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Surgical Site Infections in The Age Of COVID

SSI rates decreased during the COVID pandemic


Surgical site infections (SSIs) are a complication of surgery that all surgeons wish to avoid, and the COVID-19 pandemic has proven to be influential in decreasing SSI cases. This can primarily be attributed to the increase in mask usage, hand washing, and social distancing, actions that were common during the COVID-19 era and play a central role in preventing the spread of all germs, not just coronavirus.


As the mandates regarding COVID-19 continue to be lifted, it is important for both surgeons and patients to recognize the drop in SSIs observed during the course of the pandemic, and what actions to take to ensure that this decrease persists.


What is an SSI?


SSIs are the most common infection acquired while in the hospital, and they involve infection in the part of the body which had undergone surgery.


In some cases, SSIs are superficial and only affect the skin, but more severe cases can infect the tissues lying under the skin, organs, or implanted material. It’s easy to see the potential danger of SSIs, especially those that progress deep into the body and are not cared for adequately.


Most SSIs, especially those treated early, only require the proper antibiotic to clear the infection. However, more severe cases of SSIs, especially those that impact implanted material, may require additional surgery to treat the infection, prolonging the patient’s recovery time.

Surgeons in Operating Room
Surgery

What causes SSIs?


An infection that affects the surgical site is due to bacteria, with some of the most common varieties being Staphylococcus, Streptococcus, and Pseudomonas. The introduction of the bacteria to the surgical site can occur through many methods, including touching the surgical site with something that is contaminated, either an instrument or a hand. Bacteria can also infect surgical sites if they are in the air or already on/in the body.


The length of the surgery also increases the risk of SSIs, with longer surgeries carrying a higher risk because the surgical area is potentially exposed to germs for a longer period of time.


How to prevent SSIs


There are many actions that a surgeon and those on the surgical team implement to prevent SSIs. Since SSIs develop due to the introduction of bacteria or viruses to the surgical site, enforcing sterile environments helps to prevent SSIs.


This includes the surgeon cleaning their hands and arms (up to the elbows) with an antiseptic agent just before surgery and then wearing special gloves during the procedure to keep the surgery site clean.


Some patients may benefit from cleansing with chlorhexidine gluconate soap before surgery. Patients also often have to wear masks, gowns, and special hair covers during surgery to maintain cleanliness in the operating room. Before making an incision, the surgical team uses a special soap, chlorhexidine, to clean the area and kill any germs.


During the surgical recovery time, doctors should clean their hands with soap or an alcohol-based hand sanitizer before and after caring for the patient, especially when touching the surgical site. This ensures that no bacteria are introduced to the open wound.


Antibiotics are often started within 60 minutes of surgery and stopped within 24 hours after surgery. This action acts as a preventative for bacterial infection, allowing for the eradication of any bacteria that happen to enter the body when the surgical site is at its highest risk of infection, which is when the surgery itself is taking place.


SSIs and COVID


The COVID-19 pandemic has resulted in a significant shift in our everyday lives while also introducing a constant fear of exposure. It’s easy to think of a handful of things that have changed for the worse with the appearance of COVID-19, but surprisingly, SSI rates are not one of them. In fact, SSI rates have seen a significant decrease during the COVID-19 pandemic.


Research-Backed Evidence of Lower SSI Rates


One study on 2614 patients found that the increased compliance with handwashing, mask usage, and social distancing during the COVID-19 pandemic led to a 23% lower chance of SSIs in major oncologic resections.


Another study evaluated 541 patients overall, with 198 from March to April 2018, 220 from March to April 2019, and 123 from the COVID era of March to April 2020. The study found that there was a lower rate of global SSIs in the COVID-19 era (3.3% vs. 8.4%). Among these numbers, only a few patients developed superficial SSIs, and none experienced deep SSIs.


By adding two pre-COVID years into this analysis, for comparative purposes, the researchers were better able to focus solely on the impact of COVID-19 on SSI rates. Since there was no significant change in SSI numbers between the two pre-COVID years, they can accurately assume that the significant difference in SSI numbers is due to the COVID-19 pandemic.


COVID Protocols That Have Led to This Decrease


In an effort to slow and prevent the spread of COVID-19, a viral infection spread through aerosol droplets, widespread mask mandates have been implemented. There has also been an increase in glove usage due to the likelihood of touching the infected droplets and then touching the mouth, eyes, or nose.


While helping to prevent the spread of coronavirus-infected droplets is the primary goal of these extra precautions, these actions also prevent other bacteria from spreading, which has proven to be a significant benefit for those recovering from surgery.


Before COVID, it was only the surgical team and doctors taking these precautions by wearing the proper attire, cleansing their hands, and taking other such precautions during surgery. However, with COVID-19 protocols, healthcare providers always wear masks (and, in many cases, gloves), ensuring even less risk of spreading contagions. In addition, patients must also wear a mask for the duration of the hospital stay, a mandate that also helps to decrease the risk of aerosol contamination.


This extends to more than just the patient, however. Many hospitals have limited the number of friends and family allowed to visit in-hospital patients, limiting the number of people coming in contact with their surgical site and potentially spreading bacteria. In addition, those who do visit must also follow the same mask mandates required of the patients.


The Importance of Lowering SSI Rates


SSIs can be a significant detriment to patients. First and foremost, their appearance increases the length of the hospital stay and requires additional treatments, which then increases the overall cost.


While many SSIs can be treated with antibiotics, some cases require additional surgery, which tacks on an additional treatment cost that was unplanned. In addition, more surgery results in a longer amount of time in the hospital.


To put the financial burden of SSIs on the patient into perspective, it has been quoted that the direct costs to a patient with a surgical site infection are twice that of a patient without.


In addition to the financial burden, there is also the health risk that SSIs pose to the patient. Some of these complications include delayed wound healing and increased use of antibiotics, both factors that can cause further health problems. Some patients also require revision surgery for the infection, and with every surgery, there is always the risk of further complications.


The use of masks, frequent hand washing, and social distancing are relatively simple guidelines to follow that can produce significant benefits to those recovering from surgery. In addition to pre-surgery antibiotics and sanitizing the surgical location, these implementations can also prevent the development of SSIs, improve patient outcomes, and reduce the financial burden of SSIs.


These protocols are even more important for individuals at a higher risk of developing SSIs, such as those who:


- have surgery lasting more than 2 hours

- are an elder

- are overweight

- have additional medical problems and diseases

- smoke

- have cancer

- have diabetes

- have a weak immune system

- have abdominal surgery

- have an emergency surgery


Anyone who falls into the above high-risk categories would benefit from continuing to wear masks, wash hands frequently, and observe social distancing while the surgical site heals.


Yet another innovation that helps to lower SSIs is BiPAD, a hand-activated switch for bipolar electrocautery. BiPAD prevents nurses from crawling under the operating table during the surgical procedure to reposition the foot pedal, exposing nurses to non-sterile areas and potential cross-contamination. Additionally, using BiPAD encourages quicker coagulation, which can further decrease the risk of SSIs contracted during the recovery period.


Final Remarks


Surgical site incisions are among the most common complications within the hospital, with the CDC reporting that SSIs account for 20% of all healthcare-associated infections. They occur when germs infiltrate the surgical site from outside sources or internal organs.


Immense measures are taken to prevent SSIs, including observing standard sanitation guidelines and administering antibiotics throughout the procedure, but SSIs still happen.


The COVID-19 pandemic has been a challenging time for society as a whole, which is why it is all the more important to acknowledge the good things that came from the pandemic, including lower SSI rates.


The COVID-19 pandemic was a drastic shift in regard to protecting our health and safety, with the implementation of mask mandates, social distancing, and frequent handwashing. These actions served the additional benefit of decreasing SSIs and should continue to be implemented even once the mandates drop. All surgeons wish to limit the development of SSIs in patients, and the COVID-19 pandemic has introduced an additional, and simple, way to do this.


A promising innovation for reducing SSIs is BiPAD, a hand-activated switch that reduces time spent searching for the foot pedal on potentially non-sanitary floors while also promoting faster coagulation, two actions that help lower SSIs and result in better surgical outcomes.

 

References

https://pubmed.ncbi.nlm.nih.gov/34729779/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488636/

https://pubmed.ncbi.nlm.nih.gov/21587113/

https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf




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