Bundled Interventions to Reduce Surgical Site Infections Are Effective and Urgently Needed | Infectious Diseases | JAMA Network Open | JAMA Network
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Invited Commentary
Infectious Diseases
March 27, 2020

Bundled Interventions to Reduce Surgical Site Infections Are Effective and Urgently Needed

Author Affiliations
  • 1Section of Acute Care Surgery, Department of Surgery, Stanford University, Stanford, California
JAMA Netw Open. 2020;3(3):e201895. doi:10.1001/jamanetworkopen.2020.1895

The study by Loftus et al1 is an important addition to the literature supporting bundled infection prevention interventions to reduce the burden of surgical site infections (SSIs). The authors prospectively randomized patients undergoing a heterogeneous mix of surgical procedures to receive a standardized perioperative infection prevention bundle vs existing standard of care and followed patients for 60 days. The study was terminated early because it was found to be successful at interim analysis—among patients receiving the prevention bundle, perioperative transmission events of Staphylococcus aureus and the number of SSIs decreased significantly. This was despite the intervention group being composed of patients who were older and more seriously ill than those in the control group. Notably, Loftus et al1 confirmed that increased perioperative transmission events led to increased SSIs, with a perioperative transmission event increasing the relative risk of SSI 6-fold. The authors concluded that adopting a bundled package of interventions designed to diminish the reservoir of infectious pathogens in the perioperative setting decreases transmission events and SSIs.

There remain several important unanswered questions from this study that deserve discussion. Loftus et al1 argued that they identified “sustained improvements in basic perioperative preventive measures.” However, while the authors clearly showed a decrease in SSIs during the study, it is unclear how resilient these interventions are over time; therefore, to call their intervention sustained is premature. Behavioral interventions are challenging to maintain in the long term, and interventions are well known to be subject to the Hawthorne effect and procedural fatigue.2 Before sustained improvements can be concluded, compliance should be tracked longitudinally to determine whether this bundle will continue to reduce transmission events and SSIs long after the study has ended.

Loftus et al1 implemented a 7-component bundle in the perioperative setting, including interventions aimed at clinician hand hygiene, vascular access care, environmental cleaning, and patient decolonization. This bundle inevitably required additional equipment and personnel exceeding the institution’s usual care. How much did this bundle cost per patient? What was the cost needed to prevent an infection? What is the value added by this bundled intervention designed to reduce the pathogen reservoir compared with existing Centers for Disease Control and Prevention recommendations3 that target perioperative antibiotic administration and host optimization? Demonstrating a reduction in transmission events and infections was important, but Loftus et al1 could have taken this study a step further by showing that their intervention was cost-effective. In an increasingly lean health care environment driven by cost-conscious health care administrators, providing cost-effectiveness data is critical to facilitate bundle implementation at other institutions.

In 1867, in his seminal article “On the Antiseptic Principle on the Practice of Surgery,”4 Sir Joseph Lister wrote “to prevent the occurrence of suppuration with all its attendant risks was an object manifestly desirable.” In the more than 150 years since Sir Lister wrote those words, now, more than ever, health care practitioners who deliver care to patients undergoing surgical care must integrate effective infection prevention interventions with a fervor. The pathogens causing SSIs are cunning, pernicious, and powerful. Despite the $10 billion spent per year combating SSIs in the US, more than 20% of all hospital-acquired infections are directly related to surgical care, the most of any group of hospital-acquired infections.5 Multidrug-resistant pathogens are increasingly prevalent, and the antibiotics used to treat these pathogens are less effective and less available.6 In the modern health care environment, health care practitioners must continue to identify new infection prevention tactics, enact and combine existing infection prevention interventions, and support these interventions so that they are successful over time. The health of our patients depends on it.

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Article Information

Published: March 27, 2020. doi:10.1001/jamanetworkopen.2020.1895

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Forrester JD. JAMA Network Open.

Corresponding Author: Joseph D. Forrester, MD, MSc, Section of Acute Care Surgery, Department of Surgery, Stanford University, 300 Pasteur Dr, H3591, Stanford, CA 94305 (jdf1@stanford.edu).

Conflict of Interest Disclosures: None reported.

Loftus  RW, Dexter  F, Goodheart  MJ,  et al.  The effect of improving basic preventive measures in the perioperative arena on Staphylococcus aureus transmission and surgical site infections: a randomized clinical trial.  JAMA Netw Open. 2020;3(3):e201934. doi:10.1001/jamanetworkopen.2020.1934Google Scholar
Chen  LF, Vander Weg  MW, Hofmann  DA, Reisinger  HS.  The Hawthorne effect in infection prevention and epidemiology.  Infect Control Hosp Epidemiol. 2015;36(12):1444-1450. doi:10.1017/ice.2015.216PubMedGoogle ScholarCrossref
Berríos-Torres  SI, Umscheid  CA, Bratzler  DW,  et al; Healthcare Infection Control Practices Advisory Committee.  Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017.  JAMA Surg. 2017;152(8):784-791. doi:10.1001/jamasurg.2017.0904PubMedGoogle ScholarCrossref
Lister  J.  On the antiseptic principle in the practice of surgery.  Br Med J. 1867;2(351):246-248. doi:10.1136/bmj.2.351.246PubMedGoogle ScholarCrossref
Zimlichman  E, Henderson  D, Tamir  O,  et al.  Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system.  JAMA Intern Med. 2013;173(22):2039-2046. doi:10.1001/jamainternmed.2013.9763PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention.  Antibiotic resistance threats in the United States, 2019. Accessed February 1, 2020. https://www.cdc.gov/drugresistance/pdf/threats-report/2019-ar-threats-report-508.pdf
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