JPOSNA Nov 2022: Preventing SSI: What Do We Know, What Don't We Know?

Introduction
Surgical site infections (SSIs) are a devastating and resource intensive complication of surgical intervention. The most recent, comprehensive data available suggests that the risk of surgical site infection in all orthopaedic procedures is approximately 1%.(1) In pediatric orthopaedic spine fusion procedures, SSI rates range from 1% in idiopathic scoliosis up to 19% in patients with myelomeningocele.(2) Financial costs associated with surgical treatment of SSIs in spine fusion patients are estimated to be from $66,000 up to $1 million.(3) Implant-heavy surgeries significantly increase the risk of a SSI; accordingly, the surgeon aims to be extremely vigilant with these higher-risk situations. The majority of orthopaedic implants are made of materials that are avascular in nature and are therefore susceptible to infection and the formation of biofilms, making eradication of the infection significantly more difficult.(4)

The purpose of this quiz is to probe our knowledge of the history of antisepsis, the evolution of infection prevention, and current best practices applicable in pediatric orthopaedic surgery. How many of our actions are truly dogma, and how many are evidenced-based practice? What elements are historical, and what elements are best practices? 

“If I have seen further, it is by standing on the shoulders of giants.”
– credited to Sir Isaac Newton

References
1. McLaren AC, Lundy DW. AAOS Systematic Literature Review: Summary on the Management of Surgical Site Infections. J Am Acad Orthop Surg. 2019;27(16):e717-e720. doi:10.5435/JAAOS-D-18-00653
2. Cohen LL, Birch CM, Cook DL, et al. Variability in Antibiotic Treatment of Pediatric Surgical Site Infection after Spinal Fusion at A Single Institution. J Pediatr Orthop. 2021;41(6):e380-e385. doi:10.1097/BPO.0000000000001811
3. Hedequist D, Haugen A, Hresko T, Emans J. Failure of attempted implant retention in spinal deformity delayed surgical site infections. Spine (Phila Pa 1976). 2009;34(1):60-64. doi:10.1097/BRS.0B013E31818ED75E
4. Saeed K, McLaren AC, Schwarz EM, et al. 2018 international consensus meeting on musculoskeletal infection: Summary from the biofilm workgroup and consensus on biofilm related musculoskeletal infections. J Orthop Res. 2019;37(5):1007-1017. doi:10.1002/jor.24229

 

Quiz Author
Ryan P. Farmer, MD
Our Lady of Lourdes Women’s and Children’s Hospital, Department of Pediatrics; Pediatric Orthopedics Section, Lafayette, LA 

Prior to 1847, puerperal or child bed fever, caused the death of up to 10% of pregnant mothers at maternity clinics in Vienna, Austria. There were two maternity clinics in Vienna with different rates of maternal death due to puerperal fever. Clinic #1 had a maternal death rate approaching 10%, clinic #2 had a death rate of 4%. An observant practitioner overseeing both clinics noted differences between the staffing of both clinics and through a change in practices, was able to reduce the mortality rates due to puerperal fever to near zero in 1 year. Who was this practitioner?

In contemporary surgery, there are generally three chemicals used in the antiseptic preparation of the hands of surgical team members. These are preparations utilizing chlorhexidine, iodine-based products, or alcohol-based hand rubs. Which of these products has demonstrated the least efficacy in reducing the number of colony forming units (cfu) found on the hands?

 

 

There are generally three types of surgical head coverings: the bouffant style, disposable surgeons cap, and the reusable cloth surgeon cap. Which of the head coverings is associated with the lowest number of fomites, potential infective particles, present in the operating room?

Prior to the final skin preparative agent, some practitioners utilize an initial skin antisepsis routine such as at home chlorhexidine wipes or an initial alcohol wipe down of the surgical site. Which of the following preoperative skin preparations demonstrate the greatest efficacy at reducing the surgical site microbial burden in clean orthopedic surgeries?

 

 

The goal of preoperative skin preparation is to decrease the total number of surface bacteria to allow the patients’ immune system to prevent an infection. Skin preparative agents generally contain a chlorhexidine or povidone iodine compound as the final skin antisepsis step prior to incision. Which of the following demonstrates the greatest efficacy at reducing the surgical site microbial burden in clean orthopaedic surgeries?

Preoperative antibiotics administered within 1 hour of the initial incision is a well-supported practice with multiple studies demonstrating its effectiveness in reducing SSIs.¹ According to the available data, how long should postoperative antibiotics be given?

Following Louis Pasteur’s seminal work on the putrefaction of various liquids in his swan neck flask experiments, another pioneer, in 1862, developed methods to decrease the mortality and morbidity associated with open fractures. In the face of calls to abandon all surgical procedures due to the high mortality rate from infection, whose work paved the way to performing safer orthopedic surgery?