The Mölnlycke O.R. blog
Is 'belt and braces' the best approach for preventing surgical site infections? – Part one
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 English language, a popular and time-honoured idiom is 'belt and braces'. Both are designed for holding up trousers. Going 'belt and braces' is a therefore double insurance against one's trousers falling down! Or more generally speaking, using more than one method to make sure that something is safe.
Although this phrase is often used in a humorous context, it neatly sums up an important concept in safety engineering; for example in the aviation industry, having a back-up or fail safe is mandatory for all the key systems that keep an aircraft flying.
What, you may ask, has this got to do with preventing surgical site infections? Quite a lot actually. For example, when a patient undergoes general surgery, he may be given preoperative antibiotics, in order to prevent infectious complications. The surgeon may also wear double gloves, in part to help prevent wound contamination, in the event of a glove puncture.
Is one strategy better than the other, or should both be used in tandem? These are important questions that can only be answered with good clinical evidence. Unfortunately there has until recently been very little trial data to help clinicians arrive at a decision. In fact there is very little hard data on the impact of glove perforation on risk of surgical site infection1.
Fortunately this omission has largely been remedied by a major study2 undertaken by Dr Walter Weber, Head of the University Hospital of Basel Breast Centre and attending surgeon at the Department of Surgery, Division of Visceral Surgery, Basel University Hospital, Switzerland.
Together with surgical and infectious disease specialist colleagues, Dr Weber closely monitored more than 6,000 consecutive patients undergoing general surgery. Patients were followed up for one year after their surgery, during which time they were closely monitored for any evidence of a surgical site infection.
This prospective observational cohort study included 6,283 general surgery procedures, including visceral, vascular and trauma surgery. Data were collected on a range of potential surgical site infection risk factors, including timing of surgical antimicrobial prophylaxis, glove perforation, anaemia and transfusion. These data were analysed using multiple logistic regression to find out the influence of each factor on infection risk. Further analysis also assessed the economic burden of surgical site infections, the efficiency of infection surveillance systems and the spectrum of pathogens causing these infections.
The overall rate of surgical site infection (SSI) was 4.7 percent. Some interesting findings emerged when the authors turned their attention to the relationship between SSI, glove perforation and use of preoperative antimicrobial prophylaxis. In a cohort of 4,147 procedures eligible for this analysis, there were a total of 188 SSIs (4.5 percent). Glove perforation was recorded in 677 cases (16.3 percent). Statistical analysis clearly showed that in the absence of 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.
Commenting on their findings in a related publication3 the authors note: "To our knowledge, this is the first study to explore the correlation between SSI and glove leakage in a large series of surgical procedures... 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. Irrespective of possible precautions, however, the risk of glove perforation continues to be a clinical problem."
In the second and final part of this article, the study results are looked at in terms of practical applications of the findings.
- Mistel H et al. Surgical glove perforation and the risk of surgical site infection. Arch Surg. 2009;144(6)553-558.
- 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.
- Mistel et al. ibid.