A Simple Intervention that Can Reduce Surgical Site Infections

Doctor in consultation for non-cosmetic surgery.

A Simple Intervention that Can Reduce Surgical Site Infections

A multi­center study led by infection control experts with the University of Iowa Health Care has found that surgical­site infections (SSIs) can drastically be reduced by up to 40% with a series of simple interventions.

The study, published in the Journal for the American Medical Association (JAMA) tested the effectiveness of lowering SSIs in patients suffering from Staphylococcus aureus (staph) bacteria after undergoing heart surgery or hip or knee replacement procedures.

Approximately one in three people have staph bacteria inside their noses, and so the interventions included screening patients for the presence of staph bacteria in their noses; and instructing patients who tested positive to apply an antibiotic ointment in their noses and bathe with an antimicrobial wash for up to five days before the surgery. All patients received appropriately targeted antibiotics just before surgery, and patients who tested positive for methicillin­resistant S. aureus (MRSA) received vancomycin and cefazolin or cefuroxime, while all other patients received cefazolin or cefuroxime only.

If these bacteria get into a surgical incision they can cause a severe infection, which can have serious health and financial consequences, and can cause potentially life­threatening complications.

Twenty hospitals in nine U.S. states participated in the study, and rates of SSIs were collected for a median of 39 months during the pre­intervention period and a median of 21 months during the intervention period.

The study found that 101 complex staph SSIs occurred after 28,218 operations during the pre-intervention period and 29 occurred after 14,316 operations during the intervention period. The rates of complex staph SSIs decreased for hip or knee replacement by 17 for every 10,000 operations, and by six for every 10,000 heart operations.

The intervention strategy was developed by the UI physicians based on a review of 39 studies of various surgical­site infection practices employed at hospitals nationwide.

This new study tested the effectiveness of the bundled intervention by implementing it systematically in a multi­center study. The significant effect on SSI rates was found despite the fact that a number of factors could have lowered the likelihood that the researchers would observe a strong effect.

Loreen Herwaldt, a UI professor of internal medicine, director of epidemiology at UI Hospitals and Clinics, and senior author on the study stated that “”Patients undergoing total hip or knee replacements and cardiac operations should be tested to see if they carry the staph bacteria in their noses. If they do carry the staph bacteria, the protocol we describe in the paper can lower their risk of a serious staph infection by about 40 percent.”

“We did this study in a hospital system that already had low rates of serious S. aureus SSIs and that had already implemented parts of the bundle” she explains that “in addition, we did it under real­life conditions rather than the best case conditions of a randomized clinical trial, and we included patients getting urgent or emergency surgeries who would not normally be included in a randomized clinical trial. All these factors were biasing us away from finding a significant decrease—but we did find one.”

Following a three­month phase­in period, full adherence to the bundle of interventions was 39% and partial adherence was 44%. SSI rates for patients who did not adhere to the protocol did not experience a drop in SSI rates, though for patients who followed the protocol completely, there was a significant decrease in the rate of SSI caused by staph compared with the pre-intervention period.

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