Has Biofilm Become a Modifiable Risk with Surgical Site Infections?

The future of orthopedic surgical advancement relies on technology, inventions, and research. Whether enhancing previous processes or introducing new knowledge, translating research into practice does not necessarily catch on quickly nor become widespread initially, despite the uniqueness and evidence that encourages immediate uptake and use. Surgeons are confronted with promising advances and ideas almost daily that are designed to improve surgical outcomes and optimize the perioperative experience. In medicine, technology is great until it isn’t, and as a surgeon, choosing to use new surgical innovations and techniques comes down to starting with the positive experiences of trusted peers and a fundamental need to provide high-quality care and avoid unnecessary surgical events.

One surgeon explains the adoption of technology best by saying, “When examining emerging technology, new does not mean effective, and physicians must titrate the science.”¹ Good advice in many cases, but maybe even more critical when it involves infection prevention. Today’s surgeon has more to consider than choosing sutures or surgical approaches. According to a recently updated Centers for Disease Control and Prevention (CDC) progress report,² surgical site infections (SSIs) have been associated with a three percent mortality rate, with 75 percent of SSI-associated deaths directly attributable to the SSI.³ According to CDC resources, SSI is the costliest healthcare-associated infection (HAI) type with an estimated annual cost of $3.3 billion and nearly one million additional in-patient days annually.^4,5

Efforts to dial back SSI rates have impacted the timing and use of pre- and intraoperative antibiotics, skin-to-skin surgical efficiencies, the type and duration of anesthesia, prosthetic devices, and the mechanical strategies of the operating room itself. These innovations have produced measurable reductions of SSI, yet in the surgical specialties, there remains a percentage of cases that defy current prevention strategies. As it turns out, the unseen biofilm community of bacteria that forms a self-constructed protective shell is being identified everywhere and has found its way into the surgical suite, piggybacking in patients’ noses, on skin, and on surgical instruments, equipment, and staff.

The National Institutes of Health (NIH) has proposed that 80 percent of all known human infections are associated with biofilms, and the CDC has reported that more than 65 percent of all hospital-acquired infections are attributable to biofilms, making biofilm important to manage.⁶ Equally concerning is a 2019 article on modifiable risk factors for total joint arthroplasty (TJA) patients. The author warned that infections would rise correspondingly with the number of total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures through 2030. According to the article, recognized risk factors receiving special preemptive attention—i.e., nasal and skin Staphylococcus colonization, rheumatoid arthritis, cardiovascular and renal disease, obesity, diabetes mellitus, hyperglycemia, anemia, malnutrition, tobacco use, alcohol consumption, depression, and anxiety—contribute to fewer SSIs.⁷ As the numbers of biofilm-based infections increase, the need to universally treat biofilm as a modifiable surgical risk is becoming an apparent addition to the aforementioned list.

Biofilm, as a causative factor in SSI and delayed healing, is not a new concept among chronic wound providers. Yet too many surgeons believe that biofilm can be kept at bay by careful observation of sterile technique, pre-surgical patient preps, and surgical irrigation and incision management processes that until recently, produced low to no levels of SSI. With each inexplicable SSI, surgeons are starting to think about biofilm and realize they can reduce SSIs by addressing biofilm as a modifiable risk (through prophylaxis). In the United States alone, the number of infections will grow with the industry unless something changes. Available statistics are years behind but represent sobering amounts, with the estimated overall annual incidence of SSI around 1.07 percent, or 8,000 deaths directly related to SSI, and a $10 billion treatment cost.⁸ TJA is one of the most popular, cost-effective, and highly successful surgeries in medicine. By the year 2030, TJA is expected to grow from one million procedures annually to more than four million, with an estimated 57 percent shifting to outpatient facilities.^9,10

No surgeon wants to be responsible for increasing SSIs. In orthopedic procedures, even fractional increases can cause a lifelong stream of medical visits, surgeries, and long-term antibiotic suppression therapy. Surgeons today must be more open to antibiofilm technology.

My experiences with antibiofilm technology began when I noticed the occasional breakthrough superficial infection, a process I considered unusual for my patients. I realized that while arthroplasty infection rates are generally low, the occasional infection can be costly, ranging to more than $90,000 for a single failed knee arthroplasty. I also noticed many of my colleagues using concocted irrigations and incision-management approaches as breakthrough SSIs became more frequent. Our best surgical strategies started to fail and provide inconsistent results. Looking back, I can only attribute these incidences to biofilm.

As with other surgeons, I have a responsibility to the entire surgical team and a keen awareness of cost. Initially, I saw adding antibiofilm therapies as an added cost but eventually I realized that three-minute surgical site irrigations paled in both time and cost compared to other unsuccessful activities such as dwelling time waiting periods, or product setup and dry time. Adding an extra three or four minutes to a procedure to avoid infections cost the hospital an average of $83.50 per minute ($250.53–$334-plus these days) per primary arthroplasty, and several hours of lost operating room time annually.

Three minutes per case quickly adds up in time and money. Lost revenue through reduced OR slots and added days for non-reimbursable readmission charges take a toll on dwindling medical dollars, not to mention the impact on patients and surgeons.

Since starting to use the XBIO product lines, I have had no incisional complications and find the technology effective after the development of a postoperative infection, with wounds responding rapidly with less drainage/inflammation. The technology recently cleaned up a poorly healing inflamed biopsy site well enough to proceed within days with a planned total knee replacement. Periodic reviews of wounds have occurred following use of the XBIO products SURGX and XPERIENCE for incision management and surgical irrigation, respectively, and I have not observed any negative effects on healing. In light of these positive results thus far, I have started to treat biofilm as a modifiable risk factor for my surgical cases and have found using the XBIO products an easy and efficient means of SSI risk modification. As for product selection now, the top questions I consider are:

• Does it provide sustained antimicrobial coverage beyond the initial application?
• Is the product non-toxic?
• Is it broad spectrum for bacteria and fungi?
• Is it easy to use, no rinsing, no dwelling (basically not taking extra OR time)?
• Is it easy to store?
• Does it meet industry standards for sterility?
• Is it cost-effective? 

When considering operative optimization processes, as surgeons, we recognize the other modifiable risks. By including biofilm as a modifiable risk in planning surgeries, this technology by far gives patients, surgeons, and facilities the best opportunity to reduce SSI. 

This is the place where the art and science of medicine cross paths, as now surgeons can intuitively choose to lessen the impact of biofilm as a causative factor in SSI, just like other risks. 

References

1. bit.ly/3IPhU2n
2. bit.ly/3od1LvR
3. Awad, S.S., “Adherence to surgical care improvement project measures and postoperative surgical site infections.” Surgical Infections (Larchmt), 13(4): (2012): 234-7.
4. Zimlichman, E., et al., “Health Care-Associated Infections. A Meta-analysis of Costs and Financial Impact on the US Health Care System.” JAMA Intern Med, 173(22): (2013): 2039-4.
5. Lissovoy, G., et al., “Surgical site infection: Incidence and impact on hospital utilization and treatment costs.” Am J Infect Control, 37(5): (2009): 387-97.
6. bit.ly/3IMgnKi
7. bit.ly/3KYVaP7
8. Scott RD II. “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.” Atlanta, GA: Centers for Disease Control and Prevention, 2009.
9. Kurtz S. et al. (2007). “Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.” J Bone Joint Surg Am. 2007;89: 780. doi: 10.2106/JBJS.F.00222
10. bit.ly/3Hid4u6

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Dr. Jon Minter is an orthopedic surgeon based in Alpharetta, Ga., and specializing in the surgical management of hip and knee arthritis. He is also a surgeon consultant for Next Science, a medical technology company whose proprietary XBIO Technology powers a range of medical devices to reduce the impact of biofilm-based infections in human health.