SAN DIEGO – Some almost universally accepted measures against hospital-acquired infections are more costly, annoying, and time consuming than they’re worth, presenters agreed during a panel discussion at the annual clinical congress of the American College of Surgeons.
Intra-abdominal antibiotic irrigation, chlorhexidine bathing, and even postsurgical antibiotic infusions have not consistently been shown to reduce infections. These measures do, however, ratchet up costs and can contribute to antibiotic resistance.
Some of these and other measures to prevent nosocomial infections may indeed reduce the risk, but the gain is small, said Charles H. Cook, MD.
“Chlorhexidine bathing, for example, is touted by many as a panacea for all the infections we’re talking about,” said Dr. Cook, a critical care surgeon at Beth Israel Deaconess Medical Center, New York. “A recent meta-analysis in critical care units did find a reduced relative risk of 0.44 for central line bloodstream infections. But you needed to bathe 360 patients to prevent one infection. It’s what I call a long run for a short slide.”
Therese Duane, MD, FACS, agreed. A surgeon at the John Peter Smith Hospital, Ft. Worth, Tex., Dr. Duane reviewed three different guidelines for the prevention of surgical site infections: the ACS and Surgical Infection Society, the World Health Organization, and the Centers for Disease Control and Prevention. In looking for similarities between the documents, she said she found several well-accepted practices that just aren’t supported by good data.
Presurgical antimicrobial infusions got a strong thumbs-up from all the groups, but only under a very specific circumstance: The medication has to be administered well in advance of surgery for it to be effective.
“Your goal is to get the appropriate concentration into the tissues by the time of incision,” Dr. Duane said. “It takes time to get there – if you give it after the incision, you have bleeding and cellular death, and the antimicrobials cannot get to that incision and do their job. If I’m starting a case and they haven’t been given, I don’t ever start them after the incision, because then you have all of the risks and none of the benefits. In my opinion, we need to move to no further antimicrobials once the incision or case is over because it serves no purpose and is inconsistent with good antibiotic stewardship.”
Adhesive drapes got a resounding “eh” from the guidelines, Dr. Duane said. “You really do not need them. They’re expensive and they’re not improving outcomes, so don’t waste your time or money. We need to think about minimizing what isn’t helpful and maximizing the things that are worthwhile. That’s the way to practice good socially responsible surgery without breaking the bank,” she said.
Antimicrobial sutures got weak recommendations, Dr. Duane said. The evidence supporting their use was not very strong, although she said she feels triclosan-coated sutures are helpful in all kinds of surgery. Preoperative showering with an antiseptic received strong support, with alcohol-containing preps superior to chlorhexidine, which is better than povidone-iodine–containing solutions.
Deep-space irrigation with aqueous iodophor also received a weak recommendation, but Dr. Duane said the evidence does not support the use of antibiotic-containing irrigation in either the abdomen or the incision. “And the guidelines came out strongly against using antimicrobial agents on the incision,” she said. None of the guidelines issued a recommendation for or against antimicrobial dressings.
Protocolized infection-control bundles are a very great help in reducing the incidence of surgical site infections, Dr. Duane added. “They increase attention to detail and decrease the rates of infection.”
Dr. Cook agreed. “Central line bundles are one of the things that work” for line-associated bloodstream infections, he said. Since their large-scale adoption, mortality from these infections has dropped significantly; it was hovering around 28,000 per year in the mid-2000s, he said. “That’s about how many men die from prostate cancer every year.”
Central line infections are very costly too, he added – around $46,000 per event. “That comes to around $2 billion in direct and indirect costs every year.”
A 2006 study demonstrated the efficacy of central line bundles in the fight against these potentially devastating infections.
The bundled intervention comprised hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters. The median rate of catheter-related bloodstream infections per 1,000 catheter-days decreased from 2.7 at baseline to 0 at 3 months after implementation of the study intervention.
Antibiotic-coated or impregnated catheters do not work as well. A 2016 Cochrane review of 57 studies determined that the devices didn’t improve sepsis, all-cause mortality, or catheter-related local infections.
The jury may still be out on coated dressings or securing devices, however. Another Cochrane review, of 22 studies, found a 40% decrease in central line–associated bloodstream infections with these items. “There was moderate evidence that tip colonization was reduced, but the authors said more research is needed.”
The evidence looks stronger for alcohol-impregnated port protectors, Dr. Cook said. Two studies in particular support their use. In an oncology unit, the rate of these infections dropped from 2.3 to 0.3 per 1,000 catheter days after the port protectors were instituted.
In the second study, infection rates declined from 1.43 to 0.69 per 1,000 line-days after the protectors came on board.
“The advantage was seen mostly in ICUs, so the recommendations are to use them there,” Dr. Cook said.
Neither Dr. Cook nor Dr. Duane had any relevant financial disclosures.
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