Surgical site infections cost the NHS around £758 million every year and contribute to the growing problem of antimicrobial resistance. Suzanne Callander finds out how the use of incise drapes can help reduce the risk of infection.
Surgical site infections (SSIs) affect around 5% of all surgical patients and their impact is wide-ranging, having an adverse effect on both patients and the NHS. A SSI will affect the quality of life of the patient. It doubles the risk of mortality and increases length of hospital stay following surgery. For the NHS, the minimum cost of treating a SSI is £3,000. The financial burden of SSIs to the NHS is approximately £758 million per year.1 Further, and of growing importance, is the contributory effect that treating SSIs has on antimicrobial resistance (AMR).
Overuse and misuse of antibiotics is driving the continued increase and emergence of new, resistant and multi-resistant bacteria, which is now growing at a faster pace than the speed of development and release of new drugs.
In 2013, the Chief Medical Officer for England issued a stark warning about increasing AMR, stating that within 20 years the currently available antibiotics may no longer work and that we may be heading for a ‘post antibiotic era’ unless action is taken. There have been no new antibiotic class discoveries since the introduction of daptomycin in the late 1980s and all the classes of antibiotics in use today are now beginning to show some resistance.
One of the recommendations on AMR made in the Chief Medical Officer’s annual report in 2013 was to improve how infections are prevented and managed and, at an Association for Perioperative Practice (AfPP) event Kat Topley, clinical efficiency manager at 3M, argued that clinically, more needs to be done to prevent healthcareassociated infections (HCAIs). “Clinicians need to be looking to implement optimal infection prevention and control practices to help reduce the spread of multi-resistant organisms and to help prolong the life of current antibiotics,” she said. “If we can do something to reduce HCAIs we should do it.”
SSIs are often highlighted as being the most avoidable HCAI. “We know when the window of risk for an SSI occurs, so infection prevention practice – both before and during surgery – is a hugely important factor in SSI reduction,” continued Kat Topley.
According to the National Institute for Health and Care Excellence (NICE)2 most SSIs occur as a result of contamination of a surgical incision from microbes originating from the patients own body, so it is important to reduce microbes for the duration of the surgery. Infection caused by micro-organisms from an outside source following surgery are less common.
The Centres for Disease Control and Prevention (CDC) backs up this statement. It says that the risk of SSI is linked to the number of skin microbes present on the patient’s skin and that the risk of SSI can be measured according to three distinct variables: the dose of microbial contamination; the virulence of contaminating microbes; and the resistance of the host.3
Human skin harbors up to 100,000 microbes per square cm, yet just 100 microbes per square cm can result in an SSI.4
According to the National Audit Office (2000) around 30% of infections can be prevented through application of existing knowledge and tools. These tools include incise drapes which incorporate an adhesive, breathable, film that prevents moisture build up under the surgical drape, helping to ensure that the drape stays in place throughout a surgical procedure. NICE recommends that if an incise drape is required for surgery an iodophor-impregnated drape should be used, unless the patient has an iodine allergy.
While surgical skin preparations do help reduce microbes on the skin surface, bacteria in the deeper skin layers will remain. and these microbes will recolonise the skin surface over time. However, evidence presented by Casey et al in 20155 demonstrates that iodine released from 3M Ioban 2 antimicrobial incise drapes is able to penetrate these deeper skin layers at a concentration required for microbial death.
Antimicrobial efficacy of iodineimpregnated incise drapes against MRSA was evaluated by Casey et al in ex vivo studies following application of the surgical incise drape for various times on the surface of donor skin. This research found that iodine from the iodine-impregnated drape was present at levels required for microbial death at depths of 1000 to 1100 µm, reaching the deeper skin layers. By contrast, chlorhexideine gluconate (CHG) skin preparation is only able to permeate skin at a concentration required for microbial death to a depth of 300 µm. The study concluded that the use of ioban 2 antimicrobial incise drapes suppresses microbial regrowth at and around a surgical incision site, making its use preferable to the use of a standard drape or non-use of a drape.
“Our ioban antimicrobial infused incise drapes are one of the most underused tools across the surgical pathway today,” said Kat Topley. Clinicians using the drapes include Frank McDermot, head of neurosurgery at Edinburgh Eastern General Hospital. Commenting on the drapes he said: “Ioban is a part of the gold standard of care that we provide to all of our patients. It is quick, easy and efficient to use.”
Creating a sterile field
Phillip Roberts, consultant orthopaedic surgeon at University Hospital of North Staffordshire, believes that it is never possible to fully sterilise the skin. “It is, however, possible to clean the skin and then create a sterile field by using an anti-microbial impregnated incise drape, where nothing can regrow. The site is then sealed under plastic in a sterile environment,” he said.
“Patients are always advised to wash before they are admitted for elective surgery,” continued Kat Topley. “However, they are rarely asked to confirm that they have done this and, in any case, flora and organisms will start to regrow very quickly after a bath or shower using standard soap products.”
NICE recommends that within 24 hours of knife to skin the patient should have a wash to keep the level of organisms to a minimum. Kat Topley says that this advice should be undertaken as a matter of course, as part of standard pre-operative surgical skin preparation.
As part of her presentation at the AfPP event, Kat Topley presented further evidence to demonstrate the benefits of antimicrobial incise drapes. Reporting on the use of plastic iodophor drapes during liver surgery in the World Journal of Surgery in 2003, for example, Yoshimura et al6 found that the SSI rates of patients treated with an iodophor skin prep alone was 12.1%. In contrast the SSI rate of patients who were treated with iodophor skin prep and an ioban incise drape was 3.1%.
The aim of the study was to investigate the risk factors associated with wound infection during high risk surgery, with special reference to the use of 3M ioban 2 antimicrobial incise drapes. The authors concluded that the non-use of ioban is a possible risk factor for wound infection after liver surgery.
More recently, Bejko et al7 compared the efficacy and cost of iodine impregnated drapes with standard drapes in cardiac surgery. The SSI rate for each group of patients in the study of 5,100 patients was measured from January 2008 to March 2015. The group which received a standard drape reported a SSI rate of 6.5%. The group of patients which received ioban drapes reported a SSI rate of 1.9%.
A cost analysis further demonstrated that although the upfront cost of a ioban incise drape was greater than a standard incise drape, once the additional costs associated with SSI were accounted for, the use of the ioban incise drapes offered cost savings of 957 euros per patient.
Kat Topley also discussed some of the clinical benefits of the use of antimicrobial incise drapes during surgery when compared to non-impregnated incise drapes, which simply immobilise the skin flora as it continues to grow throughout the procedure.
“Antimicrobial impregnated incise drapes provide a barrier to bacterial contamination, reducing the risk of bacteria transferring into the surgical wound,” she said. “The antimicrobial impregnated film of the ioban 2 drape ensures constant contact with the patient’s skin, even during irrigation.
“The drapes also provide continuous broad-spectrum antimicrobial activity all the way to the incision edge,’ she continued. “Secure adherence to the skin helps prevent drape lift and prep wash-off, while its low memory stretch allows for limb mobilsation or heavy retraction with reduced tension to the skin.”
Antimicrobial incise drapes have also been found to help reduce the likelihood of skin recolonisation after prepping8 which reduces the risk of wound contamination by skin flora9 which is a common cause of SSI.10
A surgeon would never think about operating without wearing sterile gloves, which in addition to protecting the surgeon, protect the wound from skin flora that may be present on the surgeon’s hands. The same care should be taken to protect the wound from the patient’s own skin flora and the use of a sterile incise drape can provide this protection, helping ensure that the skin remains bacteria-free throughout surgery. Traditional skin preparation leaves the patient vulnerable to its removal or neutralisation during surgery by blood, exudate and irrigation fluids which can result in bacterial regeneration on the skin. However, a skin surface that is covered with a sterile incise drape throughout surgery will ensure that no bacterial regeneration takes place, helping to reduce the risk of a SSI.
1 Cars O, Nordberg PA. Antibiotic resistance – the faceless threat. International Journal of Risk and Safety in Medicine2005;17;103-11Q.
2 NICE Clinical Guidelines No CG74. (2008) Surgical site infections: Prevention and treatment. (2008)
3 Centres for Disease Control and Prevention (1999) Guidelines for Prevention of Surgical Site Infection. Hospital Infection Control Practices Advisory Committee.
4 Urban, Hinrichs, Song, Hasley and Garvin. (2001) Skin bacterial counts in patients with a history of infected total join arthroplasty. Amer Acad. Orthop SurgPoster Pres.
5 Casey, Karpanene, Nightingale, Conway and Elliott et al. Antimicrobial activity and skin permeation of iodine present in an iodine-impregnated surgical incise drape. J. Antimicrobial Chemotherapy 2015 Aug;70(8):2255-60.
6 Yoshimura Y, Kubo S, Hirohashi K, Ogawa M, Morimoto K, Shirata K, Kinoshita H. Plastic iodophor drape during liver surgery operative use of the iodophor-impregnated adhesive drape to prevent wound infection during high risk surgery. World J Surg.2003 Jun;27(6):685-8.
7 Bejko et al. Comparison of Efficacy and Cost of Iodine Impregnated Drape vs. Standard Drape in Cardiac Surgery: Study in 5100 Patients. J Cardiovasc Transl Res.2015 Oct;8(7):431-7.
8 D. H. Johnston, J. A. Fairclough,et al.1987 Rate of bacterial recolonization of the skin after preparation: four methods compared Br. J. Surg., Vol. 74, January, page 64.
9. Professor John Fairclough, Consultant Orthopaedic Surgeon, University Hospital of Wales, Cardiff. 2010 10. Data on file. Tech-Product-Dev-05-000101. Statistical analysis of Ioban incise drape framed delivery focus panel results. 11. Data on file. Clin-Index-Lims08679.
10 A J Mangram et al.Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infection Control and Hospital Epidemiology20 (April 1999) 250-278
The company has a clear focus on its core business, the repair and maintenance of medical endoscopes, both flexible and rigid.We are a UK based organisation and all repairs are carried out in the UK. The team comprises of staff members that have worked in the UK endoscopy market for over 28 years.Within that time, our team...
Learn more »
Queen Elizabeth Hospital Birmingham
1st April 2017
Majestic Hotel, Harrogate
29th – 30th June 2017
The evolution of patient warming
Register now to apply for regular copies of Clinical Services Journal and free access to premium content, as well as our regular newsletters.
Don't miss out on the latest news affecting deliverers of high quality clinical services. Register FREE for our regular newsletters now, and enjoy FREE access to feature article content and to the digital version of The Clinical Services Journal.
Selected subscribers will also be considered for FREE inclusion within the distribution of the printed version of The Clinical Services Journal, too!