Preventing Surgical Site Infections: How Patients & Physicians Can Work Together

According to Infectious Disease Advisor, approximately 27 million surgical procedures are performed in the United States each year, with up to 5% resulting in surgical site infections (SSI). This is because skin acts as a natural barrier against external factors that can cause infections—and when this barrier is broken during a surgery, it places a patient at a higher risk of infection.

Here's what I want my patients to know about SSIs—and how we can work together to lower their risk.

How do surgical site infections happen?

Surgical site infections happen through the spread of bacteria, such as Staphylococcus, Streptococcus, and Pseudomonas in most areas of the body.

Bacteria can infect a surgical wound:

• From the touch of a contaminated caregiver
• Through airborne pathogens
• Through microorganisms that were already on or in the body during the time of the surgery that make their way into the incision.

Remarkably, the most common bacteria to cause infection after shoulder surgery is Cutibacterium acnes—which is the same bacteria that is related to acne that can affect skin on the face or back.

Hospital-associated infections

Having surgery in a hospital carries a higher risk of infection as compared to the same procedure done at an ambulatory service center (ASC). In a 2009 study of surgeries completed in hospital, SSIs occurred in approximately 2% of surgical procedures, while a 2013 study of surgeries done on an outpatient basis in a multi-specialty ASC showed a decreased rate of SSIs at 0.81%. The rate of infection fell even lower at single specialty ASCs to just 0.38%.

Certain types of infection have an increased risk of occuring in a hospital setting, such as: 

• Methicillin-resistant Staphylococcus aureus infection (MRSA) – This infection can spread through touch, such as from a healthcare worker with unclean hands or a contaminated surface that came into contact with the patient during surgery.
• Vancomycin-resistant enterococcus (VRE) – This infection typically spreads when a healthcare worker touches an infected surgical instrument, surface or person and fails to properly wash their hands before touching another patient. 

Who is at the highest risk for surgical site infections?

Patients who are very old or very young are at a higher SSI risk. Other factors that increase the risk of an SSI include:

• Diabetes
• Tobacco use
• Obesity
• Compromised immune systems
• Poor nutritional status
• Existing medical conditions and diseases 
• A surgery that lasts longer than two hours
• A longer hospital stay

Patients with SSIs are more than five times more likely to be readmitted to the hospital after discharge and are 60% more likely to need admission to the intensive care unit.

How to prevent surgical site infections

There are several steps patients and physicians can take before, during, and after surgery to lower the risk of infection. 

Before Surgery

Quit smoking. Tobacco use increases your chances for infection, so Dr. Romeo will ask you to quit smoking for at least four weeks before surgery to mitigate this risk as well as the risks of anesthesia due to smoking. 

Avoid shaving. Patients should avoid shaving the area where they will be having surgery, as this can irritate the skin and make it easier to develop an infection. If hair removal is necessary at the surgery site, it is best to let the surgical team perform this task on the day of surgery.

Wash the area of the surgical incision. In addition, since the most common infection around the shoulder is C. acnes, you will be asked to wash the area of the surgical incision for two mornings before and the morning of surgery with a cleaning solution that includes benzoyl peroxide. Over-the-counter skin cleansers are available at pharmacies and other stores with skin care products.

Use intravenous antibiotics. One hour before a shoulder replacement, patients receive intravenous antibiotics to help protect the surgical site during the procedure. They will also receive one more dosage of the antibiotic after the procedure. 

During Surgery

Wash and gown. All operating room staff thoroughly wash their hands and arms up to their elbows with an antiseptic agent. They also wear special hair covers, masks, gowns and gloves during surgery to keep the surgery area clean.

Clean the surgical site. The skin around the surgery site is also cleaned with a special germ-killing soap, as well as hydrogen peroxide, which targets the C. anes bacteria.

Irrigate and apply powder. During open shoulder surgery, once a shoulder reconstruction or replacement is completed, the surgical site is irrigated with a diluted betadine solution, followed by the application of an antibiotic powder to the surgical site, which can kill the most common bacteria associated with surgical infections.

After Surgery

Keep the surgical area clean. Any visitors—including healthcare workers, friends, and family—should thoroughly clean their hands with soap and water or an alcohol-based rub. No one should touch the wound or dressings unless given instructions by the doctor to do so. 

Finish a course of antibiotics. After surgery, a patient may be started on antibiotics by the doctor if there is some concern of a higher risk of infection, such as a history of previous surgery for shoulder replacement. It is extremely important to finish all of the prescribed antibiotics. In a recent study, patients who took all their antibiotics had an SSI rate of 3.3% (24 of 718 patients), while those which were non-compliant had a rate of 8.1% (5 of 62). 

Care for the incision. Patients should carefully follow any instructions from their doctor on how to care for their incision after surgery, including:

• Calling the doctor if they notice redness, swelling, heat, pain, tenderness, or drainage from the surgical incision (Note: some watery drainage from the small incisions used for arthroscopic surgery is normal for the first 24 hours)
• Attend all post-operative appointments to get incision checked
• Keep the incision and your surroundings as sterile as possible while changing dressings
• Keeping the incision dry at all times

The role of good nutrition as prevention

Good nutrition is also an essential part of preventing an SSI, so embrace your leafy greens and foods with good protein content. Eating high-quality foods before and after your surgery will boost your nutrition and lower your risk of inflammation. Before surgery, patients can work with a dietitian or use nutritional supplement kits.

While the risk of developing an SSI cannot be completely eliminated, patients and physicians can work together to lower the risk. What would you add? Please add in the comments!

I've spent my career in the pursuit of excellence for my patients by pioneering new approaches to shoulder replacement surgery and developing advanced orthopaedic implants and surgical procedures supported by cutting-edge research and patient-focused outcomes.

Currently, I serve as the Chief Medical Editor of Orthopaedics Today and the Executive Vice President of Duly’s state-of-the-art Musculoskeletal Institute. Learn more about my practice and research on my website.