Listen, I’ve spent enough time in hospital breakrooms to know that clinical “vibes” and “the way we’ve always done it” are hard habits to break. We pass down these traditions like family recipes, but in the high-stakes world of surgical site infections (SSIs), “folk medicine” is a luxury we can’t afford.
The data from Leaper (2015) is a cold shower for anyone relying on clinical instinct: SSIs still complicate between 10% and 20% of all operations. They are associated with a staggering one-third of postoperative deaths and carry an economic burden that runs into thousands of pounds per patient due to extended stays and readmissions. Evidence-based practice isn’t just a buzzword; it’s the only way to move the needle on healthcare-associated infections.
It’s time to stop the “OR theater” and look at what the research actually says. Here are ten myths we need to bury once and for all.
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Myth #1: The Pre-Op “Orange Scrub” is the Only Way to Clean a Patient
For decades, we’ve treated chlorhexidine bathing as a sacred ritual of preoperative care. We assume that if it smells like a chemistry set, it must be working.
The reality? A Cochrane review of over 10,000 patients found that preoperative showering or bathing with chlorhexidine was no more effective at preventing SSIs than using plain old soap or a placebo. Personal hygiene on the day of surgery is mandatory, but the “orange scrub” ritual doesn’t provide the superior protection we once thought.
The Verdict: There is no evidence that antiseptic bathing reduces SSI rates more than simple soap and water. Save the chlorhexidine for the actual incision site.
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Myth #2: Every Abscess Needs a Prescription Refill
There is a persistent “just in case” mentality when it comes to antibiotics following an incision and drainage (I&D). However, IDSA guidelines (Liu, 2011) are clear: for simple cutaneous abscesses or boils, I&D alone is the primary treatment.
While we still need more data to perfectly define the role of antibiotics in simple cases, current evidence shows they don’t significantly improve cure rates for routine drainage. We only need to reach for the prescription pad when the situation gets complicated:
- Severe or extensive disease (multiple sites).
- Rapid progression of associated cellulitis.
- Systemic illness (fever, malaise).
- Comorbidities or immunosuppression (Diabetes, HIV, malignancy).
- Extremes of age.
- Abscesses in difficult-to-drain areas (face, hands, genitalia).
- Septic phlebitis or lack of response to I&D alone.
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Myth #3: If the Patient is Screaming, They’re Probably “Drug Seeking”
One of the most dangerous biases in surgery is dismissing “excessive” pain. In the context of soft-tissue pathology, that bias can be a death sentence.
In the early stages of Necrotizing Fasciitis (NF), the hallmark sign is pain that is wildly disproportionate to visible symptoms. This is a surgical emergency. Magel (2008) notes that tissue destruction in NF can occur at a rate of up to 1 inch per hour. By the time the skin looks like “true” gangrene, you’ve already lost the race.
⚠️ WARNING: While excruciating pain is the early warning, a sudden loss of pain or numbness is an ominous sign. It means the infection has finished destroying the tissue and has moved on to killing the local nerves.
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Myth #4: Cellulitis is Always a MRSA Emergency
We see a red leg and immediately think MRSA. While we have to respect the bug, the IDSA guidelines (Liu, 2011) suggest a more disciplined approach based on whether the infection is purulent or nonpurulent.
- Purulent Cellulitis (associated with drainage, exudate, or abscess):
- Assume CA-MRSA and treat empirically with targeted coverage.
- Nonpurulent Cellulitis (no drainage or abscess):
- Primary targets: \beta-hemolytic streptococci.
- Decision Tree:
- Start with \beta-lactams (e.g., Cefazolin).
- Does the patient respond?
- Yes: Continue therapy.
- No (or patient shows systemic toxicity): Add MRSA coverage.
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Myth #5: Wound Guards are the Ultimate Barrier
The “attractive logic” of a physical barrier—a plastic ring protecting the wound edges—seems like a slam dunk for infection prevention. Unfortunately, the ROSSINI trial, a high-quality multicenter study, definitively killed this myth. The results showed that wound edge protection devices do not prevent SSIs. It’s a classic case of a device looking good in theory but failing to perform in the messy reality of the OR.
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Myth #6: High-Flow Oxygen is an “Infection-Killer” in Recovery
We once hoped that flooding the patient with oxygen (FiO_2=0.8) for two hours post-op would act as a chemical shield against infection. Leaper (2015) highlights a meta-analysis of seven RCTs showing no significant difference in SSI rates for the general population.
The Expert Caveat: While it’s not a universal “infection-killer,” subgroup analyses did show a significant benefit for patients undergoing colorectal surgery. For the rest of the surgical board, however, standard oxygenation is sufficient.
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Myth #7: “It Itches, So It’s Probably Leprosy”
In areas where leprosy (Hansen’s disease) is endemic, clinical myths can delay treatment. The WHO Guide (2000) provides a simple, ironclad rule: If a skin patch itches, it is not leprosy. Leprosy is a disease of nerve destruction, not irritation.
If you suspect the real deal, use the “Pen Test”:
- Take a pointed object (like a pen).
- Touch normal skin first so the patient knows the sensation.
- Have the patient close their eyes.
- Lightly touch the center of the suspect patch.
- If the patient feels nothing on the patch but feels it on normal skin, it’s leprosy. Start MDT immediately.
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Myth #8: Scalpels are Cleaner than Diathermy
Surgeons can be creatures of habit, often fearing that the thermal energy of electrosurgery (diathermy) increases infection risk compared to a “cold” scalpel. The data says otherwise. A Cochrane review of 1,901 patients found no significant difference in SSI risk between the two methods. Diathermy is faster and reduces blood loss; use it without fear of “burning” your way into an infection.
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Myth #9: Antimicrobial Sutures are “Marketing Fluff”
I’m the first person to roll my eyes at a flashy sales brochure, but triclosan-coated sutures are the real deal. This isn’t just an “industry trend”; it’s backed by Level 1A evidence. Independent meta-analyses (Wang, Edmiston, and Daoud) have shown that antimicrobial sutures reduce SSI risk by 30-33% across clean, clean-contaminated, and contaminated surgeries. If you want to cut your infection rates, this is a proven tool.
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Myth #10: Draining Wounds Must Be Left Open to “Breathe”
The idea that an infected wound needs to “air out” is a dangerous relic of 19th-century nursing. Draining wounds are bacterial factories. To prevent the transmission of MRSA to other sites or other patients, the IDSA is unequivocal: keep draining wounds covered with clean, dry bandages. Bacteria don’t need to breathe; they need to be contained.
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Conclusion: The Power of the “Care Bundle”
Clinical “tricks” don’t save lives; systems do. The reason SSI rates aren’t falling is largely due to poor compliance with established guidelines. We need to move away from individual heroics and toward the UK Department of Health’s High Impact Intervention (HII) care bundle.
To move out of 1985 and into the modern era, we must focus on the four core pillars where the evidence is strongest:
- Appropriate Hair Removal (Clippers, never razors).
- Rational Antibiotic Prophylaxis (The right drug at the right time).
- Thermoregulation (Keep them warm).
- Glycaemic Control (Keep those sugars stable).
Ditch the myths, follow the bundle, and let’s start treating wound care like the science it is.
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Reference List
- Leaper, D. and Ousey, K. (2015). Evidence update on prevention of surgical site infection. Current Opinion in Infectious Diseases, 28(2), 158-163.
- Liu, C., et al. (2011). Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Infectious Diseases, 52(3), e18-e55.
- Nienhuis, W. A., et al. (2010). Antimicrobial treatment for early, limited Mycobacterium ulcerans infection: a randomised controlled trial. The Lancet, 375(9715), 664-672.
- World Health Organization. (2000). Guide to Eliminate Leprosy as a Public Health Problem. Leprosy Elimination Group.
- Magel, D. C. (2008). The Nurse’s Role in Managing Necrotizing Fasciitis. AORN Journal, 88(6), 977-982.