Surgical Infections: Prevention Is Better than Treatment

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Nosocomial infections pose a significant threat to small animals, especially surgical patients.

An estimated 0.8% to 18.1% of small animal surgical procedures result in a surgical site infection^1-7; however, this varies greatly with the type of procedure being performed. Consequences of surgical infections, ranging from mild inconvenience to an increased mortality rate, affect all members of the veterinary team, including the client, practice staff, and most importantly, the patient. Appropriate preventive measures not only reduce the impact of infection but are also more cost-effective than treatment for both the client and veterinary team.⁸ 

While many factors that may contribute to infection are beyond the veterinary team’s control (eg, patient signalment, comorbidities, recovery period once the patient is home), certain controllable factors can limit infection within the operating room and during the immediate postoperative period. Preventive measures should be taken at every step of the surgical procedure, including both pre- and postoperative care.

Preoperative Preventive Measures

The first step towards preventing surgical infections is proper identification of at-risk patients, including patients with certain comorbidities that may predispose them to developing surgical infections (eg, diabetes mellitus, hyperadrenocorticism, neoplasia⁹). Appropriate wound classification (eg, open vs closed, clean vs contaminated) is also essential for procedure planning as well as infection risk. The presence or placement of surgical implants such as stents or grafts may increase the risk of infection, particularly with orthopedic procedures involving the placement of multiple plates, rods, and screws. 

Other unique patient factors to consider when discussing surgical options include the patient’s temperament and environment. For example, fractious patients can make postoperative care challenging, outdoor cats may not have supervision, and service animals may require a short recovery time. Understanding these uncontrollable factors allows the surgical team to be appropriately prepared through preoperative measures such as appropriate choice of procedure, proper hygiene and scrubbing technique, and adherence to aseptic technique during surgical site preparation.

Intraoperative Preventive Measures

Adherence to aseptic technique by the veterinary team should continue from the preoperative period into the operating room. Intraoperative choices such as surgical technique, implant choice, and suture choice are under the control of the veterinarian, and can help prevent infection during the intraoperative period. The formation of biofilms on both implant devices and suture material is a major risk factor for infection,⁹ and suture structure and absorbability is an important intraoperative consideration. Additionally, there is a wealth of clinical evidence supporting the use of triclosan-coated sutures (such as Ethicon PLUS) to help address the risk factor for surgical site infections, recommended by the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the American College of Surgeons and Surgical Infection Society (ACS & SIS) for that purpose.*^10-12 Appropriate patient care and monitoring of vital parameters and blood pressure during the procedure is also crucial to optimize patient outcome.

Postoperative Preventive Measures

There are also several postoperative measures to prevent surgical infections. Veterinary team members should maintain an appropriate aseptic or clean technique when dressing incision sites or wounds to optimize wound healing. Additionally, duration of postoperative hospitalization should be limited, as this has been shown to minimize the risk of surgical infections in both humans and veterinary patients, as well as minimize the risk of acquiring an MDR infection.^13,14 Antimicrobial treatment recommendations when indicated should ideally be made based on the results of cultures, and excessive antimicrobial treatment duration should be avoided.¹⁵ The overuse of antibiotics can contribute to antibiotic resistance by selecting for resistant bacterial strains; therefore, judicious antibiotic use has never been more important.

Conclusion

While nosocomial infections pose a risk to all hospitalized patients, surgical patients are at a unique risk for infection. While uncontrollable risk factors exist, many factors under the control of the veterinary team can be addressed to limit infection. In particular, growing evidence suggests newer antimicrobial coated sutures are an increasingly recommended way to reduce risk factors associated with surgical site infections (SSI). As antibiotic overuse is of increasing concern in both human and veterinary medicine, proactive measures to prevent infection and the subsequent use of widespread antibiotics is of upmost importance. Preventive measures should be taken at all points of a surgical procedure, from patient selection and surgical planning to follow up visits.

*WHO, CDC, and ACS/SIS guidelines on reducing the risk of surgical site infections are general to triclosan-coated sutures and are not specific to any one brand.