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PATIENT SAFETY FIRST

Prevention of Surgical Site Infection: Beyond SCIP DEVERICK J. ANDERSON, MD, MPH

S urgical site infections (SSIs) are a leading

cause of patient morbidity and mortality.

Each SSI that occurs is associated with

approximately seven to 10 additional postoperative

hospital days, 1,2

and patients with SSIs have a two

to 11 times higher risk of death compared with

surgical patients without SSIs. 3,4

Surgical site in-

fections have now emerged as the most common

and most costly cause of health careeassociated

infection. 5,6

Thus, hospitals and health care pro-

viders must constantly pursue and improve adher-

ence with evidence-based strategies for preventing

these devastating infections.

Several core SSI prevention strategies have been

promoted by the Surgical Care Improvement Project

(SCIP), including the appropriate choice and tim-

ing of antimicrobial prophylaxis, avoiding shaving

surgical site hair, maintaining perioperative patient

normothermia, and controlling perioperative blood

glucose. 7 During the past decade, many, if not most,

providers associated with quality-improvement

and surgical-improvement programs in the United

States have become familiar with the SCIP rec-

ommendations. In fact, health care providers are

placing great effort on improving staff member

compliance with these recommendations because

rates of performance on SCIP measures now affect

hospital payment under the Centers for Medicare

and Medicaid Services Value-Based Purchasing

Program. 8,9

Compliance with some of the SCIP

recommendations is now close to 100%; thus,

some of these quality measures have been retired

(eg, avoiding surgical site hair shaving).

If hospitals are near 100% compliance with some

of the basic SCIP recommendations, yet SSIs still

occur and harm patients, the question then becomes,

“What else can be done?” This column will sum-

marize several additional evidence-based strategies

that go beyond SCIP recommendations to prevent

SSIs: optimizing antimicrobial prophylaxis dosing,

preparing the colon with mechanical bowel prep-

aration and oral antibiotics, optimizing tissue

oxygenation, and using a surgical safety checklist.

OPTIMIZE ANTIMICROBIAL PROPHYLAXIS DOSING

Ideally, the concentration of antibiotic in the pa-

tient’s tissue should be at its highest at the time of

incision, the time when pathogenic organisms are

most likely to be introduced into the surgical field.

This ideal is, in fact, a central tenet behind the SCIP

recommendation to administer the antimicrobial

prophylaxis within 60 minutes of incision for most

medications. Additionally, for an average patient,

weighing 70 kg, during an average procedure of

three hours or less, administration of the antibi-

otic within 60 minutes of incision ensures that the

concentration of the antibiotic remains above the

threshold needed to reduce the risk of infection

during the procedure.

The relationship between the administration

of antimicrobial prophylaxis and effectiveness in

The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact

Sharon A. McNamara, column coordinator, by sending topic ideas to [email protected].

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� AORN, Inc, 2014 February 2014 Vol 99 No 2 � AORN Journal j 315

reducing the risk of SSI can be conceptualized as

a gas tank for a vehicle. That is, a driver “fills up

the tank” of a vehicle

at the beginning of a

trip (ie, the time of

incision) and the gas

tank’s level slowly

decreases over time

until, eventually, the

vehicle runs out of gas

or, in the case of surgical patients, enough antimi-

crobial concentration to prevent an SSI. In other

words, standard dosing strategies ensure that there

is enough antibiotic coverage (or gas in the tank) to

safely make it through an average procedure for the

average patient. Two specific scenarios, however,

lead to risky situations in which there is inadequate

antibiotic coverage: surgery on patients who are

obese, and prolonged surgery. Thus, two additional

approaches are needed to optimize antimicrobial

prophylaxis in certain patients and procedures.

Weight-based Dosing of Perioperative Antibiotics

For several reasons, obesity increases the risk of

SSI twofold to sevenfold compared with healthy

weight. 10-12

Adipose tissue is poorly vascularized,

and, as a result, patients who are obese typically

have decreased tissue oxygenation. 13,14

Because

of this, lower concentrations of antibiotic in the

blood and other tissues occur. 15,16

Surgery for

patients who are obese also is technically chal-

lenging and creation of dead space (ie, an actual

or potential cavity remaining after the closure of an

incision that is not obliterated by operative tech-

nique) regularly occurs. Finally, typical doses of

antimicrobial prophylaxis are not adequate to “fill

up the tank” in patients who are obese because the

volume of distribution is larger.

To address these issues, the most easily mod-

ifiable strategy is to adjust antimicrobial prophy-

laxis dosing based on patient weight. 17

This

strategy effectively “tops off” the tank. For ex-

ample, health care providers should increase

antimicrobial prophylaxis to 2 g of cefazolin for

patients weighing � 80 kg and 3 g for patients weighing �120 kg.18 Providers should ad-

minister vancomy-

cin at 15 mg/kg and

gentamicin at 5 mg/kg.

For patients who are

morbidly obese and

who are receiving

gentamicin, the weight used for dose calculation

should be the patient’s ideal weight plus 40% of

their excess weight. Additional weight-based dos-

ing recommendations can be found in the recently

published “Clinical practice guidelines for antimi-

crobial prophylaxis in surgery.” 18

Re-dose Prophylactic Antimicrobials During Long Procedures

Surgical time correlates with the risk of infection:

the longer the operative time, the higher the risk

of SSI. In a multicenter prospective trial of 4,700

patients undergoing abdominal surgery, the risk of

SSI was 6.3% for procedures lasting less than 60

minutes, 12.2% for procedures between one and

two hours, and 28% for procedures lasting longer

than two hours. 19

As a result, health care providers

should re-dose prophylactic antimicrobials during

long procedures (ie, more than three hours). 18

This

strategy is analogous to a stop at a gas station on

a long trip. In one study of 801 patients undergoing

clean-contaminated procedures, patients with pro-

longed surgery (ie, more than three hours) had a

lower rate of SSI when they received a second

dose of cefazolin at approximately three hours

after incision time compared with patients who

did not receive a second dose (ie, risk of SSI was

1.3% versus 6.1%, P < .01).20

In general, health care providers should re-dose

prophylactic antibiotics at intervals of two half-

lives of the medication measured from the time

the preoperative dose was administered. For ex-

ample, the half-life of cefazolin is approximate-

ly 1.5 to two hours. Thus, cefazolin should be

In general, health care providers should re-dose prophylactic antibiotics at intervals of two half- lives of the medication measured from the time the preoperative dose was administered.

316 j AORN Journal

February 2014 Vol 99 No 2 PATIENT SAFETY FIRST

re-dosed every three to four hours during a long

procedure.

PREPARE THE COLON WITH MECHANICAL BOWEL PREPARATION AND ORAL ANTIBIOTICS

Historically, a great deal of controversy has colored

the use of mechanical bowel preparations (ie, using

laxatives to decrease the amount of stool in the

colon) before colorectal surgery. Many surgeons

thought the practice was unsafe, whereas other

surgeons thought it was standard of care. Some of

this controversy likely was generated because of

conflicting data in studies that used different types

of bowel preparations, some used oral antibiotics

and some did not. Af-

ter 70 years and more

than 180 randomized

trials, it is now clear

that mechanical bowel

preparation alone does

not reduce the risk

of SSI. 21,22

Instead,

analysis of the pre-

ponderance of data suggests that oral antibiotics

should be combined with parenteral antibiotics. 23,24

Thus, the most effective approach for mechanical

bowel preparation includes the use of a chemical

preparation (eg, polyethylene glycol) combined

with the administration of both oral and parenteral

antibiotics. 21,23-27

OPTIMIZE TISSUE OXYGENATION

Oxygen is required for appropriate wound healing

and white blood cell functioning. 28-30

In fact, tissue

hypoxia is a known risk factor for wound infection

and dehiscence. 31

Thus, attempts to increase tis-

sue oxygenation during an operative procedure

may help prevent SSI. In fact, supplemental

oxygenation, the practice of supplying the surgical

patient with 80% FiO2 (fraction of inspired oxygen)

during and after surgery is effective at preventing

SSI. 32-34

This strategy is most effective when

combined with additional strategies to improve

tissue oxygenation, including maintenance of

normothermia and appropriate volume replace-

ment. 32-34

To date, seven randomized clinical trials have

been published comparing the use of 80% FiO2 with

30% to 35% FiO2 in patients undergoing general

anesthesia with intraoperative mechanical ventila-

tion and postoperative oxygen delivered for two to

six hours via a non-rebreathing mask. 32-38

Three

trials in patients undergoing elective colorectal

resection 32,33,37

and one each in open appendec-

tomy 34

and total gastrectomy with esophagojejunal

anastomosis 38

reported an approximately 40% de-

crease in the rate of SSI. Two trials in mixed sur-

gical populations

undergoing emer-

gency or elective

laparotomy for gas-

trointestinal, gyneco-

logic, or urologic

procedures reported

different results. 35,36

One trial reported no

difference, 35 whereas another, smaller trial reported

an increase in SSIs. 36

In this study, the 80% FiO2

group had a significantly higher proportion of pa-

tients with high body mass index (ie, > 30 kg/m2),

higher blood loss, more crystalloid infused, and

longer procedures. A meta-analysis of five of the

above referenced studies, including the “negative”

study, concluded that perioperative supplemental

oxygen led to a relative risk reduction of 25%

for SSI. 39

USE A SURGICAL PATIENT SAFETY CHECKLIST

Checklists have emerged as an important quality

improvement tool for ensuring that best practices

are performed, and the surgical arena is no dif-

ferent. The World Health Organization created

a 19-item surgical safety checklist to improve

adherence with best practices. 40

Items on the

Checklists have emerged as an important quality-improvement tool for ensuring that best practices are performed; in the perioperative arena, use of the World Health Organization checklist improves surgical outcomes.

AORN Journal j 317

PATIENT SAFETY FIRST www.aornjournal.org

checklist are separated into three areas: sign in,

time out, and sign out. During the time-out phase,

for example, the surgical team confirms that pro-

phylactic antibiotics were administered appropri-

ately or that antibiotics were not indicated.

Use of the World Health Organization checklist

improves surgical outcomes. A multicenter quasi-

experimental study conducted in eight countries

demonstrated that use of the World Health Orga-

nization checklist led to a 50% decrease in rates

of SSI and death. 41

These findings have been

confirmed in subsequent single- and multicenter

quasi-experimental studies. 42,43

CONCLUSION

Most hospitals have achieved great successes in

improving adherence to the basic quality measures

recommended by SCIP. Yet, patients continue to

have SSIs. Evidence-based strategiesdoptimizing

antimicrobial prophylaxis dosing, preparing the

colon with mechanical bowel preparation and

oral antibiotics, optimizing tissue oxygenation,

and using a surgical safety checklistdcan help

high-performing hospitals and health care pro-

viders move beyond SCIP to ensure that they

provide the best care possible to their surgical

patients and decrease the rate of SSIs.

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Deverick J. Anderson, MD, MPH, is an asso-

ciate professor of medicine at Duke University

Medical Center, Durham, NC. Dr Anderson has

no declared affiliation that could be perceived

as posing a potential conflict of interest in the

publication of this article.

AORN Journal j 319

PATIENT SAFETY FIRST www.aornjournal.org

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