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Is 'belt and braces' the best approach for preventing surgical site infections? – Part two

By: Ian Mason, PhD, March 4 2015Posted in: The Mölnlycke Health Care blog

Surgical site infections (SSIs) have a significant impact on patient morbidity and healthcare costs. This two-part article reviews recent research into risk factors for infection and appropriate preventive measures with particular focus on surgical gloves, preoperative antibiotics and double gloving practice.

In the first part of this article, we looked at a recent study1 that combats the dearth of evidence documenting the impact of glove perforation on risk of surgical site infection. The study established a strong correlation between SSI, glove perforation and use of preoperative antimicrobial prophylaxis. Without antimicrobial prophylaxis, there was a significant correlation between clinically visible glove perforation and occurrence of SSI. The infection rate was 12.7 percent with glove perforation, compared to 2.9 percent when asepsis was not breached – a statistically significant four-fold difference. This relationship was not apparent when patients had received antibiotics.

The authors of the study point to double gloving practice as one of the key factors. "The most effective method for lowering the frequency of leakage is double gloving, which reduces glove failure significantly from rates as high as 51 percent with single gloves to as low as 7 percent of inner glove puncture when two pairs are used. Furthermore, inner glove perforation rates are proving to be significantly lower with the use of indicator gloves (coloured latex undergloves to alert operators to perforations) than with the conventional variety."

Apart from these important results that lend evidentiary support to the concept of using more than one method to ensure safety, the study produced several other interesting findings. Firstly it verified the widely held suspicion that rates of surgical site infection are far higher than surgeons commonly record. In the study surgical staff documented only half of all in-hospital SSIs (48.7 percent), while the infection control team registered the remainder (51.3 percent). The poor performance of surgical staff in this respect led to a complete overhaul of the hospital's recording systems after the researchers found that infections were not being recorded due to the time taken to fill in the relevant registration forms when under time pressure to do other things.

To remedy this, an electronic SSI surveillance system has been introduced at the two hospitals involved in the study. This permits much faster registration of SSIs. The system also automatically generates reminder emails to surgeons if there is missing information about wound surveillance. As the authors point out, it is vital to have accurate SSI data due to the high cost of these infections. According to their results SSIs doubled mean length of hospital stay (an average additional postoperative hospital stay of 16.8 days and an additional 7.4 days of antibiotic therapy). This resulted in an overall mean increase in SSI-related hospital costs of 61 percent.

Another finding concerned timing of surgical antimicrobial prophylaxis (SAP). Patients who received SAP (CDC wound classes 3 [contaminated], 2 [clean contaminated] and 1 [clean] involving a nonabsorbable implant (or at the surgeon’s discretion if subsequent SSI would have proved a high risk to the patients) were given a single intravenous infusion of 1.5g of cefuroxime sodium, in conjunction with 500mg of metronidazole phosphate in colorectal surgery. In longer procedures, this dose was readministered every four hours through to the end of the procedure. While SAP was administered to most patients between 44 and 0 minutes before surgical incision, the lowest risk of SSI was recorded when the antibiotics were administered between 74 and 30 minutes before surgery. The authors commented on the lack of a current consensus regarding the use of SAP in clean surgery. They say that their results support and extended indication of SAP to all clean procedures in the absence of strict precautions taken to prevent glove perforation. They conclude that without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI. Routine change of gloves or double gloving is recommended in the absence of SAP.

Given that awareness of, and adherence with current guidelines for surgical antimicrobial prophylaxis remains poor2, including inappropriate timing of administration3, might the 'belt and braces' approach advocated in part one of this article prove the best policy? By all means use SAP in appropriate patients, but why not double glove as well? After all this would confer an additional layer of protection to both patient and surgical staff.



  1. Junker T, Mujagic E, Hoffmann H, et al., Swiss Med Wkly. 2012 Sep 4;142:w13616.  Prevention and control of surgical site infections: review of the Basel Cohort Study.
  2. Ng RS, Chong CP. Surgeons' adherence to guidelines for surgical antimicrobial prophylaxis - a review. Australas Med J. 2012;5(10):534-40.
  3. Hohmann C, Eickhoff C, et al. Adherence to guidelines for antibiotic prophylaxis in surgery patients in German hospitals: a multicentre evaluation involving pharmacy interns. Infection. 2012 Apr;40(2):131-7.
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The surgical and wound care environment is always changing. The Mölnlycke Health Care blog addresses topics and trends in surgery and wound care. Among these topics are efficiency, health economy, infection control and patient safety. Read more about this blog and how to comment.

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