Alternative Methods to Decrease SSI

Several nonantimicrobial methods have been studied for reducing the risk of SSI.16

Providing supplemental warming to patients (36.6°C [98°F]) during the intraoperative

period reduced infection rates compared to control patients (34.7°C [94.5°F]). Intensive glucose control (maintaining blood glucose to 80 to 110 mg/dL [4.4-6.1 mmol/ L]) versus conventional control (blood glucose less than 220 mg/dL [less than 12.2 mmol/L]) reduced infections and improved outcomes in cardiac patients who received intensive insulin control in the ICU after surgery.18 Also, patients randomized to 80% inspired oxygen had lower SSI rates compared to patients on 30% oxygen after colorectal resection.19 Despite these findings, there are insufficient data to make definitive recommendations on the use of these therapies.

Antimicrobial-impregnated bone cement is being used as an adjunct or alternative to traditional antimicrobial prophylaxis for orthopedic operations. Cefuroxime-im-

pregnated cement lowered the risk of deep infection after primary total knee artho-20

plasty. Other studies have been inconclusive regarding superiority of antimicrobial-

impregnated bone cement versus conventional therapies. Confounding this issue is the lack of standards regarding antimicrobial-impregnated cements. An array of drugs, from aminoglycosides to macrolides, is used in these preparations. Some ce ments are produced commercially whereas others are made in the operating room. The long-term durability of impregnated cements is also unknown, as the addition of antimicrobials may reduce the tensile strength of bone cement. Further study is needed before antimicrobial-impregnated bone cements can be recommended as an alternative to preoperative prophylaxis with traditional antimicrobials.

Antimicrobial irrigation may also be encountered in the surgical arena as an adjunct or alternative to traditional parenteral antimicrobial prophylaxis. Irrigation of wounds allows debris removal as well as an additional way to lessen bacterial contamination. However, as with the antimicrobial bone cement, evidence is mixed on the advantages of using this approach. Irrigation with detergent solutions, rather than antimicrobials, appears to provide the same results but with less wound-healing problems encountered with antimicrobial irrigation. Additionally, because antimicrobial irrigation solutions are not commercially available, irrigants are often made in the operation rooms, allowing for the possibility of higher than or lower than desired concentrations. If concentrations are higher than desired, local chemical irritation may occur as well as systemic absorption and toxicity. If concentrations fall below desired targets, development of resistant organisms may occur. Further study is required before antimicrobial irrigation is recommended for use in surgical prophylaxis.

With the increase of CA-MRSA, increased importance has been placed on screening for S. aureus, especially MRSA and decolonization. Surgical patients with nasal colonization of S. aureus have a higher risk of an SSI due to S. aureus, and decoloniz-

23 25

ation leads to a lower incidence of SSIs. " However, while this evidence may imply the opportunity for some real benefits in the surgical population, a clear consensus on how the nasal colonization should be approached has not been reached. British guidelines recommend an attempt at decolonization for patients undergoing planned surgical procedures to minimize the risk of infection.26 Harbarth and colleagues suggest MRSA screening be targeted to patients undergoing elective surgical procedures that have a high risk of MRSA infection. In addition, each hospital's infection control team, along with the surgical team, should analyze their patient population and

MRSA epidemiology to appropriately select screening guidelines, keeping in mind state and federal statutes regarding the use of active surveillance cultures. Screening methods that utilize rapid, PCR-based testing may provide an advantage in quickly identifying colonized patients and allowing decolonization to occur prior to surgery.

The most studied approach to eradication of methicillin-sensitive S. aureus (MSSA) and/or MRSA has been mupirocin applied to the anterior nares for 5 days prior to surgery. Additionally, skin decolonization with 4% chlorhexidine for 5 days prior to surgery has also been recommended. While decolonization of the anterior nares is the most common and most studied, some controversy exists because patients may be colonized elsewhere (rectum, throat, vagina, etc.) and often do not receive

complete decolonization. Furthermore, decolonization usually does not lead to lifelong eradication. Other drugs, both topical and systemic, have been studied for decolonization/eradication of MRSA, but a review of randomized controlled trials for the eradication of MRSA found insufficient evidence for the use of any agent for eradica-

tion of MRSA. Further studies are needed to elucidate this area of surgical prophylaxis.

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