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Controlling Patient Risk Factors or Antibiotics

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Controlling Patient Risk Factors or Antibiotics: Which Should Be the Primary Method of Surgical Site Infection Prevention?
Jessica CassaveccaUniversity of Rochester School of Nursing
Surgical site infections are a major issue facing healthcare today. They are characterized by redness, swelling, and tenderness around an incision site. According to Willem de Jonge et al. (2017) surgical site infections account for 21.8% of all hospital acquired infections. These infections lead to increased morbidity, mortality, readmission, and longer hospital stays. When a patient is readmitted due to a surgical site infection, insurance does not reimburse for that stay. Therefore, hospitals are looking for ways to prevent surgical site infections. Controlling patient risk factors such as hyperglycemia, skin asepsis, and normothermia can help prevent surgical site infections without the risk of creating multidrug resistant bacteria associated with antibiotic prophylactic therapy. Practitioners should consider controlling patient risk factors before they decide to use antibiotic prophylactic therapy.

A surgical site infection is defined by the Centers for Disease Control (2012) as “an infection that occurs after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material.” When a patient gets a surgical site infection, it increases overall health care costs. Studies have estimated this total cost to be between $8 million and $1.6 billion annually (Willem de Jonge et al., 2017; Jung et al., 2017). Because of this, healthcare facilities are constantly looking for ways to decrease healthcare costs and ensure optimal patient outcomes. There are a variety of different prevention methods in place including antibiotic prophylactic therapy and attempts to control patient’s modifiable risk factors. Modifiable risk factors are things a patient can change. These include things like managing hyperglycemia, proper skin asepsis, and maintaining normothermia.
Hyperglycemia is defined as having a fasting glucose greater than 130mg/dL or having a glucose greater than 180mg/dL two hours after eating (Hess-Fischel ; Gregg 2017). Hyperglycemia can be altered by a healthy diet, exercise, and medication. A healthy diet is considered one that is low in sugar and carbohydrates. Exercising twenty minutes or more per day is also recommended. There are various medications available to help control hyperglycemia. These options include short and long acting insulins, medications that stimulate the release of the body’s own insulin, and medications that help prevent the absorption of sugars. Controlling hyperglycemia in the perioperative area is important because studies have found that when uncontrolled, these patients are up to 4.71 times more likely to develop surgical site infections (Martin et al., 2016). Further research is being conducted on the topic as to why this is. It is possible that prolonged hyperglycemia is a risk factor for other comorbidities such as vascular anomalies, white blood cell abnormalities, and immune suppression (Martin et al., 2016). Hyperglycemia in the operating room increases a patient’s risk for surgical site infections 1.8 times (Martin et al., 2016). Overall, there are many ways to prevent hyperglycemia in the perioperative area. Care should be taken to do so in order to prevent surgical site infections.

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Skin asepsis is the removal of organisms from the skin to prevent infection. Patient skin asepsis is both a modifiable risk factor and a standard of perioperative care. A patient’s skin contains normal flora that has the potential to cause surgical site infections. There are numerous different types of surgical sin prep agents including chlorhexidine based, alcohol based, and povidone-iodine based. The most common prep is a chlorhexidine and alcohol-based prep. 2017 CDC guidelines suggest alcohol-based antiseptic agents unless contraindicated (Berrios-Torres et al., 2017). In certain procedures involving the mucosa, cornea, or areas dense in hair, alcohol is contraindicated (Anderson et al., 2014). It is contraindicated in these areas due to its caustic nature and potential fire hazard when pooled. When studies looked at chlorhexidine versus povidone-iodine prep when mixed with alcohol, they found that chlorhexidine had a longer residual activity time in the presence of blood (Anderson et al., 2014). This is especially important in surgery because there is often blood around the incision site, especially in orthopedic cases. Regardless of what type of surgical antiseptic prep is used for the procedure, it should be used in accordance with the manufacturers guidelines to achieve the best results.
Normothermia is defined as maintaining a core temperature range of 36.5? to 37.5? (Sessler, 2008). Perioperative hypothermia, or a core temperature below 36.5?, is a surgical site infection risk factor. Hypothermia is associated with delayed wound healing (Austin, 2017). This is due to vasoconstriction that does not allow blood and nutrients to flow properly through the body to start the healing process. Other effects of hypothermia include coagulation abnormalities, delayed anesthetic clearing, and the potential for prolonged hospitalization (Kellam, Deickmann, & Austin, 2013). It has been shown that nineteen percent of colorectal surgery patients and fourteen percent of breast surgery patients who were hypothermic developed a surgical site infection versus six percent and 5 percent, respectively, of those who were kept normothermic (Austin, 2017). While there are barriers to maintaining normothermia, clinicians should try to maintain a patient’s normothermia in the perioperative area to help prevent surgical site infections. Medical professionals should ensure that hyperglycemia, normothermia and skin asepsis are all properly managed before considering administering antibiotics.

Lending towards antibiotic prophylactic therapy as a primary means of surgical site infection prevention is that there is currently debate over the use of forced air warmers. Some say they push contaminants into the air and harbor pathogens. This claim has not been definitively proven, especially when the forced air warmer is used according to manufacturer guidelines (Kellam et al., 2013; Austin, 2017). There have been investigations that have looked into forced air warmers potentially creating air disturbances that encourage bacteria towards the surgical site using highly controlled simulations, but no definitive causal link could be established (Kellam et al., 2013). Another barrier to the use of forced air warmers may be cost. Each disposable blanket costs about six dollars in addition to the purchase of the machine itself. There are also some procedures where it may be difficult to place a forced air warmer blanket (Austin, 2017). In some vascular cases, the surgeons need access to a large area of the patient’s body, limiting where a forced air warmer blanket can be placed. There are also some specific surgical positionings that may also pose a challenge to the use of the forced air warmer blanket. However, other options are available to help maintain normothermia. Options include items like warm blankets, electric blankets, and passive insulation systems (Austin, 2017). These devices do not cause air disturbances and tend to be relatively low cost as well as are re-usable.
Antibiotic prophylactic therapy is the current standard of care for surgical site infection prevention. Many patients are prescribed prophylactic antibiotics for their surgical procedures. It is suggested that antibiotics be given within one hour before surgery and should not be given after incision (Anderson et al., 2014; Boyle & Duquin, 2018). This is done to make sure the antibiotics are at their peak effectiveness for incision. Antibiotic selection should be based on the most likely cause of infection for the procedure (Anderson et al., 2014). This helps to lessen the risk of causing multidrug resistant organisms.
Although targeted antibiotic therapy lessens the risk, antibiotic use still comes with the risk of creating multidrug resistant organisms where controlling patient risk factors does not. According to Boyle and Duquin (2018) the Centers for Disease Control estimates that between twenty to fifty percent of antibiotics used in the hospitals are unnecessary or inappropriate leading to drug resistant bacteria. Patient risk factors not being controlled is a barrier to the appropriate use of antibiotics. When patient risk factors are not controlled, antibiotics are not as effective. It is suggested to administer antibiotics within one hour of incision (Anderson et al., 2014). Low tissue concentration of antibiotic is associated with increased surgical site infection rates. Optimal timing of antibiotic administration varies depending on the specific antibiotic’s half-life and factoring in patient risk factors. When a patient is hyperglycemic, like many patients today, it creates an ideal breeding ground for bacteria that antibiotics alone cannot control. Failure to maintain normothermia causes perioperative hypothermia leading to vasoconstriction that decreases the antibiotic tissue perfusion in surgical patients, making them less effective. Proper skin asepsis kills infection causing bacteria on the skin. If proper skin asepsis is completed and all other risk factors are controlled it decreases the need for antibiotic use. These should all be factored in to and well controlled to ensure proper, if any, antibiotic administration.
Overall, there is less risk associated with control of patient risk factors than using antibiotics when it comes to surgical site infection prevention. Surgical site infections account for 21.8% of hospital acquired infections and cost hospitals anywhere from $1.6-3 billion annually (Martin et al., 2016; Jonge et al., 2017). Hyperglycemia is a modifiable risk factor that is becoming increasingly common and control helps mitigates some of this risk, Proper skin asepsis in accordance to manufacturer guidelines is also effective in prevention of surgical site infections. Hypothermia is a modifiable risk factor associated with increased surgical site infections. It can be easily modified by keeping the patient warm in the perioperative area with blankets, forced air warmers, or other devices. Controlling all these risk factors is an effective way to prevent infections without the risk of creating multidrug resistant organisms. Prevention of surgical site infections is a multifactorial issue that requires medical professionals to consider all a patient’s comorbidities and create an individualized prevention plan.

References
Anderson, D. J., Podgorny, K., Berrios-Torres, S. I., Bratzler, D. W., Dellinger, E. P., Green, L.,…Kaye, K. S. (2014). Strategies to prevent surgical site infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology; 35(2), 67-88.
Austin, P. N., (2017). Forced air warmers and surgical site infections in patients undergoing knee or hip arthroplasty. Annual Review of Nursing Research; 35(179), 179-199. dio: 10.1891/0739-6686.35.179.
Berrios-Torres, S. I., Umscheid, C. A., Bratzler, D. W., Leas, B., Stone, E. C., Kelz, R. R.,…Schecter, W.P., (2017). Centers for disease control and prevention guideline for the prevention of surgical site infections 2017. Jama Surgery Special Communication; 152(8), 784-791. doi: 10.1001/jamasurg.2017.0904.

De Jonge S. W., Gans, S. L., Atema, J. J., Solomkin, J. S., Dellinger, P. E., Boermeester, M. A. (2017). Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: A systematic review and meta-analysis. Medicine (Baltimore); 96(29), e6903. doi: 10.1097/MD.0000000000006903.

Hess-Fischel, A., & Gregg, B. (2017). Hyperglycemia: When your blood glucose levels go too high Self Help website. Retrieved from https://www.endocrineweb.com/conditions/hyperglycemia/hyperglycemia-when-your-blood-glucose-level-goes-too-high. Retrieved on 20 June 2018.
Jung P, Morris AJ, Zhu M, et al (2017). BMI is a key risk factor for early periprosthetic joint infection following total hip and knee arthroplasty. New Zealand Medical Journal; 130(1461), 24-34.

Kellam, M. D., Dieckmann, L. S., Austin, P N. (2013). Forced-air warming devices and the risk of surgical site infections. AORN Journal; 98, 356–366.

Martin, E., Kaye, K., Knott, C., Nguyen, H., Santarossa, M., Evans, R.,…Jaber, L. (2016). Diabetes and risk for surgical site infection: a systematic review and meta-analysis. Infection Control & Hospital Epidemiology; 37(1), 88-99. doi: 10.1017/ice.2015.249
Sessler D. I. (2008). Temperature monitoring and perioperative thermoregulation. Anesthesiology; 109(2), 318-338.
U. S. Department of Health and Human Services, Centers for Disease Control (2012). Surgical site infections. Retrieved from https://www.cdc.gov/hai/ssi/ssi.html. Retrieved on 20 June 2018.

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