Joseph Solomkin is Professor Emeritus in the Department of Surgery, University of Cincinnati College of Medicine, Ohio, USA. Professor Solomkin has published extensively on the mechanisms and management of surgical infection. He has been involved in the evaluation of a range of antimicrobial agents and in the development of guidelines for the selection of anti-infective agents for the treatment of surgical infections. Membership of several learned societies includes the American College of Surgeons, the Society for Critical Care Medicine, the American Society for Microbiology, the Infectious Diseases Society of America and the Society for Leukocyte Biology. Professor Solomkin is currently CEO of OASIS Global, a non-profit organisation working to lower the incidence of post-surgical infection in low and middle income countries. He actively participated in the development of the WHO Guidelines for the Prevention of Surgical Site Infections.
Prof Solomkin, you have actively participated in the development of WHO Global Guidelines for the prevention of surgical site infections. What’s news in these guidelines?
The key strength of these guidelines is that they were developed using a rigorous WHO process of systematic review, meta-analysis, and GRADE. These methods provide a transparent and thorough review of quality research (randomized controlled trials), and were generated and discussed in detail by a group of experts in surgery, infectious diseases, infection control, anesthesia, and other health care fields. These methods, now mandated for all guidelines by groups such as the Institute of Medicine, North American and European regulatory agencies, provide confidence in the strength of the evidence and in the recommendation made. Further, these were structured as a global guideline, and representatives of low and middle income countries were on the Guideline Development Group, and each recommendation was appraised for its utility and appropriateness for these health care environments.
Despite guidelines, knowledge and awareness of infection prevention and control measures among surgeons are often inadequate and a great gap exists between the best evidence and clinical practice with regards to surgical site infections prevention. According to you, how can these guidelines be implemented worldwide?
The critical element in having these guidelines implemented is to have an institutional commitment to infection prevention and control. This begins in the executive leadership, which must strongly support the work of an infection control committee, and insist on surveillance, compliance, and generally develop champions for the tasks required at each level. Without the aggressive support of the surgical departments, nursing services, and groups such as decontamination and sterilization, the likelihood of success is diminished.
How do you think can we persuade healthcare workers to follow them? Do you think that the figure of the “champion in preventing and managing infections across the surgical pathway”, can be impactful?
Health care workers are very busy during their day with large numbers of patients to care for, and with many even competing tasks and pressures to adhere to numerous guidelines. The role of champions is to provide the a positive environment that on a daily basis encourages health care workers to prioritize a culture of safety. It is leading by example.
What is the role of surgeons in the prevention and management of infections? How can surgeons participate in the fight against antibiotic resistance?
Surgeons in many ways are on the frontline of the fight against resistance. This begins with appropriate use of antimicrobial prophylaxis. The elements of this are correct selection of patients known to benefit from prophylaxis, proper choice of antibiotics at the right dose, timing (administration with 60 minutes of incision), intra-operative redosing for procedures lasting more than two half-lives of the antibiotic, and no post-operative administration. Therapeutic use of antibiotics for soft tissue, intra-abdominal, and other infections should be guided by microbiology results and attention paid to when therapy should be terminated. “Calendar-based prescribing” (one week, two weeks, etc.) should be replaced by monitoring of progress.
You have also coordinated IDSA guidelines for the management of intra-abdominal infections. What are the principles for an appropriate use of antibiotics across the surgical pathway?
The key principle is to begin empiric treatment early, be certain that antibiotics are administered again using principles of prophylaxis mentioned above, and understand the likely microbiology of the suspected infection. In these days of resistance in Gram-negatives and Gram-positives, a general rule is emerging that resistant bacteria present in more than 20% of the patients with a given infection dictates empiric coverage. Conversely, particularly with carbapenems, such therapy should be altered once susceptibility data are obtained. But the surgeon’s main task is to achieve proper source control to drain abscesses and other infected collections, prevent further soiling by resection, diversion, or anastomosis, and pay close attention to tension free wound closure.