Minimizing The Risk Of Perioperative Infection In Patients With Wounds
Given the delicate nature of the wound environment, one must be vigilant in reducing the incidence of perioperative infection. Accordingly, these expert panelists discuss skin preparation before surgery, the use of prophylactic antibiotics, hand hygiene protocol and wound irrigation techniques.
What do you use for skin preparation prior to foot and ankle surgery?
Desmond Bell, DPM, CWS, notes povidone-iodine (Betadine) is the main skin prep that his hospital uses. However, if the patient is allergic to iodine, Dr. Bell will use a chlorhexidine scrub such as Hibiclens (Molnlycke). David G. Armstrong, DPM, MD, PhD, also uses chlorhexidine.
Kazu Suzuki, DPM, CWS, notes that his institution removed all Betadine skin preparation products in favor of chlorhexidine. He cites “a convincing set of data,” based on the systemic review of nine randomized, controlled trials, that chlorhexidine significantly reduced the risk of surgical site infections in comparison to iodine.1 Furthermore, the research notes the lower rate of surgical site infections is estimated to provide $350,000 to $570,000 savings annually to the hospital.
Do you routinely prescribe prophylactic antibiotics before foot and ankle surgeries? Do you use triple antibiotic solution in your surgical irrigation solution?
Dr. Armstrong uses prophylactic antibiotics before surgery and also uses a triple antibiotic solution.
“While we have learned for some time that ‘The solution to pollution is dilution,’ we still typically use antibiotics in our irrigant. I often ask, though, if we are treating ourselves or if we are treating the patient,” he muses.
Dr. Suzuki does not believe that clean orthopedic foot and ankle surgery would benefit from prophylactic antibiotic administration in reducing post-op wound infections.
“Having said that, I am afraid it has already become a ‘community standard-of-care’ to give a gram of cefazolin or vancomycin prior to the surgical procedure,” notes Dr. Suzuki.
He cites a retrospective study in 2004 regarding the use of prophylactic antibiotic administration for elective foot and ankle surgeries that did not show any benefit.2
Dr. Bell prefers to avoid using antibiotics unless necessary. Noting that there is “nothing routine” about any of his patients, he says most have diabetes and one must keep their renal function in mind at all times as well as the potential for antibiotic resistance issues. Most of the patients Dr. Bell sees as consults have active infection present so they are often already taking antibiotics. When he was performing more elective surgery, Dr. Bell would only prescribe antibiotics afterward in cases in which a concern had arisen regarding an impending skin infection.
In the OR, Dr. Bell regularly uses either a double or triple antibiotic solution. This is due to the fact that most of his surgical patients have either infected or grossly contaminated wounds, whether the etiology is a diabetic foot ulcer or a chronic leg wound.
When irrigating infected wounds, Dr. Bell prefers using a triple antibiotic solution of gentamicin-clindamycin-polymyxin, which also helps manage the bacterial burden and biofilm of many chronic wounds that may not present as clinically infected. He prefers to saturate an alginate with the gentamicin-clindamycin-polymyxin solution and apply it to the wound.
“This protocol has been very successful in our practice and we use it to help with wound bed preparation prior to skin substitutes, or in wounds that have stalled,” says Dr. Bell.
Dr. Suzuki prefers not to use triple antibiotics in his surgical irrigation solution. He says he is not aware of any clinical study indicating that the use of a triple antibiotic reduces the infection rate at all.