The surgical site infection (SSI) represents a serious public health problem due to its high rates of morbidity and mortality. Besides, it produces direct and indirect costs and prolonged hospital stay. Recently, the World Health Organization published the global guide for the prevention of surgical site infections with several strategies recommended. However, it is the first time the surgical wound irrigation has been placed in an important role in SSI prevention.
Currently, several studies refer to the use of antiseptics such as chlorhexidine gluconate (CHG) in irrigation, creating a multimodal strategy for the use of CHG in FDA-approved pre, trans and postoperative activities. Indiscriminate application of substances, such as antibiotics, has become a challenge as it, at the end of the day, causes increases in antimicrobial resistance and failures in hospital treatment worldwide. This article serves to urge the comprehensive analysis of the published literature regarding surgical wound irrigation so as to create better documentation and research evidence that help the formation of a criterion for health personnel to prevent of infections associated with health care, particularly SSI.

Keywords: surgical wound irrigation, infection control, surgical site infection, perioperative nursing

A recent prevalence study found that surgical site infections (SSI) were the most common healthcare-associated infection (HAI), accounting for 31% of all HAIs among hospitalized patients.¹ The World Health Organization (WHO) report on the global burden of endemic HAI-SSI incidence was 11.8 per 100 surgical patients undergoing surgical procedures (95% CI:8.6–16.0) and 5.6 per 100 surgical procedures (95% CI:2.9-10.5).² SSI extends the postoperative hospitalization by an average of 9.7 days and increased health care and costs of US $ 20,842.³ In Mexico; in the years 2014 and 2015, the Department of Epidemiology of Health reported that there were 15 incidents of surgical site infection in 100 entries, the mortality was 25.5%, the additional hospital stay ranged from 7 to 20.7 days, and the unit costs per episode was more than USD 6,005 per episode.^3,4

Several prevention strategies and policies regarding the SSI prevention have been established, including preoperative bathing, surgical site preparation, antimicrobial skin, surgical hand preparation, antimicrobial prophylaxis⁵ and the most recent and updated one is the global guidelines for the prevention of surgical infection initiated by the WHO. While several evidence-based recommendations were established previously for the preoperative, trans-operative and postoperative prevention of surgical site infection, the WHO guideline is the first to recommend surgical wound irrigation as an important strategy.^2,3

In México, orthopedic surgeons made a consensus in 2013 which recognized the theoretical basis of irrigation to reduce wound infection but without establishing specifications in methods and irrigation solution to be used.⁶ Saline irrigation reduces infection when compared with the non-irrigated cases.^7,8 Irrigation pressure below 15 pounds per square inch (psi) and above 35 psi was regarded as low and high pressure respectively while the use of low pressure is recommended, as the use of high pressure causes damage to the adjacent tissue and the process of healing.⁹ Regarding the containers for the irrigation solution at the procedure field, one study showed that in 13 of 21 irrigating solutions in containers were contaminated at the end of the surgical procedures.^10–12 Our experience recommends the use of sterile devices and adapters to avoid contamination of the solution and hence reduce SSI incidence.

The Food and Drugs Administration (FDA) has warned the inappropriate use of antibiotics in surgical wound irrigation as it increases antimicrobial resistance and reduces the effectiveness of established antibiotic treatments and increased health costs and mortality.^13,14 The antiseptics are also commonly used (the most common one is the iodopovidone) in the surgical wound irrigation to exert a bactericidal effect, but it also lacks FDA’s authorization. Evidence found it associated with cellular toxicity and delayed the healing process. Particularly, similar findings were observed in high concentrations sodium hydrogen, sodium hypochlorite and parachoroxylenol.¹⁵ The chlorhexidine gluconate (CHG) at a concentration of 0.05% is one of the substances which is authorized and approved by the FDA for surgical wound irrigation due to its null toxicity for granulation and wound healing. It also has a beneficial effect on the prevention of SSI and should replace the inappropriate use of antiseptics or antibiotics.¹⁶ The CHG has a joint beneficial effect on the prevention of SSI with hand washing, skin preparation and sterile dressings covering the surgical wound.^15,16 Besides, several studies suggested that the use of CHG for surgical wound irrigation was associated with improved patient recovery as well as reduced costs in health management.^17–19 Currently, CHG 0.05% has been used in some hospital operating rooms in México.

The national associations especially the operational health personnel should conduct research to strengthen their knowledge of the risk and protective factors and adherence to the protocols on the use of wound irrigation to prevent SSI. This practice has been well documented in Mexico, in terms of standardization of irrigation, sterilization policies, antiseptics and disinfectants, and reuse of disposable material.^3,20 Currently, the Mexican national legislation for the epidemiological surveillance, prevention, and control of infections, emphasized the need to strengthen the existing system and to extend the coverage through effective information management which will maximize the effort to control infections, and specifically, surgical site infection.²¹

The role of nursing has been described and emphasized in each of the manuals, guides, protocols and studies as approximately up to 80% of the total of actions, procedures and techniques are done directly or indirectly by nurses in a health institution.²² The journey to control infection is long but progressing, we can increase the attachment and adherence of the evidence-based recommendations from research in order to improve the quality and safety of patients, and the prevention of infections associated with health care.

None.

The author declares no conflict of interest.

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