September 15, 2017
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Thorough preoperative evaluation may reduce infections

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Linda A. Russell

NEWPORT BEACH, Calif. — Thoroughly assessing a patient prior to surgery can go a long way toward decreasing the patient’s postoperative risk of developing an infection, according to a presenter here.

“Patients with postoperative fever should be evaluated at the bedside and a direct fever work up done, if needed,” rheumatologist Linda A. Russell, MD, Director of Perioperative Medicine at Hospital for Special Surgery and Assistant Professor of Medicine at Weill Cornell College of Medicine, in New York, said at the Interdisciplinary Conference of Orthopedic Value-Based Care.

“Have a strong team in place for surgical site infection and consider a protocol for sending off specimens of evaluations of [Clostridium difficile] C. diff,” Russell said.

Routine bathing, antibiotic use

In her presentation, Russell noted most early postoperative fevers are caused by the inflammatory stimulus of surgery and will resolve in 2 days to 3 days. However, fever can also be a manifestation of a serious complication, so preoperative evaluation of the patient, including a skin evaluation, is an important step to help reduce infections, she noted.

“We do not want any infections postoperatively, so we want to look at the patient preoperatively to decrease the risk of infection as much as possible postoperatively,” Russell said.

According to Russell, patients should undergo routine bathing. If psoriasis is present, it should be cleared completely prior to surgery to avoid skin breakdown and infection. High risk patients also should undergo MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) screening.

Antibiotic prophylaxis has been shown to decrease the risk of postoperative infection, but giving patients antibiotics perioperatively can also increase the risk of C. difficile.

Stool tests for C difficile

“I think a lot of people do not realize that often people in the community are colonized with C diff,” Russell said. “They are asymptomatic, but they are colonized with C. diff. We give antibiotics perioperatively which increases the risk of C diff.”

She said the CDC website includes information about which patients need stool testing for C. difficile, which stems from practices at Vanderbilt University, includes testing for C. difficile in patients “with clinically significant diarrhea that is defined as three or more loose stools in a day over 1 to 2 days.”

Also, laxatives should be discontinued if they are being used and then the patient should be reassessed, Russell noted.

C. diff is tricky because if — we all have had patients probably have had a severe C. diff infection — they go on to bowel perforation and even death, so you have to watch these patients and evaluate them closely,” Russell said.

She emphasized how important it is to have a team evaluate the rate of surgical site infections for every procedure and then set the rules for skin preparation, perioperative antibiotic use, MRSA and MSSA screening and decolonization, hand hygiene and OR traffic.

Bedside evaluation

Fevers can also stem from a noninfectious cause. Therefore, if the patient has no localized signs or symptoms of fever and has a temperature less than 39° Celsius, physicians do not need to perform an infection work up until postoperative day four, unless the history and physical support testing. Patients can be discharged to home if they have no localized signs or symptoms of fever and their temperature is trending downward, Russell said.

“I think [escalation] is important in this day and age,” she said. “We have a lot of providers touching the patient, but there needs to be a culture of safety for escalation.” – by Casey Tingle

Reference:

Russell LA. Postoperative fever, hospital acquired infections. Presented at: Interdisciplinary Conference of Orthopedic Value-Based Care; Jan. 20-22, 2017; Newport Beach, Calif.

For more information:

Linda A. Russell, MD, can be reached at Hospital for Special Surgery, 535 E. 70th St., New York, NY 10021; email: russelll@hss.edu.

Disclosure: Russell reports no relevant financial disclosures.