|Year : 2022 | Volume
| Issue : 5 | Page : 89-97
Surgical site infections in solid organ transplant recipients: Expert group opinion for prophylaxis and management in South Asia
Abhinav Seth1, Ashish Sharma2, Ashwinin B Gadde3, Milind Mandwar2, Shyam Bihari Bansal3
1 Department of Transplant Surgery, University of Iowa Hospital and Clinics, Iowa, USA
2 Department of Renal Transplant Surgery, PGIMER, Chandigarh, India
3 Department of Nephrology and Renal Transplant Medicine, Medanta Kidney and Urology Institute, Gurugram, Haryana, India
|Date of Submission||01-Oct-2021|
|Date of Acceptance||24-Feb-2022|
|Date of Web Publication||18-Oct-2022|
Prof. Ashish Sharma
Department of Renal Transplant Surgery, PGIMER, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Surgical site infections (SSIs) are defined as superficial infections, deep incisional infections, and organ/organ space infections that occur within 30 days of the surgical procedure or up to 90 days if a prosthetic implant has been used. Incidence of SSI is highest in recipients of small bowel transplant, followed by liver, pancreas, and kidney transplant. These are diagnosed by the presence of at least one of the following: purulent discharge from the wound, organism identified from the specimen obtained from the site with culture/nonculture-based methods, evidence of infection on gross/histopathological examination or on imaging, or a clinical diagnosis of SSI by a physician. The spectrum of organisms implicated in SSIs in solid organ transplant recipients is more diverse due to underlying end-stage organ failure, need for immunosuppression, prolonged hospitalization, colonization or active infection in the deceased organ donor, contamination during organ transportation/preservation. SSI in solid organ transplant can be prevented leading to hospital stay and cost of transplantation. Minimizing surgical operative time, sterile and appropriate surgical technique and antimicrobial prophylaxis, management of patient comorbidities as well as glucose and temperature regulation are important for prevention of SSI. This article discusses useful preventive strategies for preventing SSI such as preoperative bathing, use of appropriate preoperative antibiotic prophylaxis, surgical site and hand preparation, use of wound protectors, drapes and gowns, incisional wound irrigation, adequate nutritional support, and use of perioperative oxygenation.
Keywords: Antimicrobial prophylaxis, renal transplantation, surgical site infections, wound protectors
|How to cite this article:|
Seth A, Sharma A, Gadde AB, Mandwar M, Bansal SB. Surgical site infections in solid organ transplant recipients: Expert group opinion for prophylaxis and management in South Asia. Indian J Transplant 2022;16, Suppl S1:89-97
|How to cite this URL:|
Seth A, Sharma A, Gadde AB, Mandwar M, Bansal SB. Surgical site infections in solid organ transplant recipients: Expert group opinion for prophylaxis and management in South Asia. Indian J Transplant [serial online] 2022 [cited 2022 Dec 9];16, Suppl S1:89-97. Available from: https://www.ijtonline.in/text.asp?2022/16/5/89/358668
| Introduction|| |
Surgical site infections (SSIs) are defined as any infection of a surgical incision (superficial/deep) or involving an organ/organ space, occurring within 30 days of the surgical procedure or up to 90 days of deployment of a prosthetic implant. The most common solid organ transplantation (SOT) recipients prone to get SSI are the patients undergoing small bowel/organ transplants followed by liver and pancreas transplant recipients. Renal transplant (RT) recipients have the least incidence of SSI varying between 3% and 11%., However, the reported incidence is higher in South Asian countries, ranging from 8.6% to 26%.,
The SOT recipients are highly susceptible to various microbiological infections due to multiple reasons. They are already immunocompromised because of underlying end-stage organ failure, prolonged hospital/intensive care unit (ICU) stay resulting in increased exposure to multidrug-resistant organisms. There could be preexisting infection in the donated organ, or could be acquired during organ retrieval, transportation, or preservation. Prior use of antibiotics in both donors and recipients also increases the chances of developing antibiotic resistance giving rise to multidrug-resistant infections. The Gram-positive bacteria (Staphylococcus aureus, coagulase-negative Staphylococcus, and Enterococcus) account for majority of SSI in RT patients, although the incidence of multidrug-resistant organisms (MDROs) is rising.,
SSI can impact the short-term patient and graft survival.,,,, Therefore, it is crucial to know the risk factors to have preventive measures in place. Preexisting conditions such as diabetes mellitus, obesity, and previous surgeries in the recipient increase the susceptibility of recipients to SSI. Institution of immunosuppression in the postoperative period also makes the recipients prone to infection. The use of blood products can directly transmit infectious agents. The presence of preexisting donor infection, acute graft rejection, delayed graft function, and surgical complications including hematomas are the other risk factors, contributing to SSI.
While there are many published manuscripts regarding SSI in transplant recipients, most have only detailed risk factors related to SSI. There are only a few good studies where outcomes have been compared after specific interventions. Many of the below mentioned guidelines have been adapted from studies done in patients undergoing general surgical procedures. However, there is no reason not to believe that if something has worked in general surgical population, it is also going to work in transplant recipients.
| Clinical Presentation|| |
Superficial infections are limited to skin and subcutaneous tissue, while deep SSI involves fascia/muscles. Organ space SSI is defined as infection deeper to fascia/muscle in any body part which was exposed during the operation. It should meet at least one of the following prerequisites: purulent discharge from the infected area, organism identified from the specimen obtained from the site of infection with culture or nonculture-based techniques, abscess/evidence of infection on gross or histopathological examination or on imaging, or clinical diagnosis of SSI by the treating physician.
| Differential Diagnosis|| |
Hematomas, seromas, urinary leak, biliary or pancreatic leak can mimic SSI, but careful clinical, laboratory testing will help confirm the diagnosis. Mild redness and stitch abscess do not qualify for SSI.
| Preventive Strategies|| |
The appropriate management of comorbidities in the recipient such as diabetes mellitus and obesity decreases the risk of SSI. Standardizing and maintaining aseptic conditions in the operating theater, as well as minimizing the surgical operative time, are important in preventing SSI. Below are the infection control practices which are in practice to lower the incidence of SSI. The basis of many of these recommendations is from studies done in general surgical patients [Table 1].
|Table 1: Summary of recommendations for prevention of surgical site infections in organ transplantation|
Click here to view
Preoperative whole-body bathing or showering on the day of surgery with soap is considered a good clinical practice. This makes the skin as clean as possible prior to surgery and reduces the bacterial load, especially at the site of incision. This can be done with plain soap or an antimicrobial soap. Preoperative showering with antiseptic agents is a well-accepted procedure for reducing skin microflora,,, but it is less clear whether this procedure lowers the incidence of SSIs., There is some evidence that having a bath with chlorhexidine gluconate does not reduce SSI rates as compared to bathing with a plain soap. In addition, the use of chlorhexidine may lead to allergic reactions, such as contact dermatitis, photosensitivity, and in rare cases, anaphylactic shock.
It is suggested that patients should take a preoperative bath on the day of surgery with a plain soap.
Decolonization with mupirocin for the prevention of Gram-positive infections
S. aureus remains one of the most common causes of nosocomial infections. In recent years, there has been a rise in incidence of methicillin-resistant S. aureus leading to increased mortality and morbidity. It is the leading cause of postoperative skin and SSI, pneumonia, and catheter-related bacteremia, especially in hemodialysis population.,,,, S. aureus nasal colonization has been reported as an independent risk factor for postliver transplant infections.
Mupirocin nasal ointment is a safe, effective, and inexpensive option for eradicating carriage with methicillin-resistant Staphylococcus aureus (MRSA)/methicillin susceptible Staphylococcus aureus (MSSA). It is commonly prescribed as intranasal application twice daily for 5 days. Intranasal mupirocin in S. aureus carriers can reduce staphylococcal infections in surgical patients. On the other hand, mupirocin resistance, recolonization, and intestinal MRSA carriage have also been reported., There is currently limited rigorous evidence available in transplant recipients to support screening of patients for nasal colonization for S. aureus.
Screening for Staphylococcal carrier status is currently not recommended, but decolonization with mupirocin ointment can be carried out in known nasal carriers who are undergoing surgery.
Preoperative surgical antibiotic prophylaxis
Preoperative administration of antibiotics has become the cornerstone to prevent the development of SSI. The success of prophylaxis is determined by the adequacy of antibiotic concentration in the operative site at the beginning of the procedure. Majority of transplant surgeries are categorized as clean or clean-contaminated surgeries, therefore, antibiotic prophylaxis will help in preventing SSI. The timing of administration of antibiotic for surgical prophylaxis should be within 120 min of placing the incision, and there is conflicting evidence about any greater benefit of administration closer than 120 min. Due consideration should be given to the half-life of the antibiotic. Low tissue antibiotic concentration during wound closure increases the risk of SSI., The American Society of Health-System Pharmacists advocates additional doses if the expected timing of the procedure exceeds two half-lives of the drug or in case of massive intraoperative blood loss. First-generation cephalosporins (like cefazolin) are recommended for surgical prophylaxis owing to better bioavailability, adequate coverage of organisms causing SSI in RT recipients, and minimal side effects. In units having a high incidence of infection by extended-spectrum β-lactamase-producing Enterobacteriaceae, amikacin prophylaxis has been shown better results compared to cephalosporins in RT recipients. However, a higher rate of delayed graft function was associated with the use of amikacin as antimicrobial prophylaxis. Choice of prophylactic antibiotic for patients undergoing deceased donor transplant with sepsis may be suited to the organism identified or as per the empirical choice of therapy decided according to local sensitivity pattern of the ICU.
As opposed to RT where cause of SSI is mostly Gram-positive organisms, SSIs in liver transplant are mostly caused by Gram-negative organisms. In pancreas and liver transplant, a broader coverage is required. Third-generation cephalosporins with ampicillin, ampicillin-sulbactam, or piperacillin-tazobactam are preferred as per IDSA guidelines. Considering higher chances of candida sepsis, antifungal prophylaxis is also used in these surgeries.
Vancomycin or clindamycin along with gentamycin may be used to replace cephalosporins in patients who are allergic to penicillin.
Surgical antibiotic prophylaxis should be administered within 120 min of planned incision. First-generation cephalosporins or amikacin may be used as antibiotic prophylaxis in RT patients.
Third-generation cephalosporin with ampicillin, ampicillin- sulbactam, or piperacillin-tazobactam for up to 48 h has been recommended for perioperative prophylaxis in liver transplant recipients.
Antifungals should be used routinely as part of perioperative prophylaxis in pancreatic transplant. Use in liver transplant recipients can be individualized as per risk, but most centers prefer to give it.
Antibiotic prophylaxis prolongation
There is a tendency for the physicians to continue the antibiotics in the postoperative period for varied reasons, which might not have any additional benefit but may lead to development of antimicrobial resistance., It has been shown that there is no difference in incidence of SSI in RT recipients, who receive single-dose or multidose antibiotic prophylaxis. A deceased donor transplant from a patient with sepsis can be the exception. In liver and pancreatic transplant, antibiotic prophylaxis is recommended for about 48 h. Antifungal prophylaxis may be extended in patients with enteric drainage, high model for end-stage liver disease score, vascular thrombosis, postperfusion pancreatitis, acute rejection, poor initial allograft function, anastomotic problems, need for hemodialysis, or laparotomy after transplantation.
Antibiotic prophylaxis should not be routinely prolonged after 24–48 h after surgery.
Hair removal may be needed for adequate exposure, preoperative skin marking, and application of wound dressings. There is no benefit of depilation for preventing SSI. Shaving of skin with razors causes microscopic skin trauma and can increase risk of SSIs as compared to clipping/electric/chemical depilation, especially when done hours before the surgery. There is no clear evidence on the exact timing of hair removal in the preoperative period, but most units do it in the recovery room just before the surgery.
If hairs have to be removed, then it should be performed using hair clippers/electric depilator just before surgery.
Surgical site preparation
Preoperative treatment of skin around the site of surgical incision reduces the skin microbial load and helps prevent SSI. The most commonly used agents for surgical site preparation are chlorhexidine gluconate and povidone-iodine-based solutions.,, Alcohol-based antiseptic solutions are more effective as compared to aqueous solutions in reducing the risk of SSIs, and chlorhexidine gluconate is better than povidone-iodine in preventing SSIs., Alcohol-based solutions should not be used on mucosal surfaces as they tend to cause irritation. These should also be allowed to dry completely before any use of diathermy as it may ignite with sparks generated by electrosurgical units.
Chlorhexidine gluconate alcohol-based antiseptic solutions should be used for surgical site skin preparation. The harmful effects of alcohol-based antiseptic solutions should be kept in mind.
Antimicrobial skin sealants
The cause of SSI is mainly thought to be bacteria residing on patient's skin. There is no evidence that sterile antimicrobial cyanoacrylate-based skin sealants which remain in place and prevent the migration of flora from the surrounding skin help reduce SSI.
Antimicrobial skin sealants have not been shown to reduce rates of SSI and are not recommended.
Surgical hand preparation
Surgical hand preparation reduces transient and resident flora of the skin. Nails should be kept short, and jewelry, artificial nails, or nail polish should be removed before surgical hand preparation. Surgical hand and forearm antisepsis can be performed using an antimicrobial soap for 2–5 min or alcohol-based hand rub (containing 60%–80% alcohol) for at least 1.5 min. Hands and forearms should be dry before donning sterile gloves. Alcohol-based hand rub with additional antiseptic ingredients has been suggested to be more effective to reduce the growth of bacteria as compared with aqueous scrubs, but the evidence for same is not robust.
Surgical hand preparation can be performed either by using an antimicrobial soap or alcohol-based hand rub.
Drapes and gowns
Sterile surgical drapes are used during surgery to maintain the sterility of environmental surfaces, equipment, and the patient's surroundings. Similarly, sterile surgical gowns are worn over the scrub suit of the operating team during surgical procedures to maintain a sterile surgical field and reduce the risk of the transmission of pathogens to both patients and staff. During surgical procedures, the risk of pathogen transmission increases if the barrier materials become wet. Consequently, the multiple- or single-use materials of the drapes and gowns used in a surgical procedure should prevent the penetration of liquid. One can use disposable, nonwoven or sterile, reusable woven drapes and surgical gowns during surgical operations for the purpose of preventing SSIs. There is no role of plastic adhesive incise drapes with or without antimicrobial properties for the purpose of preventing SSIs.
The use of either disposable, nonwoven or sterile, reusable woven drapes or surgical gowns during surgical operations is recommended. There is no role of plastic adhesive incise drapes to reduce the incidence of SSI.
Wound protector devices
Surgical wound protector devices help to better reinforce the aspects related to wound edge isolation. These new surgical devices comprise a nonadhesive plastic sheath attached to a single- or double-rubber ring that firmly secures the sheath to the wound edges. They facilitate the retraction of the incision during surgery without the need for additional mechanical retractors. The use of these wound protector devices reduced SSI in clean-contaminated, contaminated, and dirty abdominal surgical procedures for the purpose of reducing the rate of SSI. However, wound protection devices are expensive but may provide benefit in contaminated procedures like urinary diversion along with RT or in a case of simultaneous kidney–pancreas transplant.
The use of wound protector devices is only recommended in contaminated procedures like urinary diversion along with RT or in a case of simultaneous kidney–pancreas transplant.
Irrigation of incisional wound
Irrigation of incisional wound by flow of warm physiologic saline across the surface of an open wound, with or without active additives, is a widely followed practice with up to 97% of surgeons reportedly using this practice. It helps in wound hydration and removes tissue debris, surface bacteria, and body fluids. Irrigation with aqueous povidone-iodine solution or saline may be beneficial, but there is no advantage of adding antibiotics to irrigation fluid.
Incisional wound irrigation can reduce SSIs and may be done with aqueous povidone-iodine solution or warm physiologic saline but not with antibiotic solution.
Prophylactic use of negative pressure wound therapy
Negative pressure wound therapy comprises a closed-system device connected to a vacuum pump, which maintains negative pressure on the wound surface. Prophylactic negative pressure wound therapy is used on primarily closed surgical incisions to prevent SSIs. The possible side effects include development of blisters or maceration at the site of application. The use of prophylactic negative pressure wound therapy in patients on primarily closed surgical incisions in high-risk wounds, may prevent SSIs, but there is currently no robust evidence for the same.
The use of prophylactic negative pressure wound therapy in RT patients on primarily closed surgical incisions in high-risk wounds awaits further evidence before routine use can be recommended.
The surgical wound is covered with a dressing which acts as a physical barrier to protect the wound from contamination from the external environment until the wound becomes impermeable to microorganisms. The dressing material also absorbs exudate from the wound and keeps it dry. Many advanced dressings such as hydrocolloid, hydroactive, silver-containing (metallic or ionic), and polyhexamethylene biguanide dressings are available but have not shown to be advantageous over standard dry absorbent dressings. Caution should be made while using silver-containing dressings, as in some patients, it can cause allergic reactions or skin irritations.
Advanced dressing provides no benefit over a standard dressing for preventing SSIs of primarily closed surgical wounds.
Extending antimicrobial prophylaxis in the presence of a drain
Drains are placed to remove any fluid or blood collections after operation which may result in complications such as infections or mass affect. The use of prolonged antibiotic prophylaxis in the presence of wound drain has not been shown to prevent SSI renal allograft recipients. On the other hand, drains can cause seeding of bacteria along its track and lead to infection of the surgical wound. Hence, the drains should only be placed if clinically indicated and removed as early as possible. Nonjudicious usage of antibiotics can lead to Clostridium difficile infection, antimicrobial resistance, and fungal superinfections.,
Increasing duration of antibiotic prophylaxis is not recommended in the presence of a wound drain for the purpose of preventing SSI and drain should be removed as soon as possible.
Enhanced nutritional support
Nutritional status of a patient plays an integral part in recovery of patient. Malnutrition leads to delayed recovery, impaired immune response, higher infections, higher rates of morbidity and mortality, prolonged hospital stay, increased health-care costs, and a higher early readmission rate.,,,,, Surgical stress and inflammation leads to a negative nitrogen balance. Early nutritional support can improve the outcome following major surgery and decrease the incidence of infectious complications in selected malnourished or severely injured patients.,, Oral or enteral multiple nutrient-enhanced nutritional formulas can prevent SSI in this subgroup of patients.
Oral or enteral multiple nutrient-enhanced nutritional formulas should be administered for the purpose of preventing SSIs in severely malnourished patients.
An optimized blood flow to the surgical incision reduced SSIs rates through the avoidance of hypothermia, hypoxia, and decreased perfusion. Hemoglobin oxygen saturation should be at least 95% for prevention of SSIs., A reduction in rate of SSI in patients undergoing general anesthesia can be achieved by providing an 80% fraction of inspired oxygen (FiO2) during surgical procedures and in the immediate postoperative period for 2–6 h.
Keeping FiO2 of 80% during perioperative period can reduce the risk of SSI.
Body temperature: Normothermia
In the operating room, a cold environment and an esthetic-induced impairment of thermoregulatory can lead to hypothermia., Skin surface exposure during the perioperative period can increase heat loss. Published research has correlated unplanned perioperative hypothermia with impaired wound healing, adverse cardiac events, altered drug metabolism, and coagulopathies.,, It is important to keep the patient's body warm in the operating room by using warming devices.
Hypothermia should be prevented in the operating room by using warming devices.
Guideline for perioperative blood glucose control
Surgical stress leads to increase in blood glucose levels and inhibition of insulin with release of catabolic hormones. There is a risk of hyperglycemia even in nondiabetic patients which predisposes patients to SSI, whereas hypoglycemia is more life threatening and all care should to keep blood glucose above 80 mg/dl. There should be intensive perioperative blood glucose control for both diabetic and nondiabetic adult patients undergoing a surgical procedure which reduces the risk of SSI. Blood sugar monitoring can be performed every 4–6 h till the patient is on IV fluids and titrated as per sliding scale in patients with diabetes till subcutaneous/oral regimen are introduced. Patients undergoing pancreas transplant or those with labile hyperglycemia may require a more frequent monitoring of blood sugars. The American Diabetic Association recommends a target glucose level of 140–180 mg/dl in the majority of critically or noncritically ill patients admitted to Hospital, whereas, there is no published literature on transplant recipients 1dl in patients admitted to general medical-surgical wards and 140–180 mg/dl in majority of critically ill patients admitted to ICU.
Hyperglycemia increases risk of SSI, and there should be an intensive perioperative control of blood glucose level.
Adequate circulating volume control: Normovolemia
Hypovolemia and fluid overload are both likely to have a poor clinical outcome in a surgical patient. Sufficient tissue oxygenation is essential for collagen synthesis and wound repair and is improved by adequate arterial oxygenation. Ideally, perioperative fluid therapy prevents tissue hypoxia by maximizing the cardiac output and thus improving arterial oxygenation. Fluid overload results in lower arterial oxygen tension, whereas hypovolemia lowers arterial and tissue oxygenation by a reduction in cardiac output. However, there is no standardized method for assessment of volume status. Noninvasive parameters such as urinary output, serum markers, and invasive techniques such as cardiac output or cardiac index can be used to set a goal. It is important to have goal-directed fluid therapy intraoperatively which helps to maintain adequate tissue perfusion and reduce SSIs. The frequency of monitoring of these parameters can be hourly in the early postoperative period and later can be increased as per the needs of the patient.
Goal-directed fluid therapy can help to reduce tissue SSIs.
The World Health Organization defines overweight (25–29.9), obese (body mass index [BMI] 30–34.9), morbidly obese (BMI 35–39.9), and very morbidly obese (BMI ≥40).
It has been shown that there is a graded increase in the frequency of SSI with higher BMI, from 8.5% among those with BMI 20–25 and rising to 40% in patients with BMI >40. SSI has also been associated with a significant increase in the risk of renal allograft loss at 3 years (hazard ratio: 2.2, 95% confidence interval: 1.36–3.55). Similarly, a systematic review and meta-analysis has reported a higher risk of wound infection and dehiscence (respiratory rate = 3.13 and 4.85) in obese patients and concluded that end-stage renal disease patients with a BMI >30 preferably should lose weight prior to RT. If this cannot be achieved with common measures, bariatric surgery could be considered in morbidly obese candidates prior to RT. There is some evidence that outcomes may improve with weight loss after bariatric surgery. Robotic surgery has also been shown to reduce the incidence of SSI in obese patients in individual series, but larger experience is still awaited. The perioperative dose should be weight based, particularly in obese patients (including cefazolin, which should be increased to 3 g when the patient's weight is over 120 kg.
Morbid obese patients should be discouraged to proceed for transplant till the time they reduce their body weight. Benefit of robotic surgery in these situations awaits larger experience.
mTOR inhibitors have higher rates of wound healing complication events as compared to various other different maintenance immunosuppression., However, there is little evidence to suggest that a low dose mTOR inhibitor regimen along with low exposure calcineurin inhibitors has a higher incidence of wound healing problems as compared to a standard CNI-MPA regimen., Until more data are available, it is advisable to avoid mTOR inhibitors in obese patients and avoid the high dose regimens.
MTOR inhibitors should be avoided in the perioperative period as they impair wound healing.
Management of surgical site infections
Infected wounds should be opened, irrigated, debrided, and treated with basic wound care. A sterile aspiration or tissue should be obtained for culture to identify the organism and to decide regarding antibiotic strategy. Wound swab can be cultured of aspiration if biopsy is not feasible, but it has higher chances of polymicrobial contamination hence not preferred.
In larger wounds, or wounds in which frequent dressing change is not feasible, negative pressure wound therapy (vacuum dressing) can be used. In the case of organ space/deep-seated infections, source control is important. A percutaneous/operative drainage is necessary for infection control.
As opposed to immunocompetent patients, where a superficial SSI can be managed with only incision and drainage without antibiotics, SOT patients often need empirical followed by culture-based systemic antibiotic for infection control. Empiric treatment should be started using broad-spectrum antibiotics with coverage of Gram-positive cocci and considering type of transplant procedure, colonization status, and patient risk factors. First-generation cephalosporins can be used. Border coverage for MRSA and MDROs is required for high-risk patients (recent hospitalization/antibiotic use, prior colonization, prolonged intubation, urological manipulation, history of recurrent urinary tract infections, etc.).
| Conclusion|| |
SSI is one of the preventable complications of transplant surgery which results in greater morbidity, mortality, and worse graft function. Basic general surgical preventive strategies must be adhered to for prevention of SSI. Choice of empirical antibiotics as part of prophylaxis and for treatment depends upon the type of transplant, colonization status, and local culture sensitivity data. More transplant-specific studies are needed for further improvisation in preventive and management strategies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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