Simple Device Tames Surgical Site Infections in

Contaminated Wounds

The risk for a surgical site infection developing in a contaminated wound can be dramatically
reduced by a simple daily wound probe, a new study shows.

“We are really excited about this study, as I personally feel it will revolutionize how we manage
contaminated/dirty wounds with improved outcomes for the patient,” said lead author Shirin
Towfigh, MD, associate professor of surgery at Cedars-Sinai Medical Center in Los Angeles.

In a randomized study of 76 patients undergoing open appendectomy for perforated appendicitis,

surgical site infections declined 16% in patients who had daily wound probing compared with a
similarly matched control group (2.6% vs. 18.9%; P=0.028).

Wound probing is a simple technique that was carried out daily by a member of the surgical
team. The wound was swabbed with iodine, then penetrated with a sterile cotton tip applicator.
Any extra fluids are patted dry before the wound is redressed.

“We would recommend this technique for management of contaminated abdominal wounds,”
said Ankur Gupta, MD, a study co-author and surgery resident at Cedars-Sinai. He presented the
results at the 2010 annual meeting of the Surgical Infection Society. Full details will be
published in the Archives of Surgery.

Several surgeons who spoke with General Surgery News said they are intrigued by the results
and are considering the technique.

“This is a simple and potentially very useful technique. Intuitively it makes sense. I certainly
would consider trying [it],” said Michael Englesbe, MD, assistant professor of surgery in the
transplantation division of the University of Michigan Health System, in Ann Arbor.

He said his only concern is identifying the patients who will benefit from this approach. “Most
patients do not get a surgical site infection, so subjecting them to wound probing must be
considered.”

Dr. Towfigh was introduced to the concept of wound probing while she was a resident at the
University of California, Los Angeles, where pediatric surgeon Eric Fonkalsrud, MD, now a
professor emeritus of surgery, was probing wounds. In the 1980s, Dr. Fonkalsrud started probing
wounds in pediatric patients and published a small paper describing his results in 1993 (Am Surg
59:838-841).

“I assumed everyone was probing wounds. It worked great,” said Dr. Towfigh. But at her first
job after residency, she was surprised that surgeons and residents had never heard of wound
probing. “When I asked the residents to probe the wound daily, they looked at me like I was
crazy.”
To convince the residents and her colleagues, Dr. Towfigh devised a randomized trial. Between
2007 and 2009, investigators randomized 77 patients with perforated appendicitis to either loose
primary wound closure with staples or loose primary closure with staples (n=39) and daily
wound probing (n=38).

In addition to lower rates of surgical site infections, patients treated with wound probing had a
shorter hospital length of stay (4.7 vs. 6 days; P=0.049), with no increase in pain (P<0.05). Other
complications were similar.

The investigators could not say definitively why wound probing reduces infection. They believe
that the probing expedites wound healing by releasing contaminated fluid and decreasing local
bacterial burden.

Patients underwent wound probing until the wound was closed and no longer draining, a process
that took, on average, three days. In a few cases, the wound took up to five days to heal.

“We recommend that wound probing be practiced for contaminated wounds due to open
appendectomy for perforated appendicitis. We would argue, too, that it be practiced in the first-
line management of other abdominal contaminated wounds, regardless of incision length,” said
Dr. Towfigh.

She believes the technique may improve long-term outcomes such as facial dehiscence and
incisional hernias, reduce labor for care of infected wounds by nursing staff and physicians,
improve cosmetic results and reduce overall costs of care.

The investigators also conducted a chronological study of the bacterial flora in contaminated
wounds. Analysis revealed a mixed flora of aerobic bacteria in the wounds, with one-third also
having anaerobic bacteria.

There was little correlation between the intra-abdominal cultures and the wound cultures, with
much higher ratios of gram-positive to gram-negative bacteria in the wound cultures. Anaerobic
gram-positive bacilli and α-Streptococcus were the predominating bacteria in the wound
cultures.

Almost all bacterial counts fell to less than 105 cfu/mL by the first postoperative day, likely due
to preoperative initiation of antibiotics.

“This is a very elegant study, conducted prospectively in a controlled manner that adds
considerably to our knowledge of surgical site infections,” said Kamal Itani, MD, chief of the
surgical service at the VA Boston Medical Center and professor of surgery at Harvard Medical
School, in Boston.
COMMENT:

It’s quite great to have this device because infection is a bit dangerous and with skin opened
during operations, it’s possible for the patient to acquire infection. But with this device, you can prevent
the microorganisms from spreading thus preventing further complications. It is cheap, very affordable
and easy to do even if you will do it every day. Everyone should implement this, for faster wound healing
and closure. And I am good with it.

Keenen Engel Pascua BSN-III-Amaryllis