An in-hospital workup of a 78-year-old hypeensive, mildly asthmatic man who is receiving chemotherapy for colon cancer reveals symptomatic gallstones. Preoperative laboratory results are notable for a hematocrit of 24% and urinalysis with 18 to 25 WBCs and gram-negative bacteria. On call to the operating room, the patient receives intravenous penicillin. His abdomen is shaved in the operating room. An open cholecystectomy is performed and, despite a lack of indications, the common bile duct is explored. The wound is closed primarily with a Penrose drain exiting a separate stab wound. On postoperative day 3, the patient develops a wound infection. Which of the following changes in the care of this patient could have decreased the chance of a postoperative wound infection?
High-Yield Explanation
The determinants of a postoperative wound infection include factors predetermined by the status of the patient (eg, age, obesity, steroid dependence, multiple diagnoses , immunosuppression) and by the type of procedure (eg, contaminated versus clean, emergent versus elective). However, there are several factors that can be optimized by the surgeon. Decreasing the bacterial inoculum and virulence by limiting the patient's prehospital stay, clipping the operative site in the operating room, administering perioperative antibiotics (within a 24-hour period surrounding operation) with an appropriate antimicrobial spectrum, treating remote infections, avoiding breaks in technique, using closed drainage systems (if needed at all) that exit the skin away from the surgical incision, and minimizing the duration of the operation have all been shown to decrease postoperative infection. Making a wound less orable to infection requires attention to basic Halstedian principles of hemostasis, anatomic dissection, and gentle handling of tissues as well as limiting the amount of foreign body and necrotic tissue in the wound. Although they are the most difficult factors to influence, host defense mechanisms can be improved by optimizing nutritional status, tissue perfusion, and oxygen delivery.