safety and the quality of postoperative care, and reducing the percentage of SSIs in orthopaedic surgeries.
In the presented work, the recommendations of individual organizations may differ from each other due to the method of identifying priority topics, asked questions, perception of critical points, research methodology, and the method of obtaining evidence. Global SSI oversight aims to standardize recommendations with proven effectiveness. The issued recommendations should be universal, innovative, and applicable in countries supervising SSI [21]. The application of these recommendations is not obligatory; however, it is expected that they are implemented according to the patient’s needs and the possibility of their implementation in a given country [22, 40]. In line with the recommendations of the WHO and the European Commission, each country should have a developed HAI control strategy, including a strategy for SSI supervision at the national level. In Poland, however, there is no opinion-forming centre operating in the area of HAI prophylaxis [41]. One of the tasks of such a centre could be SSI prophylaxis, e.g. in the field of HPRO and KPRO, and others, such as staff hand hygiene and drug resistance monitoring [19, 41]. Centres of this type, which exist in other European countries, are expected to issue opinions on recommendations using the GRADE methodology (Grading of Recommendations Assessment, Development, and Evaluation), which can be implemented by consensus with individual organizations and associations. One of the most important documents on which the HAI supervision system in Poland is based are the recommendations of the Council of the European Union of 2009, which only set out general principles of the system’s operation [42]. In Poland, as in other European Union (EU) countries, there is a differentiated approach to SSI monitoring, prevention programs, and personnel competences. ECDC is also attempting to standardize SSI control methods for certain orthopaedic procedures such as KRRO and HPRO in European countries [41]. As a result of the activities of ECDC, the HAI-Net (Healthcare-Associated Infections Surveillance Network), EARS-Net (European Antimicrobial Resistance Surveillance Network), and ESAC-Net (European Surveillance of Antimicrobial Consumption Network) networks were created for the EU countries [19, 41].
In Poland, since 1989, attempts have been made to organize the supervision of HAI, but it was not until 2001 that the first legal acts introduced the definition of HAI and systematized the practice of control. Despite the passage of many years, the passive system of HAI supervision is still dominant in Polish hospitals, the consequence of which is the lack of data necessary for the analysis and conclusions in the field of SSI prophylaxis [41, 43, 44]. The Infection Control Teams operating in Polish hospitals have a statutory obligation to develop and update HAI prophylaxis procedures in accordance with the current knowledge, but they rarely receive systemic support in the form of knowledge based on evidence-based medicine (EBM). It seems that the establishment in Poland of a consultative and advisory organizational unit with legal personality, supervised by the minister competent for health, could facilitate the activities of the healthcare management. This organization should evaluate scientific publications and the latest medical technologies in a repeatable, transparent manner, according to a defined methodological standard and based on scientific evidence in accordance with the EBM. However, until such an opinion-forming organization is established, efforts should be made to publish illustrative works by scientists attempting to conduct literature reviews such as this work.

Disclosure

The authors declare no conflict of interest.

References