The role of surgery worldwide and its effects on skin and wound care is the common theme for this journal issue. A diversity of topics is included in this issue, so depending on your specialty, there is sure to be something that you can implement in your practice. In this editorial, we discuss two articles in this issue; the first focuses on care bundle use to prevent postoperative surgical site infection (SSIs). In the second article, researchers interviewed women with hidradenitis suppurativa (HS) to better understand how the disease impacts their life experiences.
In a systematic review, Dr Pinar Avsar and colleagues examined the impact of care bundles on the incidence of SSIs. The authors analyzed 35 studies published between 2011 and 2021 and found that care bundles reduced SSIs from 7% to 4% overall: a 45% reduction.
These data have several additional modifying factors to consider, including different components across various care bundles limiting cross-study comparisons. The healthcare team's compliance with the SSI care bundle components is often suboptimal and this additional factor may increase costs, including longer length of stay and higher SSI readmission rates. Quality assurance and auditing may result in improving these gaps in practice.
Any postoperative impact starts with the preoperative assessment and treatment, including HbA1c to diagnose diabetes or optimize blood sugar control; smoking cessation and weight loss; and medications, allergies, and nutrition status. To increase patient adherence to treatment, patient education for surgical preparation and postoperative care is essential.
During hospitalization and in the recovery period, care may also include skin preparation, bowel preparation for gastrointestinal surgery, antimicrobial prophylaxis for high-risk patients, hand hygiene, preoperative hand scrub, and surgical site preparation. Evidence-informed postoperative wound care will include monitoring and auditing for infection both in the hospital and at home for 30 days. Auditing SSI bundled care compliance will facilitate quality improvement. Only with policies and procedures to facilitate bundled care can the SSI rates be optimally low. Healthcare providers need to determine optimal bundled care for the various surgical procedures linked to the monitoring of SSIs.
The International Wound Infection Institute has released the third edition of their freely downloadable “Wound Infection in Clinical Practice” consensus document.1 This updated document summarizes the current evidence for infection risk factors, the role of biofilm in infection, antimicrobial resistance, and new technologies to manage wound infection. This document also contains a new glossary of terms that is intended to formalize an internationally consistent wound infection terminology. Be sure to listen to the Words on Wounds podcast episode, Antimicrobial Stewardship and Proactive Infection Care, for more information about the guideline (available at ASWCjournal.com).
Hidradenitis suppurativa affects patients’ quality of life more than any other dermatologic disease;2 however, this condition can be improved with early surgical management. In this issue, Fisher and Ziv interviewed 22 women with HS and conducted thematic and content analysis. The authors identified pain, the emotional burden of shame, and loss of femininity/intimacy as common themes across interviews, but noted that interviewees also expressed strength and optimism.
There is hope for treatment with the new European guidelines3 recommending early surgery for both mild and advanced HS. In early disease, painful nodules or cysts should be deroofed or excised surgically or with lasers. Excision is an important option because it will relieve pain from blocked and ruptured hair follicles. These excisions should include removal of the amorphous material below the lesions because this material often forms a nidus for new inflammatory lesions. Advanced HS often requires extensive excisions of the axillary, groin, or perianal regions with rotational flaps, skin grafts, or delayed healing by secondary intention.
If patients do not improve with topical treatment or oral antimicrobials, they may benefit from anti–tumor necrosis factor agents, including adalimumab (FDA approved). Clinicians should be sure to rule out secondary infections; if infection develops while the patient is on biologic agents, it should be treated. “Wholistic” care includes the blending of medical management with appropriate surgical procedures that are optimally monitored to prevent complications.
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
1. International Wound Infection Institute. Wound infection in clinical practice. Wounds International. 2022. https://woundinfection-institute.com/wp-content/uploads/IWII-CD-2022-web.pdf
. Last accessed May 9, 2022.
2. Alavi A, Anooshirvani N, Kim WB, Coutts P, Sibbald RG. Quality-of-life impairment in patients with hidradenitis suppurativa: a Canadian study. Am J Clin Dermatol 2015;16(1):61–5.
3. Zouboulis CC, Bechara FG, Dickinson-Blok JL, et al. Hidradenitis suppurativa/acne inversa: a practical framework for treatment optimization—systematic review and recommendations from the HS ALLIANCE Working Group. J Eur Acad Dermatol Venereol 2019;33(1):19–31.