Important issues on the prevention of surgical site infections and the management of prophylactic antibiotics

Abstract

In this article, we have addressed the recent published article by Wang et al which examines risk factors associated with surgical site infections (SSIs) and evaluates the effectiveness of prophylactic antibiotics in their prevention. Wang et al identified several significant risk factors of SSIs, including age ≥ 60 years, diabetes mellitus, and surgical complications such as insufficient cystic duct stump closure, gallbladder perforation, empyema, and postoperative hematoma. Their findings suggest that prophylactic antibiotics can serve as a protective factor against SSIs. However, other reported risk factors and preventive strategies warrant consideration to further reduce the incidence of SSIs, lower healthcare costs, and enhance patient outcomes. Additionally, the judicious use of prophylactic antibiotics is crucial in light of the growing global challenge of antibiotic resistance caused by the misuse and overuse of antibiotics. Effective management strategies for prophylactic antibiotic use should be prioritized to balance infection control with the need to combat antimicrobial resistance.

Key Words: Surgical site infections; Prophylactic antibiotics; Risk factors; Preventive measures; Management

Core Tip: The occurrence of surgical site infections is associated with patient’s characteristics and surgical factors. Preventive strategies such as risk assessment, disinfection, and enhanced nutrition are essential to reducing the incidence of surgical site infections and healthcare expenditures and improving patient’s clinical outcome. In addition, the use of prophylactic antibiotics should be individualized and precise.

TO THE EDITOR

We read with great interest the recent article by Wang et al[1] entitled “Evaluating risk factors for surgical site infections and the effectiveness of prophylactic antibiotics in patients undergoing laparoscopic cholecystectomy”, which demonstrated that age, diabetes, and certain surgical complications could impact the occurrence of surgical site infections (SSIs) in patients undergoing laparoscopic cholecystectomy based on a retrospective analysis, highlighting that effective management of these factors and the use of prophylactic antibiotics can reduce the incidence of SSIs. Surgical incisions often expose sterile tissues to the outside environment which make it difficult to prevent contamination[2]. This is a common and serious complication occurring after surgery, with a global incidence of 2%-3% and up to 20% of some iatrogenic infections, which together have a significant negative impact on patient recovery and the global healthcare system, especially in the context of increasing antibiotic resistance and increased surgical complexity[3]. In recent years, although the incidence of SSIs has reduced to a certain extent with the advancement in aseptic technique and optimization of perioperative antibiotic management, the prevention and control of SSIs continues to face several difficulties.

INFLUENCING FACTORS OF SSI’S

Individual factors

Extensive research has identified advanced age, obesity, and tobacco use as significant risk factors for SSI development[4,5]. The Asia Pacific Society of Infection Control Guidelines for SSI prevention also highlight these factors, defining older age as 65 years and above[6]. Wang et al[1] similarly observed a heightened risk of SSIs in older patients, attributing this to a weakened immune response and reduced physiological reserve. Additionally, preoperative metabolic abnormalities play a critical role in increasing SSI risk. A meta-analysis of 13 million individuals found that metabolic syndrome is associated with a significantly elevated risk of all types of SSIs (odds ratio = 1.64; 95% confidence interval: 1.52-1.77; P < 0.01)[7]. Obesity, particularly with a body mass index (BMI) ≥ 35 kg/m², has also been shown to increase SSI risk, as evidenced in a retrospective study on abdominal wall reconstruction patients[8]. The role of preoperative comorbidities, especially diabetes mellitus, is critical. Wang et al[1] emphasized the importance of stringent perioperative glycemic control, as poor preoperative glycemic management are well-documented high-risk factors for SSIs. Long-term hyperglycemia reduces the body’s immunity and fosters high-sugar conducive to microbial growth[6,9]. Hypertension is another comorbidity associated with SSI risk[10,11]. Poorly managed hypertension increases the likelihood of intraoperative bleeding, complicates surgical procedures, and impairs wound healing due to long-term vascular changes. Other conditions, such as chronic obstructive pulmonary disease, further elevates SSI risk. Long-term glucocorticoid use in chronic obstructive pulmonary disease patients can lead to immune dysfunction[12]. Peripheral vascular disease and coronary artery disease are also significant risk factors, likely due to impaired white blood cell chemotaxis[13,14]. Approximately 70%-95% of SSI are attributed to the patient’s endogenous flora[15]. Additional factors, such as recent radiotherapy and a history of skin or soft tissue infections, may disrupt the patient’s microbiome and immunity, further increasing SSI risk[6].

Surgery-related factors

Surgical complexity, prolonged operation time, and intraoperative blood loss are key contributors to the incidence of SSIs. Schlager et al[16], in a review of 25928 surgical procedures across 15 observational studies, reported higher SSI rates in cases involving local flaps and skin grafting. A separate meta-analysis of 32 studies identified complex operations, such as deficit repairs, neck dissections, mandibular surgeries, tracheostomies, as significant risk factors[17]. Laparotomy and blood transfusion have been consistently associated with increased SSI risk[17-19]. Patients with a history of surgeries face an elevated likelihood of developing adhesions, which can complicate subsequent procedures, extend operation times, and heighten SSI risk. For example, a meta-analysis of 23 studies identified prior knee surgery and the use of hamstring autografts as risk factors for SSIs following anterior cruciate ligament reconstruction[5].

Medications

The use of medications such as steroids, immunosuppressants, and biologics is associated with an increased risk of infection due to their immunosuppression properties[5,16]. Clindamycin, an antibiotic, has been identified as a significant risk factor for SSIs in patients with head and neck cancer[17]. Conversely, perioperative antibiotics have been shown to significantly reduce the risk of SSIs, particularly in high-risk procedures such as abdominal surgeries and organ transplants[20]. However, inappropriate use of perioperative antibiotics can elevate the risk of SSIs. A multicenter randomized controlled trial in Japan found that intravenous antibiotics alone, without preoperative oral antibiotic prophylaxis, were associated with higher SSI rates during laparoscopic colon surgery[21]. Indiscriminate or improper antibiotic use has further exacerbated the emergence of drug-resistant bacterial strains, making antibiotic resistance a critical public health concern. Studies have indicated that over-reliance on broad-spectrum antibiotics, especially prolonged postoperative use, significantly increases the prevalence of drug-resistant infections[22].

Preoperative nutritional status

Nutritional deficiencies are a key risk factor for SSIs. Chen et al[18] analyzed published studies on gastric cancer patients and found anemia and hypoproteinemia were significant contributors to SSI risk. Additionally, BMI < 20 kg/m² was identified as a major risk factor for SSIs in head and neck cancer patients[17]. A meta-analysis by Xie et al[23], involving 24 studies and 179388 patients, confirmed that malnutrition is a significant predictor of SSIs (odds ratio = 1.811; 95% confidence interval: 1.512-2.111; P < 0.001). Similarly, a review on spinal surgeries revealed that malnourished patients, particularly those undergoing thoracolumbar or sacral procedures, are more prone to SSIs[24]. To mitigate these risks, the European Society for Clinical Nutrition and Metabolism recommends early preoperative nutritional support and supplementation for malnourished surgical patients, which can effectively reduce SSI risk[25].

PREVENTION STRATEGIES OF SSI’S

Risk prediction

The American Society of Anesthesiologists (ASA) score is a widely used classification system developed by the United States Society of Anesthesiologists for surgical patients. This system is used to predict perioperative risks based on patients’ physical status and surgical factors, including BMI and comorbidities. An elevated ASA score has been consistently associated with an increased risk of SSIs[26]. Patients with high ASA scores should be closely monitored and provided with individualized care. The United States Centers for Disease Control and Prevention (CDC) uses the National Healthcare Safety Network for SSI surveillance. A study employing stepwise logistic regression on National Healthcare Safety Network data developed risk-specific models by surgical type, improving the predictive accuracy of SSI risk[27]. Similarly, Wang et al[1] utilized univariate and multivariate logistic regression to identify risk factors for laparoscopic cholecystectomy, tailoring a predictive model for laparoscopic procedures. Preoperative laboratory tests can provide valuable insights into SSI risk. Key markers include preoperative albumin < 3.5 mg/dL, total bilirubin > 1.0 mg/dL, and hemoglobin A1c level of ≥ 8%, indicating poorly controlled diabetes, requires immediate attention[6]. Additionally, inflammation-related markers should be monitored to detect potential infections early, enabling timely interventions to reduce SSI risk.

Surgical management

Effective SSI prevention requires meticulous management across the preoperative, intraoperative, and postoperative stages. The operating room environment and equipment must adhere to stringent hygiene standards, with thorough cleaning and disinfection of the surgical area prior to the procedure[9]. Nurses should ensure proper preparation by organizing surgical tools and dressings, verifying counts, and supporting the surgical team efficiently. Adherence to aseptic techniques and robust postoperative wound care are essential components of infection control[28]. Clinicians must also monitor and regulate patient’s body temperature and positioning during surgery to minimize complications. Emerging infection prevention strategies, such as antibacterial drug coatings and advanced disinfectants, are proving effective. For instance, antibacterial coatings can significantly reduce postoperative infection rates, particularly in high-risk surgeries such as orthopedic and neurosurgical procedures[29]. Antimicrobial-loaded cement and beads have been instrumental in managing infections in orthopedic surgeries[30]. Silver- and iodine-based dressings are widely used for their potent antibacterial properties[31]. Dialkylcarbamoyl chloride-coated dressings have shown promise in reducing SSIs, as indicated by a systematic review of 17 studies involving 3408 patients[32]. Similarly, antibiotic-coated absorbable sutures, such as triclosan-coated sutures, are increasingly employed in surgeries to lower bacterial loads and promote wound healing. These have proven especially effective in abdominal surgeries and are recommended in guidelines by the CDC and the World Health Organization[33-35].

Optimization of antibiotic use

The administration of surgical antibiotic prophylaxis within 120 minutes before surgery is a cornerstone of SSI prevention[36]. The effectiveness of prophylactic antibiotics in reducing SSIs is supported by the article under discussion[1]. For adult patients undergoing elective colorectal surgery, a combination of mechanical bowel preparation and oral antibiotics, in addition to standard intravenous antibiotic prophylaxis, is recommended[36]. Postoperative surgical antibiotic prophylaxis duration should be determined by the type of surgery, with most guidelines advocating a maximum duration of 24 hours[36].

Recent studies emphasize the importance of individualized prevention strategies, tailored to the surgical site and the patient’s health status. Common pathogens associated with SSIs include Staphylococcus aureus (S. aureus), coagulase-negative staphylococci (CoNS), and Escherichia coli[33,37]. Targeted antibiotic regimens, based on surgical type and patient factors, significantly improve SSI prevention[37,38]. For S. aureus, first-generation cephalosporins and antistreptococcal penicillin are commonly used[33]. Preoperative nasal decolonization with intranasal mupirocin ointment, combined with or without chlorhexidine gluconate soap, is recommended for carriers[35]. However, methicillin-resistant S. aureus (MRSA) poses a significant challenge due to its resistance to most β-lactam antibiotics through a change in the properties of penicillin-binding proteins[39]. In cases of MRSA colonization or high institutional MRSA rates, vancomycin may be employed, though its usage must be strictly monitored to avoid resistance development[33,39]. CoNS species are increasingly resistant to common antimicrobials, including methicillin[40]. Although rare, resistance to vancomycin in CoNS has been reported, underscoring the need for the cautious use of this antibiotic to prevent resistant strains[41]. Surveillance data from the China Antimicrobial Resistance Surveillance System highlight the high resistance of Escherichia coli to quinolones (e.g., levofloxacin and ciprofloxacin). Consequently, the perioperative use of these drugs should be regulated to limit resistance development[42]. The medical community is increasingly adopting individualized antibiotic treatment strategies based on etiological evidence. Studies have demonstrated the benefits of precise antibiotic selection through preoperative microbial culture and pathogenic testing (e.g., multiplex PCR panels). This approach effectively reduces the incidence of SSIs, while alleviating the pressure of drug-resistant strain selection[43,44]. Additionally, hospital infection control committees play a critical role in supervising rational antibiotic use and minimizing unnecessary prescriptions. In the United States, the CDC has implemented a national hospital antimicrobial use and management model, introducing the standardized antimicrobial administration ratio. This tool quantitatively assesses prescribing practices, identifies areas for improvement, and evaluates the impact of interventions[45,46].

Enhanced nutritional support

Nutritional status is a critical determinant of surgical outcomes. Healthcare workers should use validated nutritional screening tools to identify malnutrition and provide targeted nutritional support[47]. Dietary guidance on adequate protein, vitamin, and mineral intake can improve immune function and overall health[9]. A retrospective study suggested that improving vitamin D levels can reduce SSI incidence[48]. For patients with a BMI of < 18.5 kg/m² undergoing major surgery, oral or enteral nutrient-enhanced formulas should be prioritized[36]. However, prophylactic feeding tube placement is not recommended, as it may harm the patient and delay procedures[36].

CHALLENGES

The coronavirus disease 2019 pandemic has posed unprecedented challenges to global healthcare systems, including SSI prevention and control. Disruptions in preoperative infection screening and postoperative infection management have complicated prevention efforts. However, measures such as enhanced hand hygiene and stricter disinfection protocols have contributed to reducing some infection risks[49]. Lessons from pandemic control efforts have driven improvements in operating room air purification systems and aseptic operation procedures, offering new perspectives on SSI prevention[50]. Developing predictive models tailored to specific patient populations is vital. Strategies should include epidemiologically significant infection definitions, stratified analyses of SSI risk factors, and effective data feedback mechanisms. The transition from generalized to individualized prevention measures is crucial, as patient-specific factors - such as immune status, genetic background, and pathogen characteristics - significantly influence the risk of infections[51]. Emerging genomics and multi-omics technologies are poised to revolutionize SSI prevention. These tools can identify susceptibility genes and biomarkers, enabling highly personalized preoperative risk assessments and precise infection control strategies.

CONCLUSION

Preventing SSIs and managing antibiotics are critical for surgical success, especially amid rising surgical complexity and antibiotic resistance. While Wang et al[1] effectively highlighted SSI risk factors, conventional preventive measures, and antibiotic challenges while proposing individualized, evidence-based approaches. Future research should integrate multi-omics technologies to develop personalized prevention programs. Rational antibiotic use, informed by precise microbial diagnostics, is vital to mitigate resistance and improve patient outcomes. Additionally, incorporating lessons from pandemic control - such as improved aseptic techniques and optimized preoperative screening - combined with robust nutritional support can significantly advance SSI prevention and control. By adopting these strategies, we can enhance postoperative outcomes and reduce the burden on global healthcare systems.