Preventing Surgical Site Infections: A Surgeon's Perspective, Part Two

Educational Objectives

The goal of this program is to improve prevention of surgical-site infections (SSI). After hearing and assimilating this program, the clinicians will be able to:

1. List factors in noncardiac surgery that are associated with increased risk for SSI.
2. Assess postoperative blood glucose (BG) of patients undergoing total knee and hip arthroplasty to reduce risk for SSI.
3. Explain how BG predicts 30-day mortality in noncardiac and cardiac procedures.
4. Compare effects of subcutaneous insulin vs intravenous insulin in the postoperative period.
5. Optimize patient outcomes by using the World Health Organization Surgical Safety Checklist.

Summary

Perioperative hyperglycemia: can be dangerous to individuals with or without diabetes

Zerr et al (1997): showed that deep sternal surgical site infection rates were increased in patients with blood glucose (BG) levels >150 mg/dL, and dramatically increased if level was >250 mg/dL

Furnary et al (1999): showed that aggressive monitoring and management of diabetes in the intraoperative and perioperative period after cardiac surgery with intravenous insulin reduced the infection rate by 3 times, and reduced mortality rate; focused on the average of every BG measurement over a 3-day period, starting from the day of operation

Latham et al (2001): also found increasing rates of surgical-site infection (SSI) with higher BG levels after median sternotomy; stratified patients into those with perioperative BG <200 mg/dL and BG >200 mg/dL; found no increased risk with elevated hemoglobin A1c (HbA1c) if BG was <200 mg/dL, but found an increased risk with diagnosed diabetes, as well as any postoperative BG >200 mg/dL within 48 hr of surgery; the speaker published an editorial pointing out that in this study, while 48% of patients with diabetes had BG >200 mg/dL, so did 12% of patients without diabetes, and 47% of high BG episodes occurred in nondiabetic persons

Duncan et al (2010): found that in patients after cardiac surgery, BG >200 mg/dL was associated with increased mortality, prolonged intubation, renal morbidity, neurologic morbidity, serious infections, and overall morbidity

Centers for Medicare and Medicaid Services (CMS) Surgical Care Improvement Program (SCIP): data from this program led to introduction of mandatory BG control for patients undergoing cardiac surgery

Vriesendorp et al (2004): found that rate of surgical-site infections (SSIs) gradually increased with BG >120 mg/dL after vascular surgery; according to speaker, higher BG levels are always associated with SSIs and other postoperative complications

Ramos et al (2008): found increased incidences of pneumonia, SSI, urinary tract infection, or sepsis in the first 30 days after noncardiac surgery for patients with perioperative hyperglycemia; any postoperative BG >200 mg/dL was associated with an 80% increase in infection rate vs patients with lower BG levels; a 30% increase was seen with every 40 mg/dL increase in BG

Villar-Compte et al (2008): found that rates of SSI after mastectomy were increased in patients >50 yr of age with preoperative chemotherapy or radiotherapy, or for any BG >150 mg/dL (SSI rate almost 3 times higher)

Ata et al (2010): showed a dose-response curve with significant increase for BG >140 mg/dL up to >220 mg/dL

King et al (2011): found that among diabetic patients undergoing noncardiac surgery, a large number had BG >150 mg/dL and a smaller number >250 mg/dL; infection rates were significantly increased with BG >150 mg/dL, and even higher with BG >250 mg/dL; the study found that while American Society of Anesthesiologists (ASA) score and clean contaminated vs clean operations were significant, HbA1c level and preoperative BG were not significantly associated with risk for SSI; peri- and postoperative BG was significantly associated with risk for SSI

Mraovic et al (2011): looked at patients who underwent total knee and hip arthroplasty and found that fasting BG on postoperative day 1 was significantly associated with infection risk; 80% of patients with BG >140 mg/dL were nondiabetic since in any usual sequence of patients, the majority are nondiabetic; persons without diabetes are at lower risk for hyperglycemia, but in terms of numbers, they may have more hyperglycemia

Mohan et al (2015): found that 43% of all hyperglycemic episodes (BG >180 mg/dL) occurred in patients without diabetes, and there was a 52% higher rate of infection in such nondiabetic patients; there was also an increased risk for sepsis and mortality

Gianotti et al (2019): found that 51% of nondiabetic patients undergoing elective abdominal surgery had BG >125 mg/dL in the first 24 h, with a 6.5% increased infection risk for every 10 mg/dL above 125 mg/dL

Perna et al (2012): found a 27% increase in infection rate for every 20 mg/dL increase in BG during hospitalization

Goodenough et al (2015): showed that for abdominal surgery, a higher HbA1c level was associated with more hyperglycemia in the perioperative period; there was a higher rate of complications for high BG, but this was not related specifically to HbA1c

Jones et al (2017): showed that patients with high HbA1c had a lower rate of complications and readmissions at 30 days postoperatively, but that rates were higher for BG >250 mg/dL in the first 48 hr; this was because patients with high HbA1c on admission underwent more aggressive surveillance and control of BG

Van den Boom et al (2018): found that although HbA1c is positively associated with perioperative glucose, it is not associated with increased 30-day mortality after controlling for glucose; perioperative blood glucose predicts 30-day mortality linearly in noncardiac procedures and nonlinearly in cardiac procedures; elevated HbA1c indicates that perioperative BG control will be more difficult, but controlling perioperative BG reduces risk for serious complications

Scalea et al (2007): found that in trauma patients, a more aggressive protocol for measuring and controlling BG reduced overall infection rate from 29% to 21%

Cao et al (2011): showed that better insulin treatment in patients with diabetes undergoing gastrectomy led to lower rates of insulin resistance, leading to better BG control; they also found that perioperative insulin increased monocyte surface antigen, a resistance factor that improves host defenses

Kwon et al (2013): found that in patients who underwent bariatric surgery or colectomy, BG >180 mg/dL on the first or second day postoperatively was associated with more infection and complications; 30% of all hyperglycemic patients were not diabetic; rate of infection was doubled in nondiabetic patients with BG >180 mg/dL vs diabetic patients; hyperglycemia appeared to be a more significant risk factor for infection in nondiabetic persons than in diabetic persons, possibly as their bodies are not used to high BG levels; the study also showed that insulin significantly reduced infection risk even if BG was higher, and that longer duration of BG >180 mg/dL increased the odds ratio for infection

Al-Niaimi et al (2015): found that patients who received intravenous insulin vs subcutaneous insulin in the postoperative period had lower BG levels and dramatically reduced rate of infections; they also showed that patients who received subcutaneous insulin had higher average BG, but also higher rates of hypoglycemia, which is dangerous in the perioperative period and increases risk for mortality and other complications; in the perioperative period, there are changes in perfusion and blood pressure, which may interfere with uniform absorption of insulin from the subcutaneous space as blood flow in the area may be suboptimal; as perfusion improves, it may be absorbed suddenly, leading to hypoglycemia; hyperglycemia impairs immunity by inactivating IgG, by decreasing complement activation, increasing collagenase activity, and impairing white blood cell function; it also impairs ischemic preconditions and reduces collateral blood flow in the cardiovascular system, which makes it dangerous in cardiac surgery; regardless of a diagnosis of diabetes, hyperglycemia increases morbidity, mortality, and length of stay

Kiran et al (2013): showed that ≈66% of nondiabetic patients undergoing colectomy had BG >125 mg/dL in the perioperative period; they showed the same dose-response curve for increased mortality, sepsis, SSI, and reoperation with increasing BG

Wang et al (2014): looked at preoperative BG as a screening tool for patients without diabetes and showed the same dose-response curve; patients with preoperative BG >180 mg/dL were 8 times more likely to receive insulin than other patients, and 60% were diagnosed with diabetes within 1 yr; 30% of patients had preoperative BG >100 mg/dL, and 15% of these were diagnosed with diabetes within 1 yr

Kotagal et al (2015): showed that for every BG >125 mg/dL, nondiabetic persons were less likely to be given insulin in the perioperative period because of lack of understanding that nondiabetic persons can develop complications; they also showed that patients with BG >125 mg/dL without diabetes had a higher risk for complications vs patients with diabetes who had similar BG

Measures to improve glycemic control: the speaker's center started a protocol in 2015 to measure preoperative and postoperative BG in all patients who underwent general anesthetic operations; 17% had diabetes and 83% did not; BG >140 mg/dL in the first 24 hr following incision occurred in 91% of diabetic patients and 51% of nondiabetic patients; more recently, they found that among nondiabetic patients with any BG >140 mg/dL, insulin was used in only 42%, despite insulin use providing a 20% lower complication rate; de Vries et al (2017) looked at 15 randomized studies and found a 52% lower infection risk when target BG was <150 mg/dL vs <200 mg/dL; according to the American College of Endocrinology, use of standardized protocols developed by multidisciplinary teams is associated with improved glycemic control and lower rates of hypoglycemia; in addition to specifying insulin dose, protocols should include specific guidelines for identifying patients at high risk for hypoglycemia and actions to be taken to prevent and treat it

Surveillance for SSI: Haley et al (1985) estimated a 20% reduction in SSI rates in hospitals that implemented a surveillance program; Olson et al (1990) reported a clinically and statistically significant reduction in SSI rates for clean, clean contaminated, and contaminated incisions after the introduction of a surveillance program; Brandt et al (2006) showed a 25% reduction in multivariate risk for SSI in hospitals with surveillance; Wilson et al (2006) also found reductions in SSI rates in 8 of 10 specialties, and greater cost savings, as a result of implementing surveillance programs

SSI prevention: an SSI is considered potentially preventable if all known preventive measures (ie, prophylactic antibiotics, sterile instruments, normothermia, hyperoxia, euglycemia, uninfected patient and surgeon) are available but not employed; an apparently unavoidable SSI occurs despite appropriate application of all known preventive measures; elimination of SSIs is an unachievable goal, but eliminating potentially preventable SSIs is possible; the speaker's center started a program to investigate every SSI and ensure all preventive measures were taken, focusing on optimizing one measure at a time; this resulted in a consistent decrease in overall infection rate; Ehrenkranz et al (1991) found that postoperative acquisition of serious infections was related to infection control practices in the intensive care units, and correcting these issues improved infection rates

Teamwork, communication, and discipline: Mazzocco et al (2009) looked at the Behavioral Marker Risk Index, which classified briefing, information sharing, inquiry, and vigilance and awareness of all persons on the operating team; a bad index was associated with 4.8 times higher rate of complications or death

Checklists: the World Health Organization (WHO) Surgical Safety Checklist is designed to be used before and after each operation; testing in 8 hospitals showed it reduced SSI rates by almost half; it asks operating teams to ensure all measures to prevent SSIs are taken; it was opined (eg, Haynes et al [2009]) that benefits likely attributable to data from India, Jordan, Tanzania, and Philippines, not Canada, US, New Zealand, and England; de Vries et al (2010) also showed a statistically significant reduction in SSI rates after implementing the checklist in the Netherlands; this study also found that complication rates were higher in hospitals where the checklist was used, but incompletely; van Klei et al (2012) also found that using the WHO checklist resulted in odds ratio of 0.44 in mortality (>50% reduction) if it was used completely and effectively but no significant improvement was found if it was partially completed; Sotto et al (2021) found significant reduction in mortality, any complication, SSIs, pneumonia, return to operating room, urinary tract infections, unplanned intubation, and sepsis with use of the checklist

Team training: at the speaker's center, along with use of a checklist, each person in the operating room introduces themselves by name and role, and any questions by team members are raised and addressed; they then talk about the planned procedure and issues such as antibiotics, patient temperature, and BG measurements; Neily et al (2010) found that implementation of a medical team training program decreased surgical postoperative mortality rates continuously over 4-yr period; Young-Xu et al (2011) also found that implementation of team training programs was associated with 20% greater reduction in morbidity and 17% greater reduction in infections than hospitals without team training

Unprofessional behavior: Cooper et al (2019) found that the number of reports (ie, 0 reports, 1-3 reports, or >4 reports) of unprofessional behavior reported to hospital administration about a surgeon was associated with a significant increase in the number of complications in the operations performed by that surgeon; they also found increased SSI rates in operations performed by surgeons who had more reports of unprofessional behavior

Readings

Al-Niaimi AN, Ahmed M, Burish N, et al. Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients. Gynecol Oncol. 2015;136(1):71-76. doi:10.1016/j.ygyno.2014.09.013; Ata A, Lee J, Bestle SL, et al. Postoperative hyperglycemia and surgical site infection in general surgery patients. Arch Surg. 2010;145(9):858-864. doi:10.1001/archsurg.2010.179; Brandt C, Sohr D, Behnke M, et al. Reduction of surgical site infection rates associated with active surveillance. Infect Control Hosp Epidemiol. 2006;27(12):1347-1351. doi:10.1086/509843; Cao SG, Ren JA, Shen B, et al. Intensive versus conventional insulin therapy in type 2 diabetes patients undergoing D2 gastrectomy for gastric cancer: a randomized controlled trial. World J Surg. 2011;35(1):85-92. doi:10.1007/s00268-010-0797-5; Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg. 2019;154(9):828-834. doi:10.1001/jamasurg.2019.1738; Dellinger EP, Villaflor-Camagong D, Whimbey E. Gradually Increasing Surgical Site Infection Prevention Bundle with Monitoring of Potentially Preventable Infections Resulting in Decreasing Overall Surgical Site Infection Rate. Surg Infect (Larchmt). 2021;22(10):1072-1076. doi:10.1089/sur.2021.183; de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928-1937. doi:10.1056/NEJMsa0911535; de Vries FE, Gans SL, Solomkin JS, et al. Meta-analysis of lower perioperative blood glucose target levels for reduction of surgical-site infection. Br J Surg. 2017;104(2):e95-e105. doi:10.1002/bjs.10424; Duncan AE, Abd-Elsayed A, Maheshwari A, et al. Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology. 2010;112(4):860-871. doi:10.1097/ALN.0b013e3181d3d4b4; Ehrenkranz NJ, Pfaff SJ. Mediastinitis complicating cardiac operations: evidence of postoperative causation. Rev Infect Dis. 1991;13(5):803-814. doi:10.1093/clinids/13.5.803; Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67(2):352-362. doi:10.1016/s0003-4975(99)00014-4; Gianotti L, Sandini M, Biffi R, et al. Determinants, time trends and dynamic consequences of postoperative hyperglycemia in nondiabetic patients undergoing major elective abdominal surgery: A prospective, longitudinal, observational evaluation. Clin Nutr. 2019;38(4):1765-1772. doi:10.1016/j.clnu.2018.07.028; Goodenough CJ, Liang MK, Nguyen MT, et al. Preoperative Glycosylated Hemoglobin and Postoperative Glucose Together Predict Major Complications after Abdominal Surgery. J Am Coll Surg. 2015;221(4):854-61.e1. doi:10.1016/j.jamcollsurg.2015.07.013; Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol. 1985;121(2):182-205. doi:10.1093/oxfordjournals.aje.a113990; Jones CE, Graham LA, Morris MS, et al. Association Between Preoperative Hemoglobin A1c Levels, Postoperative Hyperglycemia, and Readmissions Following Gastrointestinal Surgery [published correction appears in JAMA Surg. 2018 Aug 1;153(8):782]. JAMA Surg. 2017;152(11):1031-1038. doi:10.1001/jamasurg.2017.2350; King JT Jr, Goulet JL, Perkal MF, et al. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann Surg. 2011;253(1):158-165. doi:10.1097/SLA.0b013e3181f9bb3a; Kiran RP, Turina M, Hammel J, et al. The clinical significance of an elevated postoperative glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control?. Ann Surg. 2013;258(4):599-605. doi:10.1097/SLA.0b013e3182a501e3; Kotagal M, Symons RG, Hirsch IB, et al. Perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97-103. doi:10.1097/SLA.0000000000000688; Kwon S, Thompson R, Dellinger P, et al. Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Ann Surg. 2013;257(1):8-14. doi:10.1097/SLA.0b013e31827b6bbc; Latham R, Lancaster AD, Covington JF, et al. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol. 2001;22(10):607-612. doi:10.1086/501830; Mohan S, Kaoutzanis C, Welch KB, et al. Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database. Int J Colorectal Dis. 2015;30(11):1515-1523. doi:10.1007/s00384-015-2322-7; Mraovic B, Suh D, Jacovides C, et al. Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty. J Diabetes Sci Technol. 2011;5(2):412-418. Published 2011 Mar 1. doi:10.1177/193229681100500231; Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700. doi:10.1001/jama.2010.1506; Olson MM, Lee JT Jr. Continuous, 10-year wound infection surveillance. Results, advantages, and unanswered questions. Arch Surg. 1990;125(6):794-803. doi:10.1001/archsurg.1990.01410180120020; Perna M, Romagnuolo J, Morgan K, et al. Preoperative hemoglobin A1c and postoperative glucose control in outcomes after gastric bypass for obesity. Surg Obes Relat Dis. 2012;8(6):685-690. doi:10.1016/j.soard.2011.08.002; Ramos M, Khalpey Z, Lipsitz S, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248(4):585-591. doi:10.1097/SLA.0b013e31818990d1; Rosenberger LH, Politano AD, Sawyer RG. The surgical care improvement project and prevention of post-operative infection, including surgical site infection. Surg Infect (Larchmt). 2011;12(3):163-168. doi:10.1089/sur.2010.083; Scalea TM, Bochicchio GV, Bochicchio KM, et al. Tight glycemic control in critically injured trauma patients. Ann Surg. 2007;246(4):605-612. doi:10.1097/SLA.0b013e318155a789; van den Boom W, Schroeder RA, Manning MW, et al. Effect of A1C and Glucose on Postoperative Mortality in Noncardiac and Cardiac Surgeries. Diabetes Care. 2018;41(4):782-788. doi:10.2337/dc17-2232; van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. Ann Surg. 2012;255(1):44-49. doi:10.1097/SLA.0b013e31823779ae; Vilar-Compte D, Alvarez de Iturbe I, Martín-Onraet A, et al. Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy. Am J Infect Control. 2008;36(3):192-198. doi:10.1016/j.ajic.2007.06.003; Vriesendorp TM, Morélis QJ, Devries JH, et al. Early post-operative glucose levels are an independent risk factor for infection after peripheral vascular surgery. A retrospective study. Eur J Vasc Endovasc Surg. 2004;28(5):520-525. doi:10.1016/j.ejvs.2004.08.006; Wang R, Panizales MT, Hudson MS, et al. Preoperative glucose as a screening tool in patients without diabetes. J Surg Res. 2014;186(1):371-378. doi:10.1016/j.jss.2013.09.014; Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg. 2011;146(12):1368-1373. doi:10.1001/archsurg.2011.762; Zerr KJ, Furnary AP, Grunkemeier GL, et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg. 1997;63(2):356-361. doi:10.1016/s0003-4975(96)01044-2.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Dellinger was recorded exclusively for Audio Digest on April 20, 2023. Audio Digest thanks Dr. Dellinger for their cooperation in the production of this program.

CME/CE INFO

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