Infection prevention


(non-CABG) (1.4%) and breast surgery (0.6%).3 The likelihood of contracting an SSI shows considerable variation depending on the type of surgical procedure. The highest risk was observed in bile duct, liver or pancreatic surgery at 15.4%, followed by cholecystectomy at 9.7%, then large bowel surgery at 8.6%. This is to be expected as these procedures are carried out in the gastrointestinal tract which hosts the highest levels of bacterial contamination. Hip and knee replacement surgery carried the lowest SSI risk (0.5% and 0.4%, respectively).3 However, an SSI could lead to a periprosthetic joint infection (PJI), a catastrophic and potentially life-threatening complication that is also associated with a significant financial burden.7


SSI impact on patients SSIs have a major impact on patients and are associated with poorer outcomes, affecting mortality and morbidity, as well as quality of life.8


Interestingly, although patient narrative


research has been utilised in many areas of healthcare to improve service delivery, little work has been done in the field of SSIs. Exploring patients’ experiences can provide useful insights, particularly as patients play an active role in managing and monitoring surgical sites. In a qualitative study, former patients from


three hospitals in England were interviewed to explore their experience of having an SSI. The findings revealed the extent of the distress caused by SSIs, with people describing feeling ‘utter despair’ and ‘wanting to die’. These symptoms continued for months after discharge from hospital.9 One positive outcome from this study, was the willingness of patients to undertake interventions to help prevent infections. Participants discussed using antiseptic washes to prevent MRSA infections, demonstrating a proactive attitude towards pre-operative washing.9


This


may be useful if there is wider adoption of decontamination before elective surgery.


SSI causative organisms According to the UKHSA, positive microbiology is not essential to meet the SSI case definition, if there are other clinical indicators which identify infection. However, there was microbiological confirmation in 76.8% of SSIs in 2021-2022 (a 12.6% increase from 2011-12, when 64.2% of causative microorganisms were identified).3 Enterobacterales made up the largest


proportion of causative organisms across all surgical categories for both superficial (33.1%) and deep (30.1%) SSIs. The most common Enterobacterales species was Escherichia coli.3 The second most prevalent causative


organism was Staphylococcus aureus (S. aureus) for both superficial and deep SSIs (18.6% and 19.7% respectively). The proportion of SSIs caused by methicillin-resistant Staphylococcus aureus (MRSA) and methicillin- sensitive Staphylococcus aureus (MSSA) both increased compared to the previous year.3 Colonisation with Staphylococcus is a


known risk factor for subsequently developing surgical site infection.7


This is significant as


between 25%-30% of the United Kingdom population is positive for skin or nasal carriage of Staphylococcus.7


Although most


people colonised with Staphylococcus are asymptomatic, it does present a higher risk of subsequent infection. This is particularly significant in patients undergoing knee replacement surgery where colonisation with S. aureus is reported to be a key risk factor for developing a surgical site infection.10


Antiseptic body washing The recent spread of antimicrobial resistance has restricted the use of systemic antibiotics, meaning topically applied antiseptics are important in effective infection prevention.11 Antiseptics are used to reduce the microbial load on a patient’s skin or mucosa to help prevent endogenous HCAIs.12


Pre-operative body washing


with an antiseptic to reduce the dermal bacterial burden, and thus reduce SSIs, is not a new concept. In some hospitals, for some surgical procedures, it has become standard practice, whereas in others it is hardly used at all. Updated NICE guideline (NG125)13


on ‘Surgical


site infections: prevention and treatment’, recognises the “considerable variability in practice. In some services, decolonisation is always offered before certain types of surgery, for example, before orthopaedic surgery. In other services decolonisation is offered only to people who are identified as methicillin- resistant S. aureus (MRSA) or Methicillin- sensitiveS. aureus(MSSA) carriers.”13


NICE’s own guidance is open to interpretation. It suggests that patients should be advised to have a shower, bath or bed bath using soap either the day before or on the day of surgery. This advice is then qualified by suggesting the use of a body wash and intranasal product “before procedures in which S. aureus is a likely cause of a surgical site infection.” In essence, NICE guidance leaves the decision


to local Trusts “to consider decolonisation for people who are likely to benefit the most.” However, it is worth noting that NICE does recognise that pre-operative decontamination “may reduce surgical site infections” and that there is evidence to suggest that “any additional costs incurred…are likely to be more than recouped by savings associated with a lower incidence of surgical site infections.” In practice this means that Trusts are free to set their own policies and procedures. There is a body of published evidence to support pre-operative decontamination, which has been demonstrated to be effective at reducing infection rates.7


Some evidence is


considered here. Tanner et al published a study in 2012 which showed that pre-operative body washing products are more effective than soap in reducing colony forming units on the skin of healthy volunteers, leading to the conclusion “that body washing could have an effect on surgical site infections.”14 In patients undergoing cardiothoracic or orthopaedic surgery, screening for S. aureus nasal carriage and decontaminating carriers resulted in a substantial reduction in hospital costs. This approach resulted in a cost saving of almost £3,000 per cardiothoracic patient, compared to the non-screened and non-treated patients.15 An interventional cohort study assessed the efficacy of decontamination in reducing MRSA rates. At baseline, MRSA was detected in 25 of the 126 patients screened (19.8%) and decontamination reduced MRSA carriage by 93.3%.16


In a large, randomised multicentre


trial, the risk of developing hospital-associated S.aureus infection in MSSA-carrier patients who ‘were decolonised on admission to hospital fell by nearly 60% compared with placebo’.17 A recent study investigated the contribution


of a screening and five-day decontamination protocol prior to hip or knee arthroplasty in reducing the incidence of S. aureus joint infections. No S. aureus infections were observed among decontaminated patients even though they were all previously colonised with S. aureus. Due to the additional resources required for universal screening, the researchers concluded that a universal decontamination programme without initial


July 2023 I www.clinicalservicesjournal.com 33


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