Infection prevention


and to avoid overuse/misuse. Prof. Leaper went on to tackle the misconception that SSI is just about the surgeon’s ‘skill’. In the UK, there is now a focus on prehabilitation/ optimisation prior to surgery, Getting it Right First Time (GIRFT), Enhanced Recovery After Surgery (ERAS), and a move towards day case surgery. Important patient optimisation factors to


reduce the risk of SSI include: l Weight loss in obese patients (with a BMI greater than 30).


l Optimisation/management of diabetes. l Optimisation of nutrition prior to surgery. l Smoking cessation and optimisation of chronic obstructive airways disease (COPD).


“This makes a huge difference to outcomes,” he asserted. Prof. Leaper went on to discuss the


categorisation of surgical wounds. The US Centers for Disease Control’s definition of SSI (shown below), is most commonly used: l Reported by a surgeon (!) l 30 days (1 year prosthetics) l Purulent discharge or abscess l Isolated organisms l 1+ Celsian signs l Wound separation or need for drainage


“The definition is around 30 years old and


needs revisiting,” said Prof. Leaper. In particular, he thinks the premise of SSI


being ‘reported by a surgeon’ is especially problematic. In addition, presentation at 30 days or one year for prosthetics is “probably not long enough for surveillance”, while not all SSIs have a “purulent discharge”, he commented.


One of the challenges around gaining an


accurate picture of the true rates of SSI is the fact that patients are often treated as day cases; if there is an infection, it is likely to materialise after the patient has left the hospital. Consequently, many SSIs go unreported in the national statistics. Despite the burden placed on primary care, clinicians in this setting are not always trained to recognise or optimally treat SSIs. However, the impact on the acute sector is also significant – SSIs can lead to increased length of hospital stay (7–10 days), as well as doubled mortality, while patients with an SSI are 60% more likely to spend time in the intensive care unit and five times more likely to be readmitted. The cost for healthcare providers is generally


reported to be around $400+ [£346+] for a superficial incisional infection, to $50,000+ [£43,305+] for an organ/deep space SSI. However, there are also indirect costs to the patient and their family, which need consideration, such as the loss of productivity and functional capacity. Prof. Leaper emphasised that superficial SSIs are common and, although they may be ‘superficial’, they still cause problems for patients – including delaying their return to work, for example. Prof. Leaper went on to highlight some


research which calculated the ‘real-world economic cost of SSIs after colorectal surgery’. This included analysis of databases for IBM MarketScan, Medicaid and Medicare, and involved a total of 107,665 patients, between 2014-2018. The study revealed a 24% SSI rate – yet


only three-quarters were recognised by eight weeks. The true cost of SSI was calculated to


be >$100,000 [>£86,598] for deep incisional/ organ space SSIs at 6 months, with accurate surveillance.1


Surveillance of SSI is an integral


part of organisational infection prevention and control activities, but unless post-discharge surveillance is carried out in a robust manner, the data may be inaccurate and misleading. As part of a paper, co-authored with Judith Tanner and Martin Kiernan, Prof. Leaper called for more accurate definitions and intensive recording. Outpatient reviews, questionnaires, telephone follow-up, patient diaries (patient reported outcome measures) and patient surveillance using mobile phones are just some of the tools that can be utilised. While accurate post- discharge surveillance methodology is critical, it is also costly and requires investment, he commented.2 Other key areas for discussion included the ongoing challenges around wound definitions. Prof. Leaper showed a number of wound images and invited the audience to consider “is it an SSI or dehiscence?” For example, the wound may have broken down, but what if the swab shows there is no microbiological growth? He pointed out that the breakdown of the wound may be due to dehiscence and not SSI. Therefore, a better term is required, in his view, such as “surgical site outcome” or “wound complication”. An important message from Prof. Leaper’s


presentation was the fact that it takes significantly lower levels of microorganisms to develop an SSI when an implanted prosthesis is involved. When a biofilm forms on the prosthetic, the infection can prove especially challenging – “persister cells” in established biofilm resist the host-defences, antibiotics, and antiseptics, but still provoke inappropriate inflammatory responses. He went on to highlight guidelines for SSI prevention, including those published by WHO and NICE, as well as explaining the various levels of evidence quality available. Level one evidence (i.e. best quality) includes patient warming (64% reduction in SSIs), use of 2% Chlorhexidine gluconate in 70% Isopropyl alcohol for preoperative skin preparation, clipping of hair and not shaving, administering prophylactic antibiotics within 60 minutes of incision, perioperative glucose control, and use of (antimicrobial) Plus Sutures for wound closure when absorbable sutures are appropriate. It is worth noting that NICE also concludes, in its Medical Technologies Guidance (2021), that Plus Sutures achieve a cost saving by an average of £13.62 per patient, following a reduction in SSI. Ultimately, NICE supports the “pooling of best


practice into care bundles” and the efficacy of this approach is well supported by the evidence.3 “Care bundles really work,” Prof. Leaper


concluded. 34 www.clinicalservicesjournal.com I February 2023


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