Keys To Managing Postoperative Wound Infections

Ryan Fitzgerald, DPM, FACFAS

   Researchers have also demonstrated that preoperative skin preparation reduces the incidence of surgical site infections.28 Physicians should ensure preoperative skin antisepsis for the patient in order to reduce the risk of postoperative infection. The operation site must be well disinfected before incision. Alcoholic solutions containing long-acting skin disinfectants, such as chlorhexidine or povidone iodine, are preferred in this application.28 The use of such disinfectants with greater than 40% alcohol content, however, increases the risk of burns to the patient during diathermy.30 Bibbo and colleagues demonstrated in a prospective randomized study that chlorhexidine and alcohol were superior to povidone iodine solution in foot and ankle surgery.31 One should apply the antiseptic with friction well beyond the operation site as part of the standard preparation prior to incision, and one should allow the area to dry before operating.

   In conjunction with preparation of the surgical site, it is necessary that the surgeon prepare as well. The antiseptic utilized for the surgical scrub is also vitally important in the reduction of surgical site infections. Recent studies have shown that a scrub-less aqueous alcohol hand rub is as effective as povidone iodine and chlorhexidine gluconate scrub.32 A scrub-less technique may improve surgeon adherence and enhance the overall effectiveness of the surgeon’s preoperative scrub. If the surgeon prefers a more traditional scrub, the scrub should last at least two minutes as this is the minimum time required for iodine to be effective.

   Researchers have also identified operating room ventilation as a potential source for the development of surgical site infections. Therefore, in high-risk cases, such as cases involving implantation of total joints, laminar flow systems (airflow 0.5 m/s) that deliver about 300 air changes per hour can be helpful in maintaining positive pressure.33

What You Should Know About Common Pathogens In Surgical Site Infections

Common pathogens for surgical site infections vary somewhat based upon the nature of the procedure one is performing. In those instances of surgical site infections following clean orthopedic procedures, normal skin flora pathogens, such as Staphylococcus aureus and Streptococcus, are the most common offending organisms.19,34-36 Surgical site infections following other types of surgery can demonstrate more of a polymicrobial environment at the infection site. Virulence and pathogenicity are major factors in the development of infection. Different bacteria are known to be more or less invasive, and it is these properties that will make them more likely to be the underlying pathogen in a surgical site infection.

   Furthermore, the emerging number of multidrug-resistant strains of bacteria has made the management of surgical site infections increasingly difficult, and the consequences for untreated or undertreated surgical site infections can be devastating. It is important that clinicians appropriately recognize those patients who are at-risk to potentially reduce the incidence of multi-drug resistant, infection-related morbidities. The risk factors for methicillin resistant Staphylococcus aureus (MRSA) infections include recent previous hospitalization, nursing home residence, prior antibiotic usage and intravenous drug use.37,38 The most important risk factor, however, is a previous history of MRSA infection and one should obtain a thorough patient history as part of the preoperative workup to assess for potential MRSA risk factors.38

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