Why should the surgical community be interested in the global burden of healthcare associated infections and infection prevention and control?

September 2024

By Claire Kilpatrick

Claire is a graduate of the University of Glasgow with a post-grad Diploma in infection prevention and control and a MSc in medical sciences (travel medicine). In 2023 she was awarded a doctor of science for impact in the areas of IPC, water, sanitation and hygiene and patient and health worker safety by Glasgow Caledonian University. She is also a member of the Royal College of Physicians and Surgeons (Glasgow) and a nurse by background. She has worked in global health since 2008 and is a founding and current board member of the World Surgical Infection Society.

Infection Prevention and Control (IPC) is considered to be a practical, evidence-based approach to prevent avoidable infections in health care settings, including those caused by anti-microbial resistant germs.

This blog highlights a review article, published in 2020. It outlines the approaches to prevention of surgical site infections (SSI) and adds new information on the world of global IPC, including recently launched initiatives that might impact on and support the surgical community. It also summarizes some of the resources to implement the World Health Organization’s (WHO) SSI prevention guidelines. The founding member of WSIS, Joseph Solomkin, was chair of and played a key influencing role in this guideline evidence.

A summary of SSI prevention approaches and where we are today

Simplified surveillance – conducting surveillance using a WHO protocol suitable for and tested in low and middle income countries (LMICs), including those lacking laboratory capacity. But do we know how many people have or are using this protocol? Is it deemed helpful? Are people further modifying infection surveillance definitions to collect data in-country? Surveillance is noted in the review article as only one aspect of improvement. Do we know what follow up actions are being taken in-country to drive improvement? As one example, the recent European Centre for Disease Control and Prevention (ECDC) issued its point prevalence survey for 2022-2023, noting the prevalence of SSIs at 16.1% in the region. It also highlighted IPC recommendations, including a health systems based approach.

A multimodal improvement strategy – This WHO improvement strategy is well tested in countries, as outlined by Allegranzi et al in 2018. However, the review article notes that such strategies may be called many different things. The challenge with multimodal improvement remains to be dedicated time, commitment, and expertise, especially considering that improvement is now considered a science in its own right.

Build it, teach it, check it, sell it, live it – Five aspects of a multimodal improvement strategy for SSI prevention, very different to a bundle approach as highlighted in the review article. It involves asking questions and conducting assessments to be sure the right things are all in place in healthcare facilities and then guides improvement action. If any aspect is missing then SSI prevention is unlikely to happen. For example, for build it, can staff access quality products reliably at the right times? This includes hand hygiene supplies, sterile drapes and gowns, clippers (if hair removal is absolutely essential), chlorhexadine-alcohol–based skin preparation solution, mupirocin 2% ointment (for those testing positive for methicillin resistant Staphylococcus aueus), standard post-operative wound dressings, and resources to ensure decontamination of surgical instruments.

Research gaps – Three research recommendations in order to continue to address improvement gaps were highlighted in the review article; namely around surgical antibiotic prophylaxis, surveillance, and post-operative wound management. Do we think these are still the right areas for research? How many local studies have been published on these topics? Many global research agendas have recently been made available, including on hand hygiene, patient safety and antimicrobial resistance, with one on IPC coming soon.

Workforce - Real improvements can be only achieved if we address workforce recommendations - the staff to execute IPC strategies and action plans. This includes surgical staff as noted in the review article. Workforce is a challenge in surgical communities too, as highlighted in a publication by Mac Quene et al (2022).

The review article concluded that successful IPC approaches need targeted implementation and improvement as well as joined up working and learning. This concurs with the recently launched WHO global action plan and monitoring framework for IPC. Indicators and targets have been set for global, national and healthcare facility level, see examples in Box 1.

Box 1: Examples of healthcare facility IPC targets, 2024

The percentage of WHO’s minimum requirements for IPC met in the healthcare facility is presented.

An IPC committee is established with representation of and collaborative activities with other complementary programs.

Standard operating procedures are available integrating IPC and appropriate antimicrobial prescribing within clinical care (for example, surgery, maternal and neonatal care).

Increased compliance with IPC practices in specific wards and among specialized professionals (for example, injection safety, hand hygiene and waste management in surgical wards, operating theatres and critical care units) is demonstrated.

Increased compliance with appropriate antimicrobial prescribing (for example, at least one annual audit) is demonstrated.

Activities for WHO World Hand Hygiene Day are organized every year.

The proportion of collaborative or multidisciplinary projects, networking events or partnerships is established and presented.

In essence, ensuring all countries, wherever they are located and whatever their income level, provide safe, quality care and protection through IPC is not yet being achieved – this has been acknowledged through WHO global reports; the latest report being in 2022, with WHO preparing another now.

IPC and surgical teams working together can make an impact on practices and behaviors in all settings where care is delivered. Cultures and behaviors can and should be supported through the use of existing tools. Addressing changes in practices that need to be de-implemented, such as long- standing use of razors to remove hair around the surgical site or prolongation of surgical antibiotic prophylaxis, which are not recommended, also remain critical for safe, quality care.

WSIS is part of WHO’s Global IPC Network and while there are no active WHO SSI projects underway, continues to influence the overall IPC agenda and collaborative working.