Professor of Surgery
Department of Surgery
Krankenhaus der Elisabethinen Linz
Academic Teaching Hospital of the Medical
Universities of Innsbruck and Vienna
Past President, SIS-E
Surgical site infections (SSIs) are a well-known problem in healthcare. Recently, they have been the focus of some interest due to data from studies in surgical patients. SSIs are the most common nosocomial hospital-acquired infection, making up 14–28% of all nosocomial infections. SSIs are of significant consequence for surgical patients, causing longer hospital stays, particularly in ICUs, increased readmission rates and increased healthcare costs.
The most striking feature is that mortality rates markedly increase in patients suffering from SSIs compared with patients without SSI. In a French survey, Astagneau and colleagues reported a mortality rate of 1.3% in patients without and 5.8% in those with SSI. In this study, mortality was directly related to SSI in 38% of cases.(1) The frequency of SSIs varies depending on the procedure (see Box 1).
Several risk factors have been identified in the development of SSIs, such as adiposity, smoking, malnutrition, immunosuppression, emergency operation and wound class. However, because influence on these risk factors is very limited, strategies to fight SSIs are concentrated on appropriate antibiotic prophylaxis, avoidance of intraoperative hypothermia and postoperative infection surveillance. It has been demonstrated that the introduction of surveillance programmes, which train healthcare staff and increase awareness, can reduce the reported rate of SSIs.
It has also been shown that reducing surgical and perioperative trauma by minimally invasive surgery or by introducing the fast-track concept can further decrease the occurrence of SSIs. Nevertheless, SSIs remain a problem (see Figure 1). The recent rise in the use of microbial sealants can help to reduce their occurrence. The underlying idea is to “trap” bacteria at skin level in order to stop them from migrating into surgical incisions. Studies have shown that endogenous skin flora plays a key role in the development of SSIs. Bacteria isolated from infected wounds are often those found at skin level, such as Staphylococcus aureus, MRSA, Staphylococcus epidermis and E coli. Infections can develop even when wounds have been prepared and disinfected correctly. It is not possible to completely sterilise the skin before incision, and so the exposed tissues remain at risk for contamination. Locking bacteria at skin level and preventing their migration into the incision wound therefore makes sense.
In-vitro studies in a surgical incision model demonstrated that the microbial sealant cyanoacrylate (InteguSeal(®)) was able to reduce the occurrence of MRSA by 99.9%, Staphylococcus epidermis by 99.5% and E coli by 96.6%. The sealant is topically applied and forms a film on the skin surface. It has been demonstrated to be compatible with common surgical techniques and materials and can be used with different sterilisation wraps and also with incise drapes. It is not inflammable, and there is no need to remove this film for skin closure. As it works by locking bacteria, there is no influence on bacterial resistance mechanisms.
Microbial sealants in use
A feasibility study demonstrated that microbial sealants were easy to use and did not interfere with the routine skin sterilisation and preoperative preparation of the incision area. We at the department of surgery, Krankenhaus der Eizabethinen, Linz, took part in this feasibility study and can report that these microbial sealants are easy to handle and that their use is uncomplicated. According to our spectrum of surgical specialties, we used the microbial sealant in general surgery, especially in laparotomies and conventional hernia repair, as well as in thoracic and vascular surgery.
Microbial sealants have been demonstrated to immobilise endogenous skin flora and block their migration into incisional wounds. Their clinical application was found to be easy and uncomplicated. Microbial sealants could be a step forward in reducing the incidence of SSIs. However, despite these early promising results, further clinical research is required to verify this concept in clinical practice at a high scientific evidence level.
- Astagneau P, Rioux C, Golliot F, et al. Morbidity and mortality associated with surgical site infections: results from the 1997-1999 INCISO surveillance. J Hosp Infect 2001;48:267-74.
Why do patients die postoperatively? Surg Inf 2007;8:151-8.