Introduction
Considering the etiology of surgical site infections (SSI), it can be noted that diseases of the skin and soft tissues are usually the result of any mechanical damage or surgical manipulation and are caused by a wide range of bacterial microorganisms. In this situation, they are, to some extent “programmed,” and their identification does not present any particular difficulties for the practitioner. Much less often, such infections occur spontaneously, and in such cases often there are problems of timely diagnosis and treatment.
Background of Proposal
Most infections of the skin and soft tissues are self-limiting and are easily amenable to therapy, sometimes consisting only of local treatment and surgical aids and, often even without the use of antibacterial drugs. Other variants of the course of soft tissue infections are life-threatening and require the fastest diagnosis, emergency surgery, and the choice of rational antibacterial therapy to prevent tissue damage and save lives. Defects in the diagnosis and treatment of severe infections of soft tissues, which led to extensive losses of soft tissue formations, significantly affect the quality of life in the future and require complex reconstructive plastic surgeries (Jasim et al., 2017). The growth of antibiotic-resistant strains of gram-negative and gram-positive flora, reflecting both the general tendency of the evolution of microorganisms and the result of the irrational use of antibacterial drugs, causes certain difficulties in treatment and negatively affects the clinical outcomes and with similar infections.
Problem Statement of Proposal
The modern period of development of medicine is characterized by an increase in the number of SSI and postoperative purulent-inflammatory complications. This phenomenon has been recorded everywhere over the past 30–40 years (Boas et al., 2015). This is based on general biological reasons, the basis of which is the changed immunological resistance of the human body, as well as the causes associated with technological progress and, partly, the achievements of medicine. The possibility of an invasion of chronic infection pathogens increases due to the growth of injuries, the volume, and duration of surgical interventions, as well as the widespread use of various technical means – synthetic implants, metal structures, intravascular catheters. The weakening of the discipline of surgeons in matters of strict observance of the principles of asepsis in connection with the hopes placed on the use of antibiotics is also of certain importance.
Purpose of Change Proposal
The clinical picture of surgical infections is also influenced by social factors. Localized forms of the disease – abscesses, purulent bursitis are much less common. Concomitant diseases and violation of hygiene standards by patients have a negative effect. At the same time, there is an extension of the first phase of the wound process, slow cleansing of the wound from necrotic tissues, long-term preservation of suppuration in the absence of a pronounced perifocal reaction of soft tissues, slowdown of reparative processes, a tendency to generalization of the inflammatory process and exacerbation of concomitant diseases (Yao, Zhou, Choma, Kwon, & Street, 2018). Thus, the change should be done by making sure that hygienic standards are met and improved.
PICOT Statement of Proposal
These features can contribute to an increase in the number of complicated and complicated forms of SSI that are difficult to respond to and cannot be treated with standard treatment, an increase in the frequency of transition of the disease to a chronic form, prolongation of treatment time, and worsening of treatment results. Changes in the course of surgical infections correspond to the evolution of several other diseases, such as tuberculosis, rheumatism, sexually transmitted diseases, diseases of the lungs, and organs of the urinary system, towards the predominance of low-manifest forms (Saziye & Afksendiyos, 2015). To solve the problem of SSI, the achievements of related sciences and production are involved. New aseptic methods are used in the form of operating rooms with a laminar flow of sterile air, gnotobiological isolation, means of physical impact on the course of the wound process. However, they do not resolve the issues that have arisen. The unresolved problem of SSI inhibits the further development of surgery and acquires social and economic significance on a national scale. In patients (P), what is the effect of surgery (I) on soft tissue damage (O) compared with non-surgical treatments (C) throughout the recovery period (T)?
Literature Search
The strategy of Literature Search Used
The literature was reviewed by analyzing etiology and pathology as the main focus areas. The vast number of research articles were scanned and overviewed, which resulted in eight studies. The selected papers were considered to be the most relevant and recent, therefore plausible, articles to review. One of the reasons for the features of clinical symptoms of SSI at present is changes in the etiological structure of pathogens of this pathology and a modification of the biological properties of pathogens.
Evaluation of the Literature
Until recently, there was an opinion in science that all microorganisms, depending on their ability to cause infection, are divided into three main groups: pathogenic, conditionally pathogenic, and non-pathogenic (Oliveira, Mancero, Faria, & Poveda, 2019). The experimental and clinical data accumulated in recent years indicate that conditionally pathogenic and saprophytic microflora, entering the body with altered reactivity, begin to multiply and become pathogenic (Boas et al., 2015). Therefore, it is difficult to distinguish between the above groups of microbes (Saziye & Afksendiyos, 2015).
The etiological structure of modern SSI is characterized by a wide range of pathogens, and its further increase due to previously considered non-pathogenic microorganisms (Yao et al., 2018). Studies show that with a decrease in living standards in patients in purulent foci, anaerobic non-clostridial microflora dominates (Langerman, Thisted, Hohmann, & Howell, 2016). The wounding process, in such cases, acquires a torpid course without a tendency to localization, is accompanied by intoxication (Jasim et al., 2017). The process requires radical surgical treatment (Parizh et al., 2018). In this case, a phlegmonous course with a tendency to spread the inflammatory process becomes characteristic (Al-Qurayshi, Walsh, Owen, & Kandil, 2019). These data show that SSI can be prevented by applying a specific set of protocols and safety measures.
Applicable Change or Nursing Theory Utilized
The evolution of pathogenic and especially conditionally pathogenic microorganisms is accelerating due to the increasing anthropogenic impact, the growth of environmental problems, and global climate change. The key nursing theory is From Novice to Expert theory, which perfectly outlines the field of SSI, where every healthcare specialist should learn a great deal (Table 1). Natural selection is one of the most important gains of evolution. The main driving forces of biological evolution are mutations, genetic recombination, such as conjugation, transduction, transformation, and transposition, and natural selection of infectious agents with certain genetic, environmental, and epidemiological characteristics (Oliveira et al., 2019). At the same time, the organization, replication, and expression of the microbial genome are of great importance.
Proposed Implementation with Outcome Measures
The main proposed implementation involves adjusting the given approaches to match the healthcare system’s operational requirements. To date, an idea has formed that microorganisms have a group of specialized genes that provide high rates of adaptability. Many microbes have, as it were, a double set of genes – saprophytic or physiological, designed to survive in the external environment and ensure symbiotic relationships, and parasitic or pathogenetic, which determines the colonization and features of the pathogenesis of the disease. In the course of evolution, microorganisms have developed many escape mechanisms from host defense factors: resistance to the lytic effect of complement, destruction of phage and lysosomes of micro- and macrophages, stimulation of immunosuppression and autoimmunity, the formation of granulomas, and antigenic mimicry.
Potential Barriers to Plan Implementation
There are several barriers to implementing the given approaches. There are new judgments regarding the pathogenicity of microbes. The terms “pathogenicity” and “virulence” are considered rather as synonyms. At the same time, the pathogenicity of the microorganism is considered to be a function not only, and sometimes not so much of the microbe itself, but also of the host organism, the immune system of which resolves one or another type of relationship between the parasite and the host, as a result of which a certain type of infection process, such as carriage, acute, chronic or persistent infection, and mild or severe.
Conclusion
In conclusion, when constructing the concept of treatment of SSI, deontological aspects should be taken into account. Of particular concern are the ever-increasing “aggressiveness” of constantly improving and newly created and invasive diagnostic and treatment methods. With SSI, these methods can be dangerous due to the possible generalization of infection. Undoubtedly, the introduction of each new approach must be preceded by a bioethical justification. Despite significant progress, the treatment of SSI has to solve difficult problems, the range of which will expand and become more complicated. A huge amount of factual material has been accumulated, requiring comprehension. Without this, it is impossible to improve surgical treatment methods. There is a need for an interdisciplinary approach to the study of factors causing morphosis of SSI.
References
Al-Qurayshi, Z., Walsh, J., Owen, S., & Kandil, E. (2019). Surgical site infection in head and neck surgery: A national perspective. Otolaryngology–Head and Neck Surgery, 161(1), 52-62.
Boas, R., Ensor, K., Qian, E., Hutzler, L., Slover, J., & Bosco, J. (2015). The relationship of hospital charges and volume to surgical site infection after total hip replacement. American Journal of Medical Quality, 30(3), 283-288.
Jasim, H. H., Sulaiman, S. A. S., Khan, A. H., Dawood, O. T., Abdulameer, A. H., & Usha, R. (2017). Incidence and risk factors of surgical site infection among patients undergoing cesarean section. Clinical Medicine Insights: Therapeutics, 13(5), 33-61.
Langerman, A., Thisted, R., Hohmann, S., & Howell, M. (2016). Antibiotic and duration of perioperative prophylaxis predicts surgical site infection in head and neck surgery. Otolaryngology–Head and Neck Surgery, 154(6), 1054-1063.
Oliveira, R. A., Mancero, J. M. P., Faria, D. F., & Poveda, V. de B. (2019). A retrospective cohort study of risk factors for surgical site infection following liver transplantation. Progress in Transplantation, 29(2), 144-149.
Parizh, D., Ascher, E., Raza Rizvi, S. A., Hingorani, A., Amaturo, M., & Johnson, E. (2018). Quality improvement initiative: Preventative surgical site infection protocol in vascular surgery. Vascular, 26(1), 47-53.
Saziye, K., & Afksendiyos, K. (2015). The vacuum-assisted closure (V.A.C) system for surgical site infection with involved vascular grafts. Vascular, 23(2), 144-150.
Yao, R., Zhou, H., Choma, T. J., Kwon, B. K., & Street, J. (2018). Surgical site infection in spine surgery: Who is at risk? Global Spine Journal, 8(4), 5-30.