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  • Writer's pictureLilian Chiwera

What's #SSIPrevention got to do with #ClimateAction?

Surgical site infections, a common healthcare-associated infection, are seasonal -- increasing in the summer and decreasing in the winter-according to new research published online today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.’ The evidence to support this statement which was published in 2017 was weak, although I must say in my experience there were times when I saw increased incidences in surgical site infections (SSI) during summer months. Furthermore, a meta-analysis by Sahtoe et al in 2021 concludes that warm weather seasons are associated with a statistically significant SSI risk increase of 39%. Wow if this is really true and this is a good quality paper, then I would be asking the question 'what does this mean to me and other in terms of climate change and proposed actions?'. If temperatures continue to increase with inadequate #ClimateAction, are SSI incidence risks likely to also increase?

A Germany paper which looked at links between climate factors and SSI risk in 2019 concluded: “An association between climatic factors and SSI rates was demonstrated. The predicted rise in global temperatures by up to 4 °C by the end of this century compared to preindustrial levels may increase the likelihood of SSI and should be taken into consideration in future preventive strategies.” I refer to my previous blog where I discussed the concept of holism in #SSIPrevention. Sometimes when politicians are discussing some of these climate issues, we or should I say I can easily mistake it as ‘it’s nothing to do with #InfectionPrevention or #SSIPrevention’. In fact, it has everything to do with all of us, whether infection control or not. Increasing evidence and dialogue suggests that infection control measures and interventions should ideally embrace the #ClimateAction. So how do we break this down in SSI prevention terms.

  • Patient X develops a deep infection following a caesarean section (CS) procedure. This patient, who is a single mother is readmitted to a healthcare facility for a wound washout and debridement. As this patient is very unwell, her niece who lives about 400 miles away must drive to her house so she can look after her baby whilst she’s receiving care to manage this infection. This infection is devastating for the patient, family and healthcare, i.e. there are human and economic and climate costs here.

So, what is the impact of this one infection on climate change? If we can’t reduce SSI incidences for whatever reason in the coming years, what is the overall impact on our climate action locally? Furthermore, how are we even going to deal with increasing SSI in incidences globally should climate change lead to significant increases in SSIs? My thoughts and interesting reading below:

  1. 'Climate change is considered to be ‘one of the greatest global public health threats of this century. This bulletin of the American College of Surgeons by Sofya et al, suggests that ‘surgeons can lead sustainability efforts in the areas of supply chain management and energy efficiency’. I would add that they must also lead on #SSIPrevention initiatives or efforts. Thus if surgery is considered to be ‘a major propellant of climate change’, from an #SSIPrevention perspective a reoperation for an infected CS above will have deleterious effects on our efforts to reduce hospital waste and energy expenditure. We must therefore aim to get it right first time and reduce those avoidable SSIs, not just as a #PatientSafety initiative, but as a #ClimateAction also. Surgeons can certainly help with this action by ensuring their technique is ‘spot on’ and where necessary facilitate peer reviews to promote learning from experienced senior surgeons. There has been reports which appear to suggest that higher superficial incisional SSI incidences may be linked to junior surgeons who are left to close wounds without close supervision. Certainly this paper by Gandhi et al from Malaysia appears to suggest that ‘surgeons level of skill’ may influence patient outcomes. In their own words ‘our study found a statistically significant positive association between surgeon seniority and SSI incidence’. To be honest though, I was a little confused as to whether the positive association meant senior surgeons were better or worse and if better up to what age. Perhaps food for thought... To echo Sofya et al, an opinion piece on climate change in General Surgery News reports that so far it’s been rare to see surgeons involved in sustainability efforts, despite them having a trusted voice within health care systems. There needs to be a momentum shift therefore to let surgeons use their trusted voices to push forward, not just #SSIPrevention efforts across surgical pathways but also generic #ClimateActions.

  2. ‘Combustion of fossil fuels contributes to air pollution by emitting particles into the air, and it contributes to global warming through the release of Green House Gases (GHGs) such as carbon dioxide (CO2).' Waste anesthetic gases ‘in particular desflurane and nitrous oxide, have significantly higher global warming potentials than CO2’. ‘One hour of desflurane use, for example, is equivalent to driving a car 235–475 miles’. Wow, what can I say? If this readmitted CS SSI woman, returns to theatres or the operating room for a washout and debridement & desflurane and nitrous oxide are used, this becomes a negative climate action over and above other devastating consequences of this infection. Furthermore a niece who’s had to drive about 400miles to look after the baby hasn’t done the environment or climate action any favours either. By doing everything we can to reduce avoidable SSIs, we’re also doing our bit to combat global warming. Certainly surgeons and the rest of the staff along a patient’s surgical pathways are key players not only in improving patient safety but also in combatting climate change.

  3. As if we already don’t have enough to worry about in infection prevention and our battle against antimicrobial resistance; these new findings left me rather perplexed… ‘compelling evidence of connections between Antimicrobial Resistance (AMR) bacteria causing surgical-site infections and arthropod’. Why ARTHROPODS!!! Yes some of the things I thought didn't matter much in infection control actually do. It means we all have to think outside the box. As #InfectionPrevention practitioners, we must actively engage with the #ClimateAction agenda and proposed actions & support and encourage others to do the same. It is thought that ‘insect and fly population will double if temperatures increase by 1.5 degrees. By 2080 there could be approximately 50,000 trillion flies carrying carbapenem resistance and spreading AMR across the planet’. As Professor Tim Walsh, Oxford University clearly points out, ‘The clinical burden of AMR is most felt in low-middle income countries, but the increase in global temperatures, due to climate change, will result in a significant increase in flies and many other insects and a subsequent increase in the global velocity of antibiotic resistance.’ In his own words ‘a problem currently seen from afar will quickly come into focus much closer to home.’ To echo his lines of thought, I say haven’t we learnt enough from the current #Covid pandemic? I have said before about how this pandemic propelled me to start collaborating with Zimbabwe on IPC, realizing that unresolved IPC issues in any country globally can have far reaching consequences for the global community. So now when I think AMR, I am also going to think ‘anthropological behaviour, dealing with human and animal waste and even climate change’ and #IPCWithoutBorders. I recommend you all read this paper.

  4. Well, what to say now… Sofya et al suggest ‘the most important initial steps is to educate ourselves on this topic and then educate our surgical colleagues, residents, students, and hospital administrators’. I am certainly educating myself on #ClimateAction and I know many others are too. I enjoyed a speech by Barbados Prime Minister which I listened to via twitter, “today we need the correct mix of voices, ambition & action.” This strengthened my #IPCWithoutBorders passion. It’s not just about actions in one country, it’s about a global collective action! Let’s tackle climate change, SSI, antimicrobial resistance together and share knowledge as required for the betterment of all humanity.

I could go on and on about climate action links for this readmitted CS SSI patient who will require additional dressings, antibiotics to manage the infection, potentially need a urinary catheter and could end up in intensive care unit with sepsis and worst case outcome dies and leaves her new born baby. Another ‘surgery is very energy-, resource- and waste-intensive, requiring sterilization processes, lighting, cooling and ventilation.’ I think you now get the gist. I will leave you to rethink single use versus reusable equipment & anaesthetic choice – balancing patient safety with #ClimateAction. To conclude, any measures or efforts to reduce SSIs will make a positive contribution to overall patient safety outcomes and the current hot topic on #ClimateAction. So yes #SSIPrevention has got everything to do with #ClimateAction. Let's all work together whether you're in infection prevention or not and make those needed changes to preserve our climate today.

Top image reference source: Centers for Disease Control and Prevention via 

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