Q&A: Preventing Infections Before, During and After Procedures

While your facility likely has robust measures in place to dodge contamination, recent developments provide a valuable reminder to examine current practices.

The government has cut reimbursement for treating certain healthcare-associated infections and has issued an action plan to prevent infections, including vascular catheter-associated bloodstream infections (BSIs) and surgical site infections (SSIs) following coronary artery bypass graft. The estimated annual cost of treating these infections is nearly $20 billion. Hospitals can improve patient care and their financials by reviewing their infection-control measures and enacting new protocols where needed.

Cardiovascular Business invited John S. Foor, MD, a vascular surgeon and infection prevention specialist at Mount Carmel Vascular and Endovascular Surgical Providers, Mount Carmel Medical Center in Columbus, Ohio, to discuss ways to prevent healthcare-associated infections.

Q What can surgeons and interventionalists do prior to a procedure to reduce the risk of infection?

A Two areas of concern are glucose control and skin preparation. Patients with consistently elevated blood sugars are at an increased risk of SSIs. Therefore, if you have a patient who is a known diabetic and scheduled for an elective procedure, it is critical to evaluate their blood sugar levels in the weeks ahead of the procedure date. For levels above 150 or 200, it is best to reschedule the procedure, allowing time to control the glucose level and thereby decrease the risk of an SSI. In one case, I decided to postpone an amputation for a diabetic patient with glucose levels above 400. After a few days in the hospital, the patient’s glucose level was reduced and I was more comfortable performing the procedure knowing that the patient would be more likely to heal successfully.

Regarding skin preparation, the evidence is not conclusive linking preoperative antiseptic showers to reduced SSI rates. However, such showers have been shown to reduce microorganism levels on patients’ skin. Chlorhexidine gluconate (CHG) is a popular antiseptic for skin prep showers due to its residual antimicrobial effect. As a best practice, the Centers for Disease Control and Prevention (CDC) recommends that patients shower or bathe with an antiseptic agent on at least the night before their operation. In my practice, I instruct patients to have two CHG antiseptic showers the day before surgery—once in the afternoon and then again in the evening. I give the patient an antiseptic CHG scrub brush similar to the type used by OR personnel and I give them detailed instructions on effective technique.

Q What precautions can surgeons take the day of the procedure?

John S. Floor, MD

A Most operating room and cath lab professionals have accepted the use of surgical clippers as the standard for preoperative hair removal, and current guidelines support their use as well. This practice results in a lower incidence of SSIs compared to traditional razors, which can create microscopic nicks and abrasions on the skin that lead to infection. That said, there are various clipper options on the market, so consider a clipper strong enough to allow for a fast and close clipping. As part of my preoperative regimen, I prefer using fully submersible electrical clippers that enable thorough cleaning and disinfecting. Also, make sure the clipper comes with disposable heads to help prevent cross-contamination. And clippers with custom blades for all hair types tend to offer faster hair removal and clipper maneuverability, which in turn can help improve the workflow in pre-op.

Q What about the use of antibiotics?

A Intravenous antibiotics are an important consideration to target skin-dwelling organisms such as Staphylococcus epidermis and Staphylococcus aureus. For instance, first-generation cephalosporins can be used, or clindamycin can be administered if the patient is allergic to penicillin. Some patients may require
the use of vancomycin preoperatively if MRSA (methicillin-resistant Staphylococcus aureus) is a concern. Additionally, optimal timing is needed to ensure that peak antibiotic levels are achieved in tissues as the incision is being made. Typically, this means administering the antibiotic drip 30 to 40 minutes prior to the
planned incision.

One practice that I feel is under-employed is the use of preoperative antibiotic IVs in patients with existing vascular grafts in the abdomen or legs who are undergoing a catheter procedure. For instance, a patient who has previously undergone an aorta bifemoral bypass and has a femoral graft in place should be given an antibiotic IV prior to an interventional procedure that would require a catheterization through the synthetic graft material. This material has a higher propensity for causing infection, calling for an extra dose of caution.

Q What are some of the factors to consider when selecting a preoperative skin preparation protocol?

A The preferred solution should have the ability to kill skin-dwelling microorganisms immediately upon application, but should also exhibit persistent antimicrobial activity throughout the procedure and keep fighting bacterial growth once the procedure is complete. The three common choices for skin preparation—iodine-based products, alcohol and a combination of CHG with alcohol—all have benefits. Alcohol has an immediate presence and begins killing skin-dwelling bacteria as soon as it is applied. The effect, however, is not long lasting. Iodine is effective for a couple of hours after application, but iodine-based antiseptic products can be neutralized in the presence of body fluids. CHG provides bacteria-killing activity that persists for a longer stretch of time, lasting up to 48 hours post-procedure for prolonged antiseptic effect and is not affected by body fluids.

My preferred antiseptic is a combination of 2 percent CHG in 70 percent isopropyl alcohol (ChloraPrep, CareFusion) due to the combined immediate and persistent action against microorganisms. The applicator also minimizes direct hand-to-patient contact, helping reduce the risk of cross-contamination of microorganisms. Data suggest that intravascular devices (IVDs) are now the leading cause of BSI, with an estimated 250,000 to 500,000 IVD-related BSIs occurring each year. Therefore, it is crucial to adhere to proper skin preparation protocols, with the above considerations in mind, for all peripheral IV insertions.

Q What tips do you have for wound care following the procedure to reduce the risk of infection?

A Have a discussion with your patients to ensure they fully understand postoperative instructions, including any bandage care needed. Patients should leave the dressing on their incision for 24 to 36 hours. After that time, epithelialization has occurred and the wound can be cleaned with soap and water. The patient should employ special care to be certain that the wound stays clean.

Q With less reimbursement for healthcare-associated infections, now is a good time for facilities to reevaluate their infection-control processes and techniques, correct?

A That’s a good point. Each facility should consider which practices are contributing to successful patient outcomes and cost reduction and which areas could be improved. For the implementation of any new protocols to be successful, they have to have the buy-in and confidence of those healthcare professionals on the front lines of patient care. Not only should they be assured that suggested protocols are scientifically sound, but there also needs to be a collaborative culture that encourages adherence.