This is a healthy question for any potential patient to ask of their medical advisors, particularly if they are about to go into hospital for some form of healthcare intervention, be it surgery or some other form of therapy. Every potential patient should be advised of all the risks they may face – that’s part of understanding and determining their decision to proceed with the advice of their physician.
The unhealthy question is much more the specific: “Should I be worried about MRSA or C diff?” It’s understandable that people ask about specific organisms but it is rather a failure on the part of healthcare to explain all the risks that patients may face when deciding to proceed with a healthcare intervention.
Surgical Site Infection
Let’s look at the problem of surgical site infection i.e. an infection which develops in the wound after surgery in a percentage of people. Why does this happen? Firstly, it’s important to remember that we are not alone! We may think in our heads that we are one and, of course, that is entirely true as we are indeed one human being. But we are not alone; there are millions of other species living with us; on our skin, in our mouths and most assuredly of all, in our gut. It’s said that if we were to dry the brown stuff that we pass from our bottoms, 50% of that dry weight will be bacteria.
Now in health we have a remarkable defensive system. Our skin keeps bugs away from the muscle and sinews that lie just beneath. Our skin will carry bacteria entirely happily, each finding a niche on our skin where they will multiply, survive for a period and be removed by competition with other bugs and by us when we wash. However, surgery is an entirely artificial event. To get at the site that needs operating on, the surgeon has to cut through our skin. As soon as s/he does that, the underlying tissues are exposed to bugs on the skin.
In the days before Pasteur began to unravel the issues of sterility, the risks from infection post surgery were huge. Surgery itself was pretty awful for all sorts of reasons, not least the absence of anaesthetics. Three important events in the past 150 years have transformed our understanding of infection risks with surgery and their management:
- sterility, cleanliness and hygiene,
- the availability of anaesthetics which allow surgeons to treat tissues with time, care, patience and skill and
- the advent of the antibiotic era
Each of these have an important role to play when a patient goes for surgery:
Sterility, cleanliness and hygiene
So long as they are fit and able and the surgery is planned, most patients will be advised to have a bath or shower before surgery. Why? This simple measure will help reduce the numbers of bacteria on the skin. Do I need an antiseptic wash? Some surgeons and microbiologists will advocate this but the evidence is limited. Washing with anything, preferably with a wetting agent (which is what soap does) will remove most of the bacteria residing with you at that time.
When you arrive in theatre, the surgeon will carefully prepare the surgical site with an antiseptic wash. Again, the aim here is to now kill any few remaining bacteria on the skin through which s/he is about to cut and gain access to the surgical area. Having undertaken the final skin preparation, a sterile site is prepared by carefully placing sterile towels around the area to be operated on.
While it is impossible to sterilise our bodies, the same is not true of the surgical equipment that will be used during the operation. Every piece of equipment that comes into contact with our tissues goes through a sterilisation process in the Hospital Sterilisation and Decontamination Unit (HSDU). This is a science in its own right and in Wales, every HSDU uses a quality assured and quality controlled process to ensure that instruments used in theatre are free from microorganisms that could cause infection if implanted into deep tissues of the body.
We’ve come a long way since Queen Victoria popularised the use of chloroform in childbirth. Anaesthetic practice is now a remarkable science in medicine. The risks from anaesthesia have dropped dramatically from those early Victorian experiments. The principle benefit of course is the absence of pain during surgery which means the individual is not kicking and screaming! This was the reality of surgery in the past when surgeons had to work incredibly fast. Now they can work with meticulous care and attention to detail, with delicacy and dexterity in the sure knowledge that their patient is in a managed state. This care allows them to manage the tissues with care and exit from the procedure, replacing everything in as near normal a state as when they entered, finally closing the skin to try and prevent access by bacteria to the tissues below.
The advent of the antibiotic era has had a remarkable effect but we also need to be aware of their limitations. They are not a universal cure-all for all types of infections. Most infections, even bacterial infections, are self-limiting. Most viral infections other than a few exceptions cannot be influenced by a specific agent. The worry of course as expressed by England’s Chief Medical Officer is that if we overuse antibiotics, we may select for more resistant bacteria. Most of the time, most people presenting for surgery will not have had antibiotics and so the bugs they carry will not have been influenced by this prior exposure. Just prior to many surgical proceedures, people will receive a short 1 to 3 dose prescription of antibiotics to act as a prophylactic against infection during the intr-operative and immediate post-operative period. This practice is based on good evidence in many areas and by extrapolation into other areas where the evidence is less good. What is key to the use of antibiotic prophylaxis is a short course. This limits the opportunity to select for antibiotic resistant organisms.
The other major benefit of all these practices combined, together with increasing key-hole surgery and pain relief, is rapid recovery, rapid mobilisation and rapid discharge from hospitals. This latter is important because we have to use antibiotics to treat anyone in hospital with a developed infection and this makes selection of antibiotic resistance in hospital more likely. Early discharge removes our planned surgical patients from these bugs and reduces the risk of their aquisition.
When it comes to managing healthcare associated infections, Wales is in a different place to the rest of the UK. This is largely because of the rational debate between professional, politicians, the press and the public. It has been gratifying to be a part of this debate over the years as we have trodden our different path. Healthcare associated infection will always be a risk associated with our premises and the life saving interventions we undertake but rates have continued to decline over the years. The new technologies and medical advances have made significant contributions to this reduction.
July 2013 Update: From July, all Health Boards in Wales began to publish information about HCAI’s on their website. You may be interested in my thoughts about this, which are available via this link.