Doctors Bolster Defenses Against Surgery Infections

Making Progress Against Infections

Linda Fan, MD, saw a significant reduction in surgical site infections among hysterectomy patients. She gives credit to a variety of improvements to care instituted by Yale Medicine and Yale New Haven Hospital.

Credit: Robert A. Lisak

Guidelines help care givers and patients avoid infections after surgery.

Guidelines for patients to avoid infections
  • Stop smoking. Doctors believe smoking decreases oxygen delivery to the wound, raising the risk of infection.
  • Lose weight if you need to. There is evidence that obesity has a negative impact on immune function, putting obese people at higher risk for wound infections.
  • Before surgery, bathe or shower using plain soap or an antimicrobial soap, as directed by your surgeon or hospital.
  • Never shave before an operation, since doing so can irritate the skin and allow bacteria to get in.
  • Ask visitors, including your healthcare providers, to wash their hands before arriving at your bedside.

In May of this year, a 49-year-old Pennsylvania woman came down with the first known United States case of a rare E. coli “superbug” that is resistant to colistin, a type of antibiotic that is used to treat people only when other antibiotics fail. In September, a 2-year-old girl in Connecticut became the fourth person in the country to get the potentially deadly bug.

Fortunately, the superbug—an informal term for bacteria that has become antibiotic-resistant—did not spread beyond the four patients. But there have been other scares involving other difficult-to-treat infections. In response to concerns, medicine’s governing bodies and Yale Medicine physicians have been strengthening their defenses against superbugs and other infections.

This month, the World Health Organization (WHO) issued 29 new recommendations aimed at avoiding infections and putting a halt to dreaded superbugs.  The WHO guidelines were developed by 20 leading experts based on 26 reviews of the latest evidence and published this month in The Lancet Infectious Diseases. They can be found in “Global Guidelines for the Prevention of Surgical Site Infection.” 

Reducing Infections at Surgical Sites

Meanwhile, performance improvement teams at Yale New Haven Hospital (YNHH) have spent more than a year refining the hospital’s infection-protection guidelines in two high priority areas: spine surgery, in addition to knee and hip replacements; and transabdominal operations, such as colon surgeries. These teams include Yale Medicine surgeons, anesthesiologists and infectious disease specialists, as well as nurses, pharmacists, and hospital leaders in infection prevention and perioperative services. The refinements are in line with the new WHO recommendations.

Earlier refinements at YNHH have already brought a significant reduction in infections for hysterectomies performed in 2015: Patients had 14 percent fewer infections than would be expected based on national data. Surgeons typically perform 700 to 800 hysterectomies a year at the hospital.

“This was a huge success. It was really a lot of persistence, a lot of teamwork,” says Linda Fan, MD, a female pelvic medicine specialist and director of Yale Medicine Gynecology. “We looked at all the different phases of care: before, during and after surgery.”  Dr. Fan, who was involved in establishing the hysterectomy guidelines, gives credit for the success not to any one change, but to a variety of improvements to care.

A focus on surgical-site infections

Richard Martinello, MD, says two teams focused on preventing surgical-site infections at Yale New Haven Hospital are seeing promising results.

The focus is on reducing infections at the site of surgical incisions—including infections that can occur on the skin, in the muscles and tissue beneath the incision area, or deeper, in body organs or the spaces between organs. Priority was placed on refining procedures for the types of surgeries frequently performed at the hospital, says Yale Medicine infectious disease specialist Richard Martinello, M.D., who serves as medical director of infection prevention at the hospital.

The two teams have been working hard to standardize guidelines wherever possible across all types of surgeries. They have been refining their best practices for providing patients with blankets and warming devices prior to and during surgery, since cooler body temperatures increase risk for infection. Shaving body hair is no longer allowed preoperatively or in the operating room because it can cause tiny nicks and abrasions in the skin that make it vulnerable to infection. If hair must be removed, clippers are used.

Minimally Invasive Surgeries Lower Infection Risk

Dr. Fan says infection prevention is another reason to emphasize minimally invasive approaches to surgery whenever possible, since small incisions produce a lower risk of infection than the large wounds created in an open surgery.

The performance teams gave particular attention in the guidelines to appropriate use of antibiotics. The Centers for Disease Control and Prevention estimates at least 2 million people in the United States become infected each year with strains of bacteria that can’t be treated with antibiotics, and at least 23,000 die. Increased use of antibiotics is expected to hasten widespread resistance to them, posing threats to people who need them to treat such common bacterial infections as strep throat and pneumonia, and for protection when they undergo everything from hip replacements to cancer chemotherapy.

 “We want to make sure we provide antibiotics so our patients are protected all the way through their surgeries. But we need to be very careful and cautious.” Depending on the patient’s infection, Yale Medicine doctors may give one of a few dozen types of antibiotics they consider to be “workhorse” medications against infections. “We need to give the right antibiotic, at the right dose, at the right time,” Dr. Martinello says.

Yale Medicine doctors also are tracking patients’ records closely to monitor the types of infections that are arising at YNHH, figure out how they developed and measure rates of infection against national benchmarks.

They have yet to see a superbug on the scale of the colostin-resistant E. coli bacteria. However, Dr. Martinello says, “We need to be constantly vigilant.”