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

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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