Two Simple Interventions Reduce Surgical Infections in Resource-Poor Settings

Routine glove and instrument changes prior to closing abdominal incisions can reduce surgical site infections (SSIs), according to a large clinical trial conducted in low- and middle-income countries (LMICs).

SSIs remain the most common complication of surgery around the world. The personal burden of these infections can be especially high in LMICs, where the expense of additional healthcare can plunge people into poverty.

The need for simple, low-cost interventions prompted the multisite ChEETAh trial, which has provided more evidence to recommend two low-cost interventions, according to a study published in The Lancet. The ChEETAh trial showed that routinely changing to sterile gloves and sterile instruments before closure of abdominal incisions can prevent as many as 1 in 8 cases of SSI.

Co-author Aneel Bhangu, MBChB, PhD, FRCS, National Institute for Health and Care Research (NIHR) clinician scientist in global surgery and senior lecturer in surgery at the University of Birmingham, told Medscape Medical News in an email, "We now need to implement this in operating theatres around the world, for the benefit of patients and care providers."

The ChEETAh Trial

Researchers conducted the multicenter trial between June 2020 and March 2022 in seven LMICs (India, Benin, Ghana, Mexico, Nigeria, Rwanda, and South Africa). After confirming that none of the surgical facilities were already routinely performing the interventions, study coordinators randomly assigned 81 surgery locations to either the current practice group (n = 42) or the intervention group (n = 39). The intervention group performed a change of sterile gloves and changed to sterile instruments before closure of the surgical incision.

Of the 13,301 patients, 7157 were in the current-practice group, and 6144 were in the intervention group. Eligible surgeries included scheduled or emergency abdominal surgeries, with wound classifications of "clean-contaminated," "contaminated," or "dirty." The study excluded cesarean deliveries and surgeries classified as "clean." The wound classifications were comparable across the current-practice and intervention groups, as were American Society of Anesthesiologists Physical Status Classification System grades and rates of use of prophylactic antibiotics. Only approximately 2% of each arm's patients underwent laparoscopic surgeries.

Reviewers assessed for SSI according to US Centers for Disease Control criteria. At 30 days, the SSI rate was 1280 of 6768 (18.9%) in the current-practice group and 931 of 5789 (16.1%) in the intervention group, a 13% reduction in the adjusted risk ratio for the surgery.

Bundled Interventions

"This is an important study that examines the more individualized effect of these two infection control elements," said Aurora Pop-Vicas, MD, MPH, associate professor, Division of Infectious Disease, University of Wisconsin School of Medicine and Public Health, in an email to Medscape Medical News. Pop-Vicas has conducted research on the effectiveness of multiple bundled interventions to prevent surgical site infections. "It offers evidence of benefit for a common-sense intervention that is also relatively easy, low-cost, and can be implemented globally."

The ChEETAh study results give extra weight to consensus recommendations such as the Delphi Consensus on Intraoperative Technical/Surgical Aspects to Prevent Surgical Site Infection after Colorectal Surgery, published in the Journal of the American College of Surgeons in January 2022. Fifteen colorectal surgeons in the United States and Europe developed the Delphi Consensus to establish best practices according to literature review and expert opinion. Preclosure glove change and use of a sterile incision closure tray were two of the five most highly rated recommendations. They also highly recommended use of wound protectors/retractors, use of negative pressure wound therapy, and use of antimicrobial (triclosan-coated) sutures.

Pop-Vicas explained, "The longer the surgery duration, the higher risk of glove contamination and perforation during surgery. This is especially true for clean-contaminated surgeries that involve the manipulation of the bowel, which contains a high bacterial burden. It makes sense to switch to a new sterile instrument tray and change gloves for the closure of the surgical wound in an open abdominal surgery."

Bhangu said in a press release, "Our work demonstrates that routine change of gloves and instruments is not only deliverable around the world, but also reduced infections in a range of surgical settings. Taking this simple step could reduce SSI by 13%, simply and cost-effectively."

The study was funded by the UK's NIHR. The NIHR had no role in study design, data collection, data analysis, data interpretation, or writing of the report. Mölnlycke healthcare provided sterile BioGel gloves to participating sites randomly assigned to the intervention group. This represented an unrestricted donation, and the company was not involved in any component of study protocol design, delivery, interpretation, or reporting.

Lancet. Published online October 31, 2022. Full text

Erin Archer, RN, BSN, CIC, is a registered nurse, infection preventionist, and freelance health writer in Tucson, Arizona.

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Cite this: Two Simple Interventions Reduce Surgical Infections in Resource-Poor Settings - Medscape - Nov 10, 2022.