Medicine in small doses.

Abstract

Reducing surgical site infections – from Listerism to NICE guidelines, 150 years on Joseph Lister was 40 and the Professor of Surgery at the University of Glasgow when his paper, ‘On a new method of treating compound fracture, abscess &c, with observations on the conditions of suppuration. I. Compound fractures’ (Lancet 1867; i: 326–9), was published 150 years ago. This was the first of five articles on the topic published in The Lancet that year. This series of articles were about his antiseptic system for healing wounds, involving the combination of carbolic acid spray over the surgical field, acid-soaked towels surrounding the incision and the instruments submerged in carbolic acid. His post-operative care included the placing of dressings soaked in carbolic acid, changed daily until the appearances of wound healing. He first applied these dressings in 1865, on James Greenlees, a young boy with a compound fracture of a tibia. The healing of the wounds with lack of suppuration encouraged Lister to experiment with other patients, with 9 of his first 12 attempts healing without evidence of suppuration. In the follow-up Lancet publications that year, he declared ‘upon this principle I have built a practice’. Lister based his principle on the germ theory of wound infection, from the writings of the French chemist, Louis Pasteur who proposed three methods to eradicate the germs: filtration, exposure to heat or exposure to solution/chemical solutions. Lister chose the last. Many surgeons in Britain, however, could not accept this simple theory of the singular cause of wound suppuration and what is more Pasteur was a chemist! Moreover, they found Lister's spray was cumbersome and unpopular with patients and surgeons. Indeed Lister's evidence was all based on clinical observation and he never published laboratory proof of the efficacy of his technique, and ultimately his techniques fell out of favour. However, Lister had may acolytes, one of his greatest being W. Watson-Cheyne who, in his article ‘Listerism and the development of operative surgery’ (BMJ 1902; 2: 1851), highlighted Lister's other significant contributions to surgery: the development of instruments more easily sterilizable and made of metal rather than the preferred wood and ivory, his flexibility in accepting the importance of steam sterilization of such instruments and the evolution from antisepsis to asepsis. By the end of the 19th century, antiseptic interventions had given way to aseptic techniques, with the acceptance of hand washing and the aseptic operating field. Large hospitals previously associated with higher mortality rates from sepsis now were safer and became the epicentre of medical care and heralded the birth of the major teaching hospitals (Barr J, Podolsky S. Lancet 2017; 389: 1002–3). So what has changed in preventing surgical site infection (SSI) in 150 years? The National Institute for Health and Care Excellence (NICE) provides evidence-based national guidance and advice to improve health and social care (www.nice.org.uk). It is apt that the NICE guidelines on surgical site infections: prevention and treatment were recently updated in February 2017 (www.nice.org.uk/guidance/cg74). The guidelines cover preventing and treating SSIs in adults, young people and children who are having a surgical procedure involving a cut through the skin, recommending effective methods to use before, during and after surgery to minimize the risk of infection. One of the updates relates to the application of intraoperative topical antiseptics/antimicrobials before wound closure, and there is lack of evidence to justify their use. We are still trying to emulate Lister! The most significant change in the management of SSIs has been the use of prophylactic antibiotics, to which Lister did not have access. One hundred and fifty years ago Lister made us aware of the importance of antisepsis and the germ theory as the aetiology of SSIs. We still follow his principles in the use of antiseptics for skin preparation, not that much different from his carbolic spray. Listerism lives on in the battle to reduce SSIs.