Announcing the UK's 20-year vision to address the challenge of antimicrobial resistance, HM Government (2019) not only noted a 7.3% decrease in human antibiotic use from 2014 to 2017, but also revealed that at least 20% of all antibiotic prescriptions in primary care are inappropriate. Given such patchy progress, it was encouraging that the Government promised to help establish ‘a full antimicrobial resistance research and development pipeline for antimicrobials, alternatives, diagnostics, vaccines and infection prevention across all sectors …’ (HM Government, 2019).
One branch of such a research and development pipeline that might usefully be explored in the pharmaceutical sector is in relation to surgical site infections (SSIs). Leaper et al (2015) warned that although SSIs ‘are probably the most preventable of the healthcare-associated infections’, despite the widespread international introduction of evidence-based guidelines for SSI prevention, SSI rates had not measurably fallen. That this warning has gone largely unheeded was confirmed recently with Menz et al (2021) observing that ‘[d]espite our advances and increasing knowledge on this topic … SSIs are one of the most prevalent hospital-acquired infections, and antibiotic resistance poses significant risks in surgery due to commonplace antibiotics having limited or no effect against some resistant organisms.’
To what extent might the widespread use of electrosurgical procedures have a role in the prevalence of SSIs? Although the ancient Egyptians, around 3000 BC, had used cautery therapeutically in the treatment of tumours, American biophysicist Dr William T Bovie (1882–1958) invented modern electrosurgical cautery, advanced the concept of surgical haemostasis, and – following its first use in 1926 during a neurosurgical operation – generously sold the patent rights in 1931 … for one dollar (Bhattacharya and Bhattacharya, 2022). While electrocautery consists of passing a ‘direct current through an instrument that is applied to the tissues directly’, electrosurgery ‘uses an alternating current, which is passed through the patient's tissues’, and in both techniques, electrical energy is converted to thermal energy, ‘causing denaturation and coagulation, slow vaporisation of the tissue water content (desiccation), and rapid vaporisation leading to incision …’ (Clancy et al, 2022).
How might electrically treated tissue be implicated in SSI? A study undertaken by Abdelaziz et al (2018) sought to quantify the bacterial contamination rate of electrocautery tips during total hip and knee arthroplasty. Although they identified bacterial contamination in 22 out of 150 collected electrocautery tips – an overall bacterial contamination rate of 14.7% – they acknowledged that ‘it is not clear how infection occurs during clean elective arthroplasty despite the use of modern antiseptic techniques with or without laminar airflow and/or adhesive draping’ (Abdelaziz et al, 2018).
In a welcome contribution to this area of research, Clancy et al (2022) have proposed a hypothesis for an association between electrical surgical incision techniques and SSIs, citing evidence showing histological similarities between burn wounds and tissues to which these electrical devices have been applied, ‘specifically collagen denaturation, vascular damage, fibrin accumulation, and necrosis.’ Noting that ‘the use of these instruments increases potential for slough and for necrotic tissue to serve as media for chronic infection, with consequent impact on health outcomes and costs’ Clancy et al (2022) suggest that the thermal damage caused by electrical surgical instruments contributes to subsequent SSI, creating a microenvironment ‘favourable for infection by specific microbes, eg P. aeruginosa, and strikingly similar to general burn injuries.’
The hypothesis proposed by Clancy et al (2022) warrants further investigation, with the possible goal of establishing a refined approach to antibiotic stewardship in relation to SSIs that takes account of data generated by attempts to prove/disprove the association the authors suggest. But as Clancy et al (2022) observe, ‘[t]he impact of electrical surgical devices on SSI may be obscured in the literature due to variation in surveillance periods,’ noting, for instance, that the 30-day limit advised by the US Centers for Disease Control and Prevention to define SSI would neither include delayed wound healing or delayed onset of wound infection in chemotherapy patients.
With Clancy et al (2022) expressing surprise at the paucity of studies in the literature regarding the concept they propose, it seems that the pharmaceutical profession might have valuable contributions to make to a much-needed review of the evidence for and against their compelling hypothesis.