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.
What is your protocol on hand hygiene between patients?
As for hand scrubs, Dr. Suzuki follows the hand hygiene guide from the Centers for Disease Control and Prevention. He uses antibacterial chlorhexidine soap scrubs for the hands in the morning or for the first case of the day. Dr. Suzuki follows this with alcohol hand gel for the subsequent cases or when entering and exiting the patient’s room in the hospital, or in the wound care center. Before applying gloves to treat the first patient, Dr. Bell always washes his hands and uses a hand sanitizer, either alcohol or iodine-based. He repeats this process immediately after seeing patients.
In between patients, Dr. Bell always washes his hands thoroughly. Likewise, between surgeries, Dr. Armstrong will use a gel prep.
As for hospital or long-term facility patients, before starting any patient contact, Dr. Bell uses a hand sanitizer as soon as he can find the nearest dispenser. Dr. Suzuki’s facility has a Purell dispenser outside each patient’s room, noting there is no excuse for staff not to use them.
“Since the hospitals are held accountable by the CMS for hospital-acquired infection these days, I’ve seen people written up for not complying with this hand hygiene protocol,” says Dr. Suzuki.
At the end of the day, Dr. Bell will repeat the washing and hand sanitizing ritual.
“It becomes second nature and sometimes feels a bit obsessive-compulsive, but you must do all you can to prevent from being the transmitter of bacteria between patients, your family and yourself,” emphasizes Dr. Bell.
Which solutions and devices do you use for wound irrigation and cleansing?
Dr. Suzuki and Dr. Bell use normal sterile saline. Dr. Suzuki will use saline in a 30 mL plastic container (Saljet Rinse, Winchester Laboratories). He calls this “a nice alternative” to a syringe and a big 500 mL saline bottle, saying the larger bottle can be cumbersome and possibly cross-contaminated if one is using the same bottle on more than one patient.
If his patients are changing their dressings at home, Dr. Suzuki encourages them to use tap water to irrigate the wound unless they have deep wounds that penetrate into bone or joints. He cites studies that drinkable, municipal tap water is clean enough for wound irrigation, and tap water does not increase the infection rate any more than using a sterile saline bottle, a prescription item that may be costly to some patients.3
In regard to irrigation in the OR, Dr. Bell says sometimes a bulb syringe is adequate but in many instances in which a deep infection is present, he most often uses pulsed lavage.
Dr. Armstrong uses Pulsavac (Zimmer) and Versajet (Smith and Nephew) for nearly all cases. If one uses the Versajet deftly, Dr. Armstrong says it can be enormously helpful in debulking flaps, removing non-viable tissue cleanly and preparing wounds for split thickness skin grafts. Dr. Bell has also found the Versajet to be an exceptional way to debride and clean wounds in the OR, where significant necrotic tissue is present. He also cites significant time savings in using the device.
Dr. Suzuki uses the Qoustic Wound Therapy System (Arobella Medical), a 35 kHz ultrasound debridement device that uses a bag of sterile normal saline (0.9% sodium chloride solution).4 He notes this device can achieve “excellent” wound cleansing and debridement as well as physically destroying the wound surface bacteria.
Dr. Armstrong is a Professor of Surgery at the University of Arizona College of Medicine in Tucson, Ariz. He is the Director of the Southern Arizona Limb Salvage Alliance (SALSA).
Dr. Bell is a board certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.
1. Lee I, Agarwal RK, Lee BY, et al. Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection. Infect Control Hosp Epidemiol. 2010; 31(12):1219-29.
2. Zgonis T. The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery. J Foot Ankle Surg. 2004; 43(2):97-103.
3. Conner-Kerr T, Alston G, Stovall A, et al. The effects of low-frequency ultrasound (35 kHz) on Methicillin-resistant Staphylococcus aureus (MRSA) in vitro. Ostomy Wound Management. 2010; 56(5):32–42.
4. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database of Systematic Reviews. 2008; Jan 23(1):CD003861.