This column will appear in the upcoming May print issue of Surgical Products.

According to a recent analysis of the financial impact of healthcare-associated infections (HAIs), surgical-site infections (SSIs) account for the largest portion of HAI-related costs.  Additional costs attributed to a surgical-site infection range from $18,900 to $22,670 with costs as high as $82,670 if the infection is due to methicillin-resistant Staphylococcus aureus (MRSA).(1)  On average 2-5 percent of patients undergoing inpatient surgery develop a surgical site infection extending the length of stay by 11.2 days (23 days for MRSA). (1)  Beginning in 2008, Medicare no longer pays hospitals for additional costs associated with SSIs following heart bypass grafts, bariatric surgery, implantable electronic cardiac devices, and certain orthopedic procedures involving the spine, neck, shoulder, and elbow. (2)  In addition to the financial toll, there is a real human toll which includes suffering from complex wound treatments, lost work days and productivity, exposure to extended antibiotic therapy increasing the risk of Clostridium difficile-associated diarrhea, and most seriously a three percent mortality rate. (3)  Microorganisms that cause SSIs frequently originate from the patient’s own skin, mucous membranes, or intestinal tract, but the source can also be the surgical team, equipment or materials used during the procedure, or the operating room environment.  Some of the many factors that increase the risk of developing a surgical-site infection are age, obesity, smoking, diabetes, nasal carriage of Staphylococcus aureus, long procedure time, contaminated versus clean wound classification, hair removal with a razor, poor nutritional status, and inappropriate choice or timing of prophylactic antibiotic.  Not all risk factors are modifiable and there is no single solution for the prevention surgical-site infections. 

It is generally accepted that the best approach for preventing SSIs uses a bundle of evidence-based practices.  The Surgical Care Improvement Project (SCIP) is a well-known prevention bundle that focuses on modifiable risk factors.  SCIP measures are required for accreditation by The Joint Commission and include appropriate antibiotic administered within one hour of surgical incision, controlled blood sugar, appropriate hair removal, timely removal of urinary catheters, and perioperative temperature management.

Hand hygiene is the only infection prevention intervention that persists across the entire continuum of perioperative care.  Compliance with hand hygiene before and after patient contact is necessary for safe patient care during the preoperative, operative, and post-operative time periods.  Strict attention to hand hygiene and gloving during wound care and dressing changes during post-operative care is essential.  Hand hygiene is a fundamental component of SSI prevention bundles.
Less progress has been made in preventing surgical site infections than other HAIs. With current evidence-based interventions, 55 percent of SSIs are considered preventable. (4) Research and quality improvement efforts are clearly needed to determine which process measures and product innovations should be added to our existing infection prevention bundles. 

Much progress has already been made in products used for both routine hand hygiene and surgical hand antisepsis.  Alcohol-based handrubs are quick, easy, more effective, and less drying than soap and water for routine hand hygiene. Convenient placement of dispensers and personal carriage of individual bottles of handrub are helpful in the fast-paced environment of perioperative care. New alcohol-based handrub formulas that are effective in practical in-use volumes add to the value of these products. 

The introduction of alcohol-based preparations has also made significant improvements in surgical hand antisepsis.  Brushes and water-assisted scrubs are no longer needed and as far back as 2009, an independent Cochrane Review concluded that alcohol rubs are at least as, if not more, effective than aqueous scrubs. (5)  More recently, alcohol-based surgical scrub preparations without the addition of chlorhexidine gluconate (CHG) demonstrated the ability to meet Federal Drug Administration (FDA) efficacy criteria for immediate and persistent bacterial kill. (6)  This is good news for healthcare professionals who have found CHG containing products to be drying and a cause of skin irritation.

As we wait for randomized, controlled clinical trials of new interventions and products, it’s imperative that we implement all the components of evidence-based bundles that have been proven to prevent surgical-site infections.


1. Zimlichman E et al.  Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system.  JAMA Intern Med 2013;173(22):2039-46.
3. Awad SS.  Adherence to surgical care improvement project measures and post-operative surgical site infections.  Surg Infect 2012;13(4):134-7.
4. Umscheid CA et al.  Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.  Infect Control Hosp Epidemiol 2011;32(2):101-14.
5. Tanner J et al. Surgical hand antisepsis to reduce surgical site infection.  Cochrane Database of Systematic Reviews 2008, Issue 1.
6. Edmonds SL et al. Comparison of the in vivo efficacy of alcohol-based pre-surgical hand rubs: chlorhexidine gluconate is not necessary to meet FDA efficacy requirements.  2013 APIC 40th Annual Educational Conference and International Meeting.  Fort Lauderdale, FL.

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