Nosocomial infections, also known as healthcare-associated infections (HAIs), are acquired in a healthcare setting and were not present at the time of admission. For surgical patients, the primary concern is the Surgical Site Infection (SSI), an infection related to the operative procedure occurring at or near the incision within 30 days (or up to a year if an implant was used). SSIs are frequent types of HAI, increasing patient suffering, hospital stay duration, and healthcare costs. The surgeon, as the leader of the perioperative team, holds responsibility for implementing preventative measures that span the entire patient journey.
Pre-Surgical Patient Optimization and Preparation
A surgeon’s role in preventing infection begins well before the patient enters the operating room by systematically addressing modifiable patient risk factors. Certain underlying health issues can compromise a patient’s immune function and ability to heal, making them more susceptible to an SSI. For example, in patients with diabetes, strict maintenance of blood glucose levels is a recognized measure that supports the body’s natural defenses.
The surgeon should also encourage the patient to engage in health-improving behaviors, such as smoking cessation, ideally at least 30 days before the procedure. Tobacco use constricts blood vessels, limiting oxygen and nutrient supply to the surgical wound and impeding healing. Likewise, malnutrition or anemia should be corrected preoperatively to ensure the patient has the necessary building blocks for tissue repair and a robust immune response.
Antimicrobial prophylaxis is another tool in the pre-surgical phase, designed to achieve an adequate concentration of antibiotic in the patient’s tissue before the incision is made. The selection of the agent should be based on the type of surgery and the pathogens most likely to cause contamination. Guidelines recommend administering the antibiotic intravenously within the 60-minute window immediately preceding the surgical incision.
Precise timing ensures the drug reaches its maximum therapeutic level in the tissue when the skin barrier is breached. For certain drugs, such as vancomycin, the infusion time is extended to 120 minutes to prevent adverse reactions. Hair removal, if necessary, should be performed immediately before the operation using electric clippers, as shaving with a razor increases the risk of infection. Preoperative skin preparation is finalized by applying an antiseptic agent, often an alcohol-based solution, to minimize the microbial load on the skin surface.
Maintaining Asepsis During the Operation
During the operation itself, the surgeon’s direct actions and adherence to strict protocols are paramount for preventing microbial contamination of the wound. Meticulous surgical technique involves carefully handling tissues to minimize trauma and preserving the blood supply to the wound edges. Excessive use of electrocautery and poor hemostasis can both create devitalized tissue or hematomas that serve as excellent mediums for bacterial growth.
The duration of the operation is an independent risk factor for infection, with the likelihood of an SSI increasing the longer the procedure lasts. This emphasizes the importance of efficient and well-planned surgical execution to minimize the patient’s exposure time. For lengthy procedures, typically those exceeding four hours, the surgeon must ensure that the prophylactic antibiotic is redosed intraoperatively to maintain therapeutic tissue levels.
A surgeon’s discipline extends to controlling the operating room environment by limiting unnecessary personnel and movement. Each time the operating room door opens, the sterile field is exposed to outside air particles and airborne contaminants. Limiting the frequency of door openings is associated with a decrease in SSI incidence.
Maintaining the patient’s core body temperature, or normothermia, throughout the procedure is also a direct responsibility of the surgical team. Hypothermia impairs the body’s immune response and decreases the oxygen supply to the wound, both of which hinder the ability to fight off invading bacteria. Additionally, the proper management of foreign materials, such as implants and sutures, involves ensuring they are handled aseptically and that the choice of suture material is appropriate for the wound tension and healing characteristics.
Post-Surgical Surveillance and Wound Management
The final phase of infection prevention involves managing the healing wound and temporary devices in the post-operative period. The initial sterile dressing placed on the incision acts as a physical barrier against external contamination. Guidance recommends that this dressing remain undisturbed for a minimum of 48 hours, and up to four days, unless there is concern for leakage or developing infection symptoms.
The timely removal of temporary devices, which represent foreign portals for bacteria to enter the body, is a straightforward but impactful preventative measure. While indwelling urinary catheters are typically removed within the first two post-operative days, other devices like central venous lines should be removed as soon as they are no longer necessary for patient management. Routine replacement of central lines is not recommended, but the need for the line must be assessed daily.
Surgical drains remove fluid that could become a culture medium for bacteria, but they also act as a foreign body that can be colonized by pathogens. Modern practice favors earlier removal, often at the time of discharge irrespective of output volume, to reduce the infection risk associated with their prolonged presence. The surgeon establishes clear protocols for monitoring the patient for signs of infection, such as fever, increasing pain, or unusual discharge from the wound. This surveillance extends for 30 days post-operation (or longer if an implant was placed) and includes providing the patient and caregivers with clear instructions on wound care and signs that warrant immediate contact.