March - April 2023
MasterSeries 60 Minutes Interactive
Surgical Site Infection (SSI): All Your Questions Answered
This is a really important topic and for this MasterSeries on SSI we have an esteemed global panel, including:
Introduction
Surgical site infection (SSI) presents a real challenge for healthcare systems across the world, but they also have a substantial impact on patients. Statistics have shown that about 60% of these surgical site infections are actually completely preventable; despite that, the rates are still high. Each patient undergoing a surgical procedure has a 5% chance of developing an SSI, which is a considerable number.
Relating to SSI, NHS costs are between £10,000 and £100,000 per patient, and it is also associated with extended hospital stays, delays in going back to work and returning to normal life for the patient.
On another note, SSI is caused by bacteria/ microorganisms that get into the body through the incisions that we make in surgery, and treating them involves use of antibiotics. This has contributed a lot to the spread of antibiotic resistance, particularly in low and middle income countries; about 11% of patients in these countries are infected, and in Africa as a whole, one in five women who have a cesarean section end up having an SSI.
Dr Jonathan Johnson, the founder and surgical director of the comprehensive wound care service in Washington DC; Dr Mark Melin, the Medical Director of the M Health Wound Healing Institute in Fairview, Minnesota, United States; Dr Hüseyin Kemal Raşa, the European president of the Surgical Infections Society; Dr Windy Cole, Director of Wound Care Research, Kent State University of Podiatric Medicine; and Dr Michael Magro consultant obstetrician and gynaecologist in London.
expert Dr Jonathan Johnson Surgical Director, Comprehensive Wound Care Services Washington DC, United States
Initial Management of the Surgical Infection
Being a surgeon and working on wounds for multiple years, I can say one of the most important aspects we look at as far as SSI’s are concerned is making sure that:
• We adequately close the wound
• We make sure we have a post-op review of the wound
If the patient needs antibiotics, start them on antibiotics and if you do see any signs and symptoms of SSI; erythema in duration, active purulent drainage, etc., you have to treat it very aggressively.
A post-op surgical review and post-op surgical followup is key; with an outpatient patient we want to make sure they come back within at least three to five days for a review.
What Do You Do Pre-Operatively to Minimize the Risk of SSI?
Firstly, you must have great communication with your patient, so they understand that this is a team-based approach; pre-operative instructions are a vital part of controlling and minimizing SSI’s. Another important thing to make sure they are taking their pre-operative antibiotics, and they make sure that they are adequately cleaning the area prior to surgery and not scrubbing the skin. After that, everything should work in an active process; firstly, prep the patient in the operating room and explain all education issues prior to surgery; secondly, in the operating room or at the bedside before starting the procedure, we need to have a timeout and make sure that everyone involved understands what their role is, like prep of the area, explaining to the patient what is going on and what the procedure is, making a clean line incision, and making sure throughout the process to extensively close everything. Another important thing is to make sure there is adequate post-op dressing on the scar.
Before making the incisions, its important to note who is at a higher risk for developing SSI, and patients with diabetes, problems with coagulopathy, ischemic problems, or comorbidities are at higher risk. In addition, patients who have had surgeries near the site of the current surgery or the same surgical incision are at a higher risk, as sometimes patients have adverse effects in the same area. Patients with autoimmune issues and nutritional defects need to be adequately prepped prior to performing the procedure.
What is your Go-To Surgical Prep?
Prepping the wound depends on whether the patient has acute or increased colonization or critical colonization, as it is required to remove the biofilm as much as possible for a clean wound bed, prior to grafting or any type of surgical debridement. If there is increased colonization at the site, then it must be removed, depending on what is available and the patient’s body and how it reacts. It’s important to remove the biofilm as much as possible; we use a device which looks at the fluorescence of the wound, at the increased amount of bio-burden and the increase in the amount of bacteria at the wound site prior to debriding, but then also after debriding to make sure we removed as much of it as possible; it’s a specific protocol that depends specifically on the patient.
How Do You Identify SSI Early in Your Patients, In Person and Remotely?
Telehealth has newly emerged within the last couple of years due to the pandemic; it’s a great tool to use for surveillance but also to monitor our patients. The number one thing to look for or to tell the patient or patient’s caregiver, is to look for:
• Redness or erythema around the wound site
• Induration/ thickness or hardness around the wound site
• Active purulent drainage or decolourization coming from the wound site
• Warmth or pain at the wound site
If the surgical site has sutures or staples that are intact, this could contribute to the wound being infected, causing pain or erythema; its best to seek medical attention as quickly as possible.
“You must have great communication with your patient, so they understand that this is a team-based approach; pre-operative instructions are a vital part of controlling and minimizing SSI’s.”
What Group of Patients May Not Present Typical Symptoms?
Patients with autoimmune issues, diabetes, and extensive comorbidities may not show active signs and symptoms of infections acutely, compared to patients that do not have these comorbidities. It’s very important to make sure patients with comorbidities, specifically in patients that are diabetic, that you’re regularly checking on the wound, discussing any issues with changes of the skin, and any of the previously mentioned signs or symptoms. One of the other major things that we need to focus on is patients that have darker skin tones, and this goes back to a lot of research and looking at the bacterial burden and fluorescence at the wound site in patients that have darker skin. If we look at what we call the Fitzpatrick scale, we have FP1 all through all the way through to FP6; typically patients that are FP1 are fair skinned and they typically burn and tan, and then we have patients that are FP6; typically darker skinned and they don’t burn or tan, but the signs and symptoms of erythema in duration, pain and changes in the skin warmth and temperature may not be apparent in these patients. Typically these are your patients that are FP4, FP5, and FP6.
We did a study utilizing bacterial fluorescent imaging because with this device we can see the increased amount of that bacterial burden and fluorescence in the patients that may not have what we call active clinical signs and symptoms through simple observation.
So, this group of patients that may not present the typical signs and symptoms are patients with comorbidities and patients with darker skin tones.
How Do You Do An Initial Management Of Somebody With An SSI?
One thing we do first of all is to observe the wound; take a look at the wound, determine the amount of erythema, determine the amount of induration; determine the amount of active purulent or abnormal colour of exudate at the wound site. Observe, talk
to your patient; is there increased pain? Is there increased temperature at the wound site?
We want to look at whether there are foreign bodies at the wound site; does the patient have staples, does the patient have sutures; are there implants at the site?
We want to make sure we can decrease the infection as quickly as possible and to make sure that the patient improves quickly. Another issue we should look at is whether the patient is post-op, and if they have active drainage; for example, if they have active drainage from a total hip or a total knee arthroplasty, then we should put a dressing over the top of the site to see if we can decrease the amount of infection actively and topically before you start the antibiotics. Sometimes in long-term care if the patient does have active infection and drainage from the wound site we will use a silver alginate dressing or a product that has a silver component.
Are There Any Adjuncts To Clinical Skills That You Use As An Initial Point Of Investigation?
We typically focus on utilizing bacterial fluorescence technology, but there is a role for culturing the wound and obviously biopsying of the wound, if the wound is not progressing after you’ve initiated the standard of care management; we do utilize these if the wound continues to decline after we’ve used POA antibiotics, or after we’ve used topical antibiotics, but typically that is what we call a ‘game time decision’, or a ‘wound time decision’ (if I may put this into the lexicon) because it just depends on how the patient reacts postoperatively; if you do need to utilize the culture or the biopsy it is an option available to us, but if not, what we should focus on is standard of care.
“Patients that may not present the typical signs and symptoms are patients with comorbidities and patients with darker skin tones.”
“The idea of wound hygiene has been taking hold in the wound care space, so we should consider wound hygiene post-operatively, too. Currently, most hospitals are not doing a good job with treating post-operative sites to prevent biofilm formation.”
• Practicing aseptic techniques
• Screening our patients; making certain that we understand our patients, their comorbidities, and their underlying conditions
The Role of Biofilm
Biofilm is a colony of polymicrobials; multiple organisms, bacteria, fungus, yeast, etc., that form on the wound surface. Planktonic bacteria are free floating bacteria that will implant on the surface of a wound or a surgical incision and then they start to connect with one another. They do something we call quorum sensing; they start to share information. They may share DNA or RNA; they could share antibiotic resistance, and they start to mutate, and begin to secrete a kind of extra polymeric substance. This substance forms a micro-dome that protects the biofilm. Interestingly, the organisms within a biofilm are not affected by oral and IV antibiotics and some topical antibiotics or antimicrobials have difficulty penetrating through the biofilm construct because of this extra polymeric substance, so these wounds initially are not necessarily infected, but they are contaminated with surface bacteria. The number of complexities of the microbes that are involved in this biofilm on the surface increases the patient’s risk of developing a wound infection. We also know that the presence of biofilm will cause inflammation, and cause wounds to be chronic, so if we have biofilms that are in the area of a surgical incision, and we allow them to develop, if we don’t treat them appropriately we can get an SSI.
We can also get inflammation that continues, and these wounds won’t heal; this becomes a particularly problematic situation for a lot of our patients postoperatively, so we all must practice strategies to prevent infection and SSI. Some of the strategies that are most commonly known in practice are these six:
• Hygiene; washing our hands frequently
• Environmental hygiene; cleaning our spaces
• Surveillance; closely monitoring our patients, especially post-operatively
• Practicing antibiotic stewardship
Associated SSI must not be neglected; this is the main cause of most hospital acquired infections, and the development of SSI is typically due to the microbial contamination of the surgical site. This is either from endogenous or exogenous sources, although most commonly it is the endogenous with superficial site infection, but they can go into deeper tissues. This causes severe patient outcomes with the infection affecting underlying organisms, organs, and then leading to more surgical procedures that are necessary and long term, amputations.
The idea of wound hygiene has been taking hold in the wound care space, so we should consider wound hygiene post-operatively, too. Currently, most hospitals are not doing a good job with treating postoperative sites to prevent biofilm formation.
Choosing the appropriate dressing is vital; we potentially manage, control, and remove the exudate from the incision site. There are newer bandages that have entered the market which also have antimicrobial properties that can assist in wound hygiene, hopefully prevent biofilm bacteria from reforming, and help to control any kind of SSI.
Antimicrobial stewardship is very important as the world is facing a crisis because we have a rising rate of bacterial resistance, due to our overuse of antibiotic agents. The bacterial resistance is directly related to overuse; most patients when they go to their primary care doctors will be prescribed antibiotics, and the statistics say that 90% of antibiotics prescriptions are unnecessary. Prior treatment with commonly used antibiotics actually increases the risk of infection in
patients, which also increases the risk of morbidity, hospital stays, and an overall increase in health care costs and mortality. So, we must practice better antimicrobial stewardship which helps support better clinical care, outcomes and lowers healthcare costs.
The first step we must follow is to avoid antibiotics when they’re not indicated, which means wound infection should be diagnosed clinically, and there must be signs and symptoms of infection. Just because there is a wound, and they’re mostly colonized, this does not indicate the need to prescribe antibiotics, although antimicrobials, surface topical agents, dressings, might be useful in some of these patients, we’re going to prescribe the appropriate regimen to narrow a spectrum for the likely bacteria present. Culture results are important to treat the most common or frequent pathogens, as it is unnecessary to treat low virulence bacteria, and antibiotics should be used for the correct duration, just long enough to achieve symptom resolution. Patients should be treated with topical therapy and usually for about one to two weeks maximum for soft tissue infection, and six weeks for bone infection. Choosing the agent that shows the least risk and best outcomes to avoid adverse reactions to patients is important.
There are many antimicrobial agents out there, for example; silver products, hypochlorous acid solutions, surfactant agents that are antimicrobial, and many new innovative dressings on the market.
temperature management is critical. Telehealth management has its place because we can fit patients in if they’re concerned about their incisions, but it can also complicate making a diagnosis. I would encourage everybody that if there’s ever a question which makes you suspect SSI in a Telehealth interview, bring the patient in for a physical examination and bring that patient in soon.
For signs and symptoms, we’ve all been taught in our medical training to listen to the patient, ask the patient the symptoms; do they have fevers, chills? Are there cognitive changes? Sometimes getting a history from a family member can be very important, and when we’re looking at the wound we’re looking for redness, increasing pain, increasing drainage, or change in the drainage.
In accurately identifying SSI, we have to be aware of the atypicals. In the immunosupressed patient, the elderly, or those with cognitive disorders, SSI may present in a relatively atypical fashion; having a high degree of suspicion is so important as clinicians.
Nutrition
Top Tips for Identifying Surgical Infection
Early identification of suspected SSI is critical; this is going to be based upon pre-operative risk factor assessment, interoperative factors, such as length of procedure, complications, transfusions, and of course perioperative and interoperative body
To emphasize prevention, one of the least talked about components with pre-operative management of patients is nutrition. I think albumin has gotten a little bit of a bad reputation in terms of being a marker for nutrition, and it may actually not be as good a marker for nutrition, as it’s a more important marker for degree of vascular hyperpermeability. The albumin is a significant component of something called the endothelial glycocalyx. It helps with permeability, much like Gore-Tex within a rain jacket. As a constituent of the endothelial glcocalyx, when albumin is low there’s increased miscrovascular hyperpermeabilty which results in increased tissue edema, which can compromise microvascular arterial perfusion at the five micron level, where all oxygen and nutrient delivery truly occurs. I think we need to start thinking about albumin not as a true marker of nutrition but as a marker of endothelial cell health, and helping ultimately with oxygen nutrient delivery, indirectly, to the incisions that
“To emphasize prevention, one of the least talked about components with preoperative management of patients is nutrition.”Global expert Dr M. Mark Melin Medical Director of the M Health Wound Healing Institute Mineapolis MN, United States
by 45% when comparing a
we’re making in our patients and expect to heal. Also, consider control of perioperative hyperglycemia; almost counter-intuitively, preoperative carbohydrate loading in patients can actually help with postoperative hyperglycemia management. This has been recognised in multiple surgical guidelines, and I would counsel you to seek out those guidelines and talk to your nutritionist within the hospital about preoperative carbohydrate loading, which is now a very validated method for assisting in glycemic control perioperatively. The other important thing to focus on is micronutrients; within our wound clinic, we routinely use micronutrients, in addition to standard of care with protein, and the micronutrients we are using are all focusing on endothelial cell function. Vitamin D has an important role of emphasising microvascular functionality. In Minnesota we have a lot of vitamin D deficiency, and it’s not unusual for us to be using 3,000 - 5,000 international units of vitamin D on a daily basis. Vitamin C at 1000mg can help decrease inflammation, which will certainly help improve microvascular perfusion; vitamin B12, B6 and methylfolate can all be part of a methylenetetrahydrofolate reductase pathway that’s connected with homocysteine ultimately resulting in recoupling endothelial nitric oxide synthase to maximise nitric oxide production which results in vasodilation, lymphangion contractility, as well as immune functionality. Vitamin A, for patients who have recently been on steroids, helps with collagen production. Micronized Purified Flavonoids Fractions (MPFF) such as diosmin and hesperidin have also been shown to be a significant component in improving microvascular health; they are inflammation quenching, decreasing ICAM-1 and VCAM-1; they improve venous function and lymphangion functionality.
Conclusion
As professionals we really have to choose counsel wisely and appropriately, and choose the correct time and pre-operative intervention such as compression, edema reduction, and nutrition maximization to result in decreased and minimized post-operative complication risk.
Strategies for Reducing Post-Cesarean Section Infections
The National Institute for Clinical Excellence (NICE) produced guidelines in 2021 using randomized controlled trials (RCT) data which show that after cesarean section, if we used a dressed called Leukomed® Sorbact® we could reduce SSI’s and as a consequence of that, also save money. Leukomed® Sorbact® is a bacteria binding, sterile wound dressing. It can be applied for up to seven days, and not only does it act as a barrier for infection, it ‘sucks’ the bacteria away from the wound and traps it in the dressing so that the bacteria load at the surgical site is less. It is also waterproof, meaning that patients can shower with it on.
We have had a very good success story at the Barking, Havering and Redbridge University Hospitals in reducing SSI after cesarean section (CS), using Leukomed® Sorbact® dressings.
For us, the dressings were roughly £10 per person, and our previous dressings were much cheaper at £1 per person, so we wanted to see if we used a much more expensive wound dressing whether it would make a difference for us over time, and whether it would be a worthwhile investment.
Our SSI rate reduced by 45% when comparing a sixmonth period in using Leukomed® Sorbact®, to the same period previously using the old dressings. For the women that were readmitted, we reduced the days spent in hospital by 61%. Antibiotic prescriptions for women with post-cesarean SSI were reduced by 36%.
We had great improvements and are really pleased with these results, and this is something we will be
“Our SSI rate reduced
six-month period in using Leukomed® Sorbact®, to the same period previously using the old dressings.”Global expert Dr Michael Magro
continuing long term.
In terms of cost savings, when we looked at the number of SSIs that we had reduced in a six-month period, and considering the average costs involved with SSIs, we were able to save nearly £140,000, even with the additional cost of the wound dressings. It is important to note that this excludes the savings from reduced antibiotic prescription, so the real figure will be even higher.
Conclusion
There is a lot of scepticism when companies approach you with their product. I had the same attitude, which is why we didn’t implement this just based on the NICE guidelines, and we kept this audit data. We were very clear that if SSI rates didn’t improve in the sixmonth period, and save us money, we would go back to the old dressing.
I would urge clinicians to try this, even if it is just in a similar six-month period, and see if your SSI rates improve. It is a very simple thing to do, and at worst you will only spend a little more money.
Guidelines
There are many SSI prevention guidelines including those from the American College of Surgeons (ACS) - 2016, the World Health Organization (WHO) - 2016, modified in 2018 because of the hyperbaric oxygen recommendation, and the Centers for Disease Control and Prevention (CDC) - 2017.
I accept that these guidelines can be tiresome, but I have no doubt that with them we can prevent half of all SSI’s. There are strong consensuses across the guidelines, as well as some conflicts.
To summarise the strongest agreements between guidelines, we have five recommendations:
• Parenteral antimicrobial prophylaxis; this is the most significant recommendation in all these three guidelines
• Alcohol-based skin preparation
• Perioperative glycemic control
• Temperature regulation to normothermia
• Maintenance of normal tissue oxygenation
Implementation of Guidelines
When we compare SSI rates in developed countries to low and middle income countries, there is a huge difference; in low and middle income countries SSI is the most surveyed and most frequent type of infection, and incidence rates range from 1.2 and 23.6 per 100 surgical procedures, with a pooled incidence of 11.8%. If we consider the clinical outcomes of SSI, it leads to significant morbidity and mortality, and extended hospital stays. Patients who develop SSI have a 2 to 11 fold higher risk of death; 75% of deaths in patients with SSI are directly attributable to the SSI.
The remaining recommendations did not achieve unanimous agreement across these three guidelines. There are however strong considerations, such as smoking cessation, screening and decolonization; colorectal surgery bundles, perioperative surgical attire; operating room traffic control, operating room disinfection, and use of the WHO perioperative checklist. These have become cornerstones of SSI prevention.
To summarise some of the conflicts and controversies when it comes to SSI prevention, they include:
• Preoperative chlorhexidine gluconate bathing
• Local antibiotics
• Surgical wound irrigation
• Antiseptic drapes
• Antiseptic-impregnated sutures
• Advanced dressings
• Wound protectors
• Prophylactic negative pressure wound therapy
“We were able to save nearly £140,000, even with the additional cost of the wound dressings.”Global expert Dr Hüseyin Kemal Raşa Surgical Infections Society, European President Kocaeli, Turkey
I believe most of these controversies will be cleared up over the next few years, and we will have a clearer consensus.
I am very proud to be part of the team that, in 2018, published the WHO implementation manual, designed to bring this dogmatic knowledge in the guidelines to the clinician and to the bedside.
We have an Inter-Process Communication (IPC) multimodal improvement strategy which involves five categories:
Build it: Training and education
What type of training should be used to ensure that the intervention will be implemented in line with evidence-based policies and how frequently?
Does the facility have trainers, training aids, and the necessary equipment?
Teach it: System change
What infrastructures, equipment, supplies and other resources (including human) are required to implement the intervention?
Does the physical environment influence health worker behaviour? How can ergonomics and human factor approaches facilitate adoption of the intervention?
Are certain types of health workers needed to implement the intervention?
Check it: Monitoring and feedback
How can you identify the gaps in IPC practices or other indicators in your setting to allow you to prioritize your intervention?
How can you be sure that the intervention is being implemented correctly and safely, including at the bedside? For example, are there methods in place to observe or track practices?
How and when will feedback be given to the target audience and managers? How can patients also be informed?
Sell it: Reminders and communications
How are you promoting an intervention to ensure that there are cues to action at the point of care and messages are reinforced to health workers and patients?
Do you have capacity/ funding to develop promotional messages and materials?
Live it: Culture change
Is there demonstrable support for the intervention at every level of the health system? For example, do senior managers provide funding for equipment and other resources? Are they willing to be the champions and role models for IPC improvement?
Are teams involved in co-developing or adapting the intervention? Are they empowered, and do they feel ownership and the need for accountability?
Take Home Messages
The prioritisation of feasible but high-impact pilots, such as SSI in intensive care units, will be a good place to start.
Slowly scaling-up, in a stepwise manner, and moving from paper to electronic forms is a good trick.
The mainstay of these strategies is multidisciplinary collaboration, and mentorship, such as yearly surveillance seminars, site support visits to assess case findings, and denominator data.
The integration of HAI and AMR surveillance efforts including a multidisciplinary working group and a master trained in surveillance that can provide leadership is also an important concept.
We definitely need careful consideration of definitions
“I believe most of these controversies will be cleared up over the next few years, and we will have a clearer consensus.”
Surgical Site Infection (SSI)
before use; this is critical. We need to discuss factors such as the use of validated standards, consistency and feasibility of data collection. We must use the same terminology and definitions.
We also need clear procedures for data management and promotion of data for action.
In almost all success stories we have incorporated an evaluation strategy to monitor performance and provide feedback to frontline staff. Monitoring and feedback can heighten the sense of urgency, promote accountability, and show clinicians how they are performing.
References
57-62, February 2009. | DOI: 10.1097/MOL.0b013e328321b587
3. Aldecoa, C., Llau, J.V., Nuvials, X. et al. Role of albumin in the preservation of endothelial glycocalyx integrity and the microcirculation: a review. Ann. Intensive Care 10, 85 (2020). https://doi.org/10.1186/s13613-020-00697-1
4. Yuwen, P., Chen, W., Lv, H. et al. Albumin and surgical site infection risk in orthopaedics: a meta-analysis. BMC Surg 17, 7 (2017). https://doi.org/10.1186/ s12893-016-0186-6
5. D. G. Armstrong, J. R. Hanft, V. R. Driver, A. P. S. Smith, J. L. Lazaro-Martinez, A. M. Reyzelman, G. J. Furst, D. J. Vayser, H. L. Cervantes, R. J. Snyder, M. F. Moore, P. E. May, J. L. Nelson, G. E. Baggs, A. C. Voss, on behalf of the Diabetic Foot Nutrition Study Group
6. Chronic Wound Care Management and Research 2015:2 129-136. International Journal of Cell Biology, Volume 2015, Article ID 701738
7. Summers S, Yakkanti R, Ocksrider J, Haziza S, Mannino A, Roche M, Hernandez
VH. Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients. J Knee Surg. 2021 Aug 31. doi:
10.1055/s-0041-1733901. Epub ahead of print. PMID: 34464986.
8. Carmichael J, Dennis D, Jennings J, Stevens-Lapsley J, Bade M. Feasibility and initial efficacy of a multimodal swelling intervention after total knee arthroplasty: A prospective pilot study with historical controls. Knee. 2022 Mar;35:25-33. doi:
10.1016/j.knee.2022.01.008. Epub 2022 Feb 17. PMID: 35183923.
9. Summers S, Yakkanti R, Haziza S, Vakharia R, Roche MW, Hernandez VH. Nationwide analysis on the impact of peripheral vascular disease following primary total knee arthroplasty: A matched-control analysis. Knee. 2021 Aug;31:158-163. doi: 10.1016/j.knee.2021.06.004. Epub 2021 Jun 29. PMID: 34214955.
10. Singh TP, Velu RB, Quigley F, Golledge J. Association of chronic venous disease with major adverse cardiovascular events. J Vasc Surg Venous Lymphat Disord. 2022 May;10(3):683-688. doi: 10.1016/j.jvsv.2021.08.021. Epub 2021 Sep 8. PMID: 34506962.
11. Patel M, Lee SI, Akyea RK, Grindlay D, Francis N, Levell NJ, Smart P, Kai J, Thomas KS. A systematic review showing the lack of diagnostic criteria and tools developed for lower-limb cellulitis. Br J Dermatol. 2019 Dec;181(6):1156-1165. doi: 10.1111/ bjd.17857. Epub 2019 Jun 28. PMID: 30844076; PMCID: PMC6916392.
12. MacLeod BG, Klarich CS, Wessman LL, Gaddis KJ, Konstantinov NK, Wubben A, Melin MM. Fluorescent Imaging as a Component of Diagnosing Pyoderma Gangrenosum: A Case Report. Adv Skin Wound Care. 2022 Jun 1;35(6):1-6. doi: 10.1097/01.ASW.0000820248.26138.bc. Epub 2022 Mar 29. PMID: 35426849.
13. Ehmann S, Walker KJ, Bailey CM, DesJardins JD. Experimental Simulation Study to Assess Pressure Distribution of Different Compression Applications Applied Over an Innovative Primary Wound Dressing. Wounds. 2020 Dec;32(12):353-363. Epub 2020 Aug 17. PMID: 33370244.
14. Anatone AJ, Shah RP, Jennings EL, Geller JA, Cooper HJ. A risk-stratification algorithm to reduce superficial surgical site complications in primary hip and knee arthroplasty. Arthroplast Today. 2018 Oct 15;4(4):493-498. doi: 10.1016/j. artd.2018.09.004. PMID: 30560182; PMCID: PMC6287286.
15. Kwon J, Staley C, McCullough M, Goss S, Arosemena M, Abai B, Salvatore D, Reiter D, DiMuzio P. A randomized clinical trial evaluating negative pressure therapy to decrease vascular groin incision complications. J Vasc Surg. 2018 Dec;68(6):17441752. doi: 10.1016/j.jvs.2018.05.224. Epub 2018 Aug 17. PMID: 30126781.
16. Report on the Burden of endemic health care- associated infection worldwide. Geneva: World Health Organization; 2011 (http://www.who.int/infectionprevention/publications/burden_hcai/en/)
17. Allegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta- analysis. Lancet. 2011; 377:228–41
18. Bagheri Nejad S, Allegranzi B, Syed SB, Ellis B, Pittet
D. Health care-associated infection in Africa: a systematic review. Bull World Health Organ. 2011; 89:757–65.
19. Monahan M, Jowett S, Pinkney T, Brocklehurst P, Morton DG, Abdali Z, Roberts TE. Surgical site infection and costs in low- and middle-income countries: A systematic review of the economic burden. PLoS One. 2020 Jun 4;15(6):e0232960. doi: 10.1371/ journal.pone.0232960. PMID: 32497086; PMCID: PMC7272045.
20. Liu Y, Xiao W, Wang S, Chan CWH. Evaluating the direct economic burden of health care-associated infections among patients with colorectal cancer surgery in China. Am J Infect Control. 2018 Jan;46(1):34-38. doi: 10.1016/j.ajic.2017.08.003. Epub
2017 Sep 28. PMID: 28967510.
21. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society surgical site infection guidelines, 2016 update. J Am Coll Surg. 2017;224(1):59-74.
22. Global Guidelines for the Prevention of Surgical Site Infection. WHO; 2018.
23. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904
24. Fields AC, Pradarelli JC, Itani KMF. JAMA. 2020 Mar 17;323(11):1087-1088.
25. Schmitt C, Lacerda RA, Turrini RNT, Padoveze MC. Improving compliance with surgical antibiotic prophylaxis guidelines: A multicenter evaluation. Am J Infect Control. 2017 Oct 1;45(10):1111-1115. doi: 10.1016/j.ajic.2017.05.004. Epub 2017 Jun
16. PMID: 28629754.
26. Allen J, David M, Veerman JL. Systematic review of the cost-effectiveness of preoperative antibiotic prophylaxis in reducing surgical-site infection. BJS Open. 2018 Apr 14;2(3):81-98. doi: 10.1002/bjs5.45. PMID: 29951632; PMCID: PMC5989978.
27. Ho YH, Wang YC, Loh EW, Tam KW. Antiseptic efficacies of waterless hand rub, chlorhexidine scrub, and povidone-iodine scrub in surgical settings: a meta-analysis of randomized controlled trials. J Hosp Infect. 2019 Apr;101(4):370-379. doi:
10.1016/j.jhin.2018.11.012. Epub 2018 Nov 28. PMID: 30500384.
28. Nthumba PM, Stepita-Poenaru E, Poenaru D, Bird P, Allegranzi B, Pittet D, Harbarth S. Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg. 2010 Nov;97(11):1621-8. doi: 10.1002/bjs.7213. PMID: 20878941.
29. Mehtar S, Wanyoro A, Ogunsola F, Ameh EA, Nthumba P, Kilpatrick C, Revathi G, Antoniadou A, Giamarelou H, Apisarnthanarak A, Ramatowski JW, Rosenthal VD, Storr J, Osman TS, Solomkin JS. Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases. Int J Infect Dis. 2020 Nov;100:123-131. doi: 10.1016/j. ijid.2020.07.021. Epub 2020 Jul 24. PMID: 32712427; PMCID: PMC7378004.
30. Ariyo P, Zayed B, Riese V, Anton B, Latif A, Kilpatrick C, Allegranzi B, Berenholtz S. Implementation strategies to reduce surgical site infections: A systematic review. Infect Control Hosp Epidemiol. 2019 Mar;40(3):287-300. doi: 10.1017/ice.2018.355. Epub 2019 Feb 21. PMID: 30786946. 31. Rasa K, Kilpatrick C. Implementation of World Health Organization Guidelines in the Prevention of Surgical Site Infection in Low- and Middle-Income Countries:What We Know and Do Not Know. Surg Infect (Larchmt). 2020 Sep;21(7):592-598. doi: 10.1089/sur.2020.163. Epub 2020 Jun 1. PMID: 32478641.
Leukoplast®
Leukomed® Sorbact®
SSIs are the third most commonly reported type of healthcare-acquired infection and the most costly¹. They place a significant impact on patient welfare² as well as presenting a heavy financial burden for the NHS³.
New NICE Medical Technologies Guidance
New NICE medical technologies guidance recommends the use of Leukomed® Sorbact® for prevention of surgical site infection (SSI) in wounds with low to moderate exudate after caesarean section and vascular surgery.
To view please go to https://www.nice.org.uk/guidance/mtg55
The guidance states that Leukomed Sorbact:
• reduces SSI in caesarean section and vascular surgery
• may reduce antibiotic use
• may reduce readmissions from wound complications
For more information, please contact support.leukomedsorbact@leukoplast.com