Win The Battle Against Postoperative Infections

Author(s): 
By Stacey Stefansky, DPM, Thanh L. Dinh, DPM, and Barry Rosenblum, DPM

Despite advances in aseptic technique and antibiotic prophylaxis, post-operative infections remain a significant complication following podiatric surgery. Postoperative infections can increase morbidity, lengthen recuperation time and compromise the success of a surgical procedure. Data collected by the Centers for Disease Control and Prevention (CDC) estimate that postoperative infections occur in 2.1 percent of all clean, uncontaminated surgical procedures.1
Studies pertaining specifically to podiatric surgery have produced comparable postoperative infection rates. Hugar, et. al., demonstrated a 1.35 percent infection rate following outpatient foot surgery.2 Miller, et. al., reported a 2.2 percent infection rate following inpatient surgery on 1,841 patients.3

What Are The Risk Factors?
Risk factors for postoperative infections can be categorized into host defenses and contamination through the surgical environment. Appropriate patient selection and adherence to proper sterile technique can potentially minimize the risk of infection.
Certain systemic conditions such as diabetes, peripheral vascular disease and malnourishment have been found to increase the risk of infection.4 Additionally, obesity and advanced age have been shown to increase the risk of postoperative infection.5

Factors influencing contamination of the surgical wound include human activity in the operating room, length of the procedure, draping technique and a break in sterile technique. Excessive movement by non-scrubbed personnel in the operating room accounts for most of the microorganisms in the air. Furthermore, it has been demonstrated that the rate of infection increases two-fold with every hour of operating time.5

Key Prevention Pointers
In addition to appropriate patient selection and maintaining sterile technique, you can prevent postoperative infections with prophylactic
antibiotics. When using prophylactic antibiotics, consider two important guidelines. First, you should direct the antibiotic against the most likely organism to cause an infection in that particular case. Secondly, you should achieve maximal antibiotic levels at the time you make the surgical incision.6
In order to adhere to these guidelines, infuse the antibiotic at least 30 minutes prior to making the surgical incision. There is no evidence that postoperative doses of antibiotic are necessary.7 If you’re going to use a tourniquet, administer the antibiotic prior to inflation of the cuff. Otherwise, inadequate antibiotic levels in the tissue will result.8
Antibiotic prophylaxis is recommended in certain situations in podiatric surgery. These situations include trauma surgery, prolonged surgery, when you’re using an implant and when you’re operating on immunocompromised patients.
There is some debate as to whether patients with damaged heart valves or diagnosed heart murmurs should be prophylaxed for podiatric surgery. In clean podiatric surgery, there is no evidence of significant bacteremia.9 However, patients undergoing incision and drainage of abscesses have been shown to develop bacteremia, primarily from manipulation of the infected skin. In this particular instance, you should use prophylaxis antibiotics.

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