Strategies to prevent surgical site infections in acute care hospitals: 2014 update

Incidence and Etiology of Surgical Site Infections in Appendectomies: A 3-Year Prospective Study

OBJECTIVES

Surgical site infections (SSIs) constitute a threat, especially in complicated appendicitis, and are commonly due to gram-negative organisms. We sought to describe the incidence of SSIs in appendectomies performed during a three-year period (January 2013 to December 2015) in a community hospital in Qatar, and compare this with external benchmarks.

METHODS

We conducted a longitudinal study at The Cuban Hospital, Qatar. We used the standardized surveillance criteria to define SSI developed by the Centers for Disease Control. Information about age, sex, smoking habits, diabetes mellitus status, body mass index, and the result of bacteriologic studies were collected.

RESULTS

Of a total 603 patients, 22 (3.6%) cases of SSI were reported, with an infection rate of 13.6%, 4.5%, and 1.0% in 2013, 2014, and 2015, respectively. SSIs were observed more frequently in patients with contaminated/dirty wounds (6.6%). About 65% of isolates from the surgical site were multidrug-resistant organisms (Escherichia coli and Klebsiella spp.).

CONCLUSIONS

This study describes the incidence of SSI in appendectomy, which could be used as a benchmark for the facility improvement program. The high frequency of multidrug-resistant organisms in SSIs requires additional studies focused on evaluating the effectiveness of the current preventive practices with a particular reference to antimicrobial prophylaxis.

Probiotic Lactobacillus Species Strengthen Intestinal Barrier Function and Tight Junction Integrity in Experimental Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a serious intestinal disease that occurs in newborn infants. It is associated with major morbidity and affects 5% of all infants admitted to neonatal intensive care units. Probiotics have variable efficacy in preventing necrotizing enterocolitis. Tight junctions (TJ) are protein complexes that maintain epithelial barrier integrity. We hypothesized that the probiotics Lactobacillus rhamnosus and Lactobacillus plantarum strengthen intestinal barrier function, promote TJ integrity, and protect against experimental NEC. Both an in vitro and an in vivo experimental model of NEC were studied. Cultured human intestinal Caco-2 cells were pretreated with L. rhamnosus and L. plantarum probiotics. TJ were then disrupted by EGTA calcium switch or LPS to mimic NEC in vitro. Trans-epithelial resistance (TER) and flux of fluorescein isothiocynate dextran was measured. TJ structure was evaluated by ZO-1 immunofluorescence. In vivo effects of ingested probiotics on intestinal injury and ZO-1 expression were assessed in a rat model of NEC infected with Cronobacter sakazakii (CS). Caco-2 cells treated with individual probiotics demonstrated higher TER and lower permeability compared to untreated cells (p<0.0001). ZO-1 immunofluorescence confirmed TJ stability in treated cells. Rat pups fed probiotics alone had more intestinal injury compared with controls (p=0.0106). Probiotics were protective against injury when given in combination with CS, with no difference in intestinal injury compared to controls (p=0.21). Increased permeability was observed in the probiotic and CS groups (p=0.03, p=0.05), but not in the probiotic plus CS group (p=0.79). Lactobacillus sp. strengthened intestinal barrier function and preserved TJ integrity in an in vitro experimental model of NEC. In vivo, probiotic bacteria were not beneficial when given alone, but were protective in the presence of CS in a rat model of NEC.

Impact of modified quality control checklist on protocol adherence and outcomes in a post-surgical Intensive Care Unit

Background and Aims:

Quality improvement (QI) is the sum of all activities that create desired changes in the quality. An effective QI system results in a stepwise increase in quality of care. The efficiency of any health-care unit is judged by its quality indicators. We aimed to evaluate the impact of QI initiatives on outcomes in a surgical Intensive Care Unit (ICU).

Methods:

This was an observational study carried out using a compliance checklist, developed from the combination of the World Health Organization surgery checklist and Society for Healthcare Epidemiology of America guidelines for the prevention of infections. A total of 170 patients were prospectively evaluated for adherence to the checklist and occurrence of infections. This was compared with a random retrospective analysis of 170 patients who had undergone similar surgeries in the previous 3 months.

Results:

Introduction and supervised documentation of comprehensive checklist brought out significant improvement in the documentation of quality indicators (98% vs. 32%) in the prospective samples. There was no difference in mortality, health-care-related infection rates or length of ICU stay.

Conclusion:

The introduction of comprehensive surgical checklist improved documentation of parameters for quality control but did not decrease the rates of infection in comparison to the control sample.

Risk Factors and Temporal Trends of Hospital-Acquired Infections (HAIs) Among HIV Positive Patients in Urban New York City Hospitals: 2006 to 2014

BACKGROUND

HIV-infected patients may be at a greater risk of Hospital-Acquired Infections (HAIs) but risks factors for HAIs have not been well described in this population.

OBJECTIVE

The aim of this study was to examine the incidence, temporal trends and risk factors of HAIs among adult HIV positive patients.

METHODS

This was a retrospective cohort study carried out in an academic health system in New York City which included four hospitals over a 9-year period from 2006 to 2014. Simple and multiple logistic regression models were built to determine risk factors associated with site-specific HAIs such as Urinary Tract Infections (UTIs), Pneumonia (PNUs) and Bloodstream Infections (BSIs).

FINDINGS

There were 10,575 HIV positive discharges and 1,328 had HAIs: 697 UTIs, 555 BSIs and 192 PNUs. The incidence rate of HAIs decreased from 19.8 to 15.1 new infections per 1000 persondays between 2006 and 2014 (p value<0.001). In addition to the expected risk factors of urinary catheter use for UTI and central venous line use for BSI, symptomatic HIV and renal failure were significant risk factors for both UTIs (95% CI OR: (1.24, 2.27) and (1.46, 2.11) respectively) and BSIs (95% CIs OR: (2.28, 4.18) and (1.81, 2.71) respectively).

CONCLUSION

HIV-infected patients had similar risk factors for HAIs as HIV-uninfected patients. Further research is required to address how patients' CD4 counts and viral loads affect their susceptibility to HAIs.

An Audit of Perioperative Antimicrobial Prophylaxis: Compliance with the International Guidelines

Objective:

Antimicrobial prophylaxis has been demonstrated to lower the incidence of postoperative infection in nearly all types of surgery. The American Society of Health-System Pharmacists (ASHP) guideline summarizes current data on the appropriate use of antibiotic for surgical prophylaxis. The objective of this study was to assess and audit the use of antibiotics in a tertiary care center according to the recommendation of ASHP guideline.

Methods:

This cross-sectional study was performed using prospective data gathered from April to September 2015 in the surgical wards of Al Zahra Hospital, Isfahan, Iran. Antibiotic indication and choice, dose, dosing interval, route of administration, and timing of first administration and duration of prophylaxis were compared with the ASHP guideline recommendations.

Findings:

A total of 100 patients with the mean age of 49.8 ± 18.2 years were recruited for this study. About 22% of procedures had full compliance with all guideline recommendations. The most frequently encounter noncompliance type were the duration of prophylaxis (14%) and appropriate agent choice (35%). Timing of the initial dose was appropriate in most of the procedures (42%).

Conclusion:

This study revealed that most of the prescribed antibiotics for surgical prophylaxis are not in accordance with standard treatment guideline. The density of antimicrobial use for preoperative antimicrobial prophylaxis is very high. Furthermore, the hospital should develop a formal strategy, including a local guideline for antimicrobial prophylaxis in surgical procedures.

Incidence of postoperative wound infections after open tendo Achilles repairs

INTRODUCTION

Tendo Achilles (TA), which is the confluence of the gastrocnemius and soleus muscles, is one of the most commonly injured tendons. The surgical repair of TA ruptures is associated with a significant risk of infection. This study examined several factors (i.e. gender, age, body mass index, history of diabetes mellitus, steroid use, acute or chronic TA injuries, type of surgical incision and type of sutures used) that may be associated with postoperative wound infection after open TA repair.

METHODS

This was a retrospective study involving 60 patients who underwent open TA repair over an 18-month period. Patients who had prior TA surgery or open TA injuries, or who needed soft tissues flaps were excluded.

RESULTS

Among the patients, 7 (11.7%) developed superficial wound infections that were successfully treated with oral antibiotics, while 3 (5.0%) developed deep wound infections that required at least one debridement procedure. No significant association was found between the risk of postoperative wound infection and gender, age, the presence of diabetes mellitus, acute or chronic ruptures, site of surgical incision and type of deep or superficial sutures used.

CONCLUSION

While diabetes mellitus and age did not appear to be associated with postoperative wound infections after open TA repair, obese patients were found to be two times more likely to develop a wound infection than normal-weight patients. The incidence of superficial wound infections in this study was similar to previously published results (11.7% vs. 8.2%-14.6%), but the incidence of deep infections was higher (5% vs. 1%-2%).

Dressing Wear Time after Breast Reconstruction: A Randomized Clinical Trial

Background

The evidence to support dressing standards for breast surgery wounds is empiric and scarce.

Objective

This two-arm randomized clinical trial was designed to assess the effect of dressing wear time on surgical site infection (SSI) rates, skin colonization and patient perceptions.

Methods

A total of 200 breast cancer patients undergoing breast reconstruction were prospectively enrolled. Patients were randomly allocated to group I (dressing removed on the first postoperative day, n = 100) or group II (dressing removed on the sixth postoperative day, n = 100). SSIs were defined and classified according to criteria from the Centers for Disease Control and Prevention. Samples collected before placing the dressing and after 1 day (group I) and 6 days (both groups) were cultured for skin colonization assessments. Patients preferences and perceptions with regard to safety, comfort and convenience were recorded and analyzed.

Results

A total of 186 patients completed the follow-up. The global SSI rate was 4.5%. Six patients in group I and three in group II had SSI (p = 0.497). Before dressing, the groups were similar with regard to skin colonization. At the sixth day, there was a higher colonization by coagulase-negative staphylococci in group I (p<0.0001). Patients preferred to keep dressing for six days (p<0.0001), and considered this a safer choice (p<0.05).

Conclusions

Despite group I had a higher skin colonization by coagulase-negative staphylococci on the sixth postoperative day, there was no difference in SSI rates. Patients preferred keeping dressing for six days and considered it a safer choice.

Trial Registration

ClinicalTrials.gov NCT01148823

Cost-Effectiveness Analysis of the Use of a Prophylactic Antibiotic for Patients Undergoing Lower Limb Amputation due to Diabetes or Vascular Illness in Colombia

BACKGROUND

The use of a prophylactic antibiotic in an amputation surgery is a key element for the successful recovery of the patient. We aim to determine, from the perspective of the Colombian health system, the cost-effectiveness of administering a prophylactic antibiotic among patients undergoing lower limb amputation due to diabetes or vascular illness in Colombia.

METHODS

A decision tree was constructed to compare the use and nonuse of a prophylactic antibiotic. The probabilities of transition were obtained from studies identified from a systematic review of the clinical literature. The chosen health outcome was reduction in mortality due to prevention of infection. The costs were measured by expert consensus using the standard case methodology, and the resource valuation was carried out using national-level pricing manuals. Deterministic sensitivity, scenarios, and probabilistic analyses were conducted.

RESULTS

In the base case, the use of a prophylactic antibiotic compared with nonuse was a dominant strategy. This result was consistent when considering different types of medications and when modifying most of the variables in the model. The use of a prophylactic antibiotic ceases to be dominant when the probability of infection is greater than 48%.

CONCLUSIONS

The administration of a prophylactic antibiotic was a dominant strategy, which is a conclusion that holds in most cases examined; therefore, it is unlikely that the uncertainty around the estimation of costs and benefits change the results. We recommend creating policies oriented toward promoting the use of a prophylactic antibiotic during amputation surgery in Colombia.

Effects of perioperative supplementation with pro-/synbiotics on clinical outcomes in surgical patients: A meta-analysis with trial sequential analysis of randomized controlled trials

BACKGROUND & AIMS

The Potential benefits and possible risks of perioperative supplementation with probiotics/synbiotics in surgical patients are not fully understood. Recent evidence has rapidly evolved and conveys conflicting results. Thus, we undertook a meta-analysis of randomized controlled trials (RCTs) to valuate the effectiveness, safety, cost-effectiveness and quality of life of perioperative supplementation with pro-/synbiotics.

METHODS

We systematically searched PubMed, Embase and the Cochrane Library through October 2015 to identify RCTs that assessed the effects of perioperative supplementation with pro-/synbiotics in surgical patients. The predefined primary efficacy outcome was surgical site infection (SSI). Random-effects model was applied to pool outcome data accounting for clinical heterogeneity.

RESULTS

Our meta-analysis included data from 34 trials comprising 2634 participants, of whom 1300 received perioperative pro-/synbiotics intervention and 1334 received valid control treatment. Compared with the control group, patients in the pro-/synbiotics group had a lower risk of SSI (relative risk: 0.65; 95% confidence interval: 0.51, 0.84; P = 0.0007). Trial sequential analysis confirmed the evidence was sufficient and conclusive. Subgroup analyses indicated the findings were consistent in all subgroup analyses except for the probiotics, enteral feeding, pre-/postoperative and live transplantation subgroups. Pro-/synbiotics also reduced the incidence of other infectious complications (including any infection, pneumonia, urinary tract infection, wound infection and sepsis); shortened antibiotic therapy, intensive care unit stay and hospital stay; and promoted earlier first defecation and first bowel movement. Pro-/synbiotics further reduced the incidence of abdominal side effects, lowered hospital costs and improved the Gastro-Intestinal Quality of Life.

CONCLUSIONS

For surgical patients, perioperative supplementation with pro-/synbiotics is effective in preventing or controlling SSI and other infectious complications. Perioperative pro-/synbiotics might also be associated with fewer side effects, lower hospital cost and better quality of life. Current evidence indicated that perioperative synbiotics supplementation is preferred and recommended as an adjunct in surgical patients.

Decolonization in Prevention of Health Care-Associated Infections

Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

Is it worth screening elective orthopaedic patients for carriage of Staphylococcus aureus? A part-retrospective case-control study in a Scottish hospital

BACKGROUND

With recent focus on methicillin-resistant Staphylococcus aureus (MRSA) screening, methicillin-susceptible S. aureus (MSSA) has been overlooked. MSSA infections are costly and debilitating in orthopaedic surgery.

METHODS

We broadened MRSA screening to include MSSA for elective orthopaedic patients. Preoperative decolonisation was offered if appropriate. Elective and trauma patients were audited for staphylococcal infection during 2 6-month periods (A: January to June 2013 MRSA screening; B: January to June 2014 MRSA and MSSA screening). Trauma patients are not screened presurgery and provided a control. MSSA screening costs of a modelled cohort of 500 elective patients were offset by changes in number and costs of MSSA infections to demonstrate the change in total health service costs.

FINDINGS

Trauma patients showed similar infection rates during both periods (p=1). In period A, 4 (1.72%) and 15 (6.47%) of 232 elective patients suffered superficial and deep MSSA infections, respectively, with 6 superficial (2%) and 1 deep (0.3%) infection among 307 elective patients during period B. For any MSSA infection, risk ratios were 0.95 (95% CI 0.41 to 2.23) for trauma and 0.28 (95% CI 0.12 to 0.65) for elective patients (period B vs period A). For deep MSSA infections, risk ratios were 0.58 (95% CI 0.20 to 1.67) for trauma and 0.05 (95% CI 0.01 to 0.36) for elective patients (p=0.011). There were 29.12 fewer deep infections in the modelled cohort of 500 patients, with a cost reduction of £831 678 for 500 patients screened.

CONCLUSIONS

MSSA screening for elective orthopaedic patients may reduce the risk of deep postoperative MSSA infection with associated cost-benefits.

The impact of surgical site occurrences and the role of closed incision negative pressure therapy

Surgical site occurrences are observed in up to 60% of inpatient surgical procedures in industrialised countries. The most relevant postoperative complication is surgical site infection (SSI) because of its impact on patient outcomes and enormous treatment costs. Literature reviews ('SSI', 'deep sternal wound infections' (DSWI), 'closed incision negative pressure wound therapy' (ciNPT) were performed by electronically searching MEDLINE (PubMed) and subsequently using a 'snowball' method of continued searches of the references in the identified publications. Search criteria included publications in all languages, various study types and publication in a peer-reviewed journal. The SSI literature search identified 1325, the DSWI search 590 and the ciNPT search 103 publications that fulfilled the search criteria. Patient-related SSI risk factors (diabetes mellitus, obesity, smoking, hypertension, female gender) and operation-related SSI risk factors (re-exploration, emergency operations, prolonged ventilation, prolonged operation duration) exist. We found that patient- and operation-related SSI risk factors were often different for each speciality and/or operative procedure. Based on the evidence, we found that high-risk incisions (sternotomy and incisions in extremities after high-energy open trauma) are principally recommended for ciNPT use. In 'lower'-risk incisions, the addition of patient-related or operation-related risk factors justifies the application of ciNPT.

Systematic review and meta-analysis of sutures coated with triclosan for the prevention of surgical site infection after elective colorectal surgery according to the PRISMA statement

BACKGROUND

Several randomized clinical trials (RCTs) conducted to evaluate the effect of triclosan-coated suture on surgical site infection (SSI) yield to controversial results. The primary purpose of this systematic review and meta-analysis was to analyze the available RCTs, comparing the effect of triclosan-coated suture with uncoated suture on the incidence of SSI after elective colorectal operations. As secondary endpoint of the analysis, we considered length of hospital stay after surgery.

METHODS

We performed a systematic literature review through Medline, Embase, Pubmed, Scopus, Ovid, ISI Web of Science, and the Cochrane Controlled Trials Register searching for RCTs published from 1990 to 2015. To conduct these meta-analyses, we followed the guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study inclusion criteria were as follows: parallel-group RCTs in adult populations reporting the closure of the abdominal wall after elective colorectal operation with triclosan-coated suture or noncoated suture, and reporting the outcomes considered in the meta-analysis.

RESULTS

Six trials including 2168 patients (1102 treated and 1066 controls) provided data on SSIs. The overall rate was 11.7% (129/1102) in the triclosan group and 13.4% (143/1066) in the control group (odds ratio 0.81, 95% confidence interval [CI] 0.58-1.13, P = 0.220). Heterogeneity among studies was moderate (I = 44.9%). No evidence of publication bias was detectable. Five RCTs (1783 patients; 914 treated and 689 controls) described hospital length of stay with no significant effect (mean difference: -0.02, 95% CI -0.11 to -0.07, P = 0.668). The I test for heterogeneity was 0% (P = 0.836). Moderator analyses showed no significant differences were detected in analyses comparing the suture materials (polydioxanone vs polyglactin). In open-label trials, the odds ratio for SSI risk was 0.62 (95% CI 0.20-1.93, P = 0.413), 0.77 in single-blind (95% CI 0.31-1.95, P = 0.583) and 0.85 in double-blind trials (95% CI 0.46-1.54, P = 0.582).

CONCLUSIONS

Our findings failed to demonstrate a significant protective effect of triclosan-coated sutures on the occurrence of SSI after elective colorectal resections. Further large RCTs are needed before introducing this technology into clinical practice.

[Incidence of surgical site infections in sub-Saharan Africa: systematic review and meta-analysis]

Introduction

Les Infections du Sites Opératoire (ISO) sont à l’origine de morbi-mortalité et des dépenses supplémentaires en santé. Les pays en développement en sont les plus touchés. L’objectif était d’estimer l’incidence poolée des ISO en Afrique Sub-saharienne et décrire ses principaux facteurs de risque.

Méthodes

Une revue systématique et une méta-analyse ont été effectuées à partir des bases de données de l’Organisation Mondiale de la Santé pour la Région Afrique, de PubMed et par recherche standard afin de sélectionner des articles électroniquespubliés entre 2006 et 2015. Seuls les articlestraitants de l’incidence et desfacteurs de risque des ISOdans les pays del’Afrique subsaharienneétaient retenus.

Résultats

Sur 95 articles trouvés, 11 ont répondu aux critères d’inclusion. Seulement 9 pays sur les 45 y ont contribués avec une grandereprésentation du Nigéria (5 articles sur 11). L’incidence des ISO variaient de 6,8% à 26% avec une prédominance en chirurgie générale. L’incidence poolée des ISO était de 14.8% (IC à 95%: 15,5-16,2%), avec une importante hétérogénéité selon la spécialité et le mode de surveillance. Les facteurs de risque les plus citésétaient la longue durée d’intervention et la classe de contamination d’Altemeir 3 et 4. Les autres facteurs concernaient l’environnement hospitalier, les pratiques de soins inadéquats et les pathologies sous-jacentes.

Conclusion

L’incidence des ISO est élevée en Afrique subsaharienne, des études dans cette région pourrait améliorer la connaissance, laprévention et la maitrise deces multiples facteurs de risques.

Strategies to Prevent Methicillin-ResistantStaphylococcus aureusTransmission and Infection in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their methicillin-resistantStaphylococcus aureus(MRSA) prevention efforts. This document updates “Strategies to Prevent Transmission of Methicillin-ResistantStaphylococcus aureusin Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Molecular microbiology in surgery

Likely to revolutionize routine laboratory testing

Improving Surveillance for Surgical Site Infections Following Total Hip and Knee Arthroplasty Using Diagnosis and Procedure Codes in a Provincial Surveillance Network

OBJECTIVE

To evaluate hospital administrative data to identify potential surgical site infections (SSIs) following primary elective total hip or knee arthroplasty.

DESIGN

Retrospective cohort study.

SETTING

All acute care facilities in Alberta, Canada.

METHODS

Diagnosis and procedure codes for 6 months following total hip or knee arthroplasty were used to identify potential SSI cases. Medical charts of patients with potential SSIs were reviewed by an infection control professional at the acute care facility where the patient was identified with a diagnosis or procedure code. For SSI decision, infection control professionals used the National Healthcare Safety Network SSI definition. The performance of traditional surveillance methods and administrative data–triggered medical chart review was assessed.

RESULTS

Of the 162 patients identified by diagnosis or procedure code, 46 (28%) were confirmed as an SSI by an infection control professional. More SSIs were identified following total hip vs total knee arthroplasty (42% vs16%). Of 46 confirmed SSI cases, 20 (43%) were identified at an acute care facility different than their procedure facility. Administrative data–triggered medical chart review with infection control professional confirmation resulted in a 1.1- to 1.7-fold increase in SSI rate compared with traditional surveillance. SSIs identified by administrative data resulted in sensitivity of 90% and specificity of 99%.

CONCLUSION

Medical chart review for cases identified through administrative data is an efficient supplemental SSI surveillance strategy. It improves case-finding by increasing SSI identification and making identification consistent across facilities, and in a provincial surveillance network it identifies SSIs presenting at nonprocedure facilities.

Infect Control Hosp Epidemiol 2016;37:699–703

A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean Delivery

BACKGROUND

Preoperative skin antisepsis has the potential to decrease the risk of surgical-site infection. However, evidence is limited to guide the choice of antiseptic agent at cesarean delivery, which is the most common major surgical procedure among women in the United States.

METHODS

In this single-center, randomized, controlled trial, we evaluated whether the use of chlorhexidine-alcohol for preoperative skin antisepsis was superior to the use of iodine-alcohol for the prevention of surgical-site infection after cesarean delivery. We randomly assigned patients undergoing cesarean delivery to skin preparation with either chlorhexidine-alcohol or iodine-alcohol. The primary outcome was superficial or deep surgical-site infection within 30 days after cesarean delivery, on the basis of definitions from the Centers for Disease Control and Prevention.

RESULTS

From September 2011 through June 2015, a total of 1147 patients were enrolled; 572 patients were assigned to chlorhexidine-alcohol and 575 to iodine-alcohol. In an intention-to-treat analysis, surgical-site infection was diagnosed in 23 patients (4.0%) in the chlorhexidine-alcohol group and in 42 (7.3%) in the iodine-alcohol group (relative risk, 0.55; 95% confidence interval, 0.34 to 0.90; P=0.02). The rate of superficial surgical-site infection was 3.0% in the chlorhexidine-alcohol group and 4.9% in the iodine-alcohol group (P=0.10); the rate of deep infection was 1.0% and 2.4%, respectively (P=0.07). The frequency of adverse skin reactions was similar in the two groups.

CONCLUSIONS

The use of chlorhexidine-alcohol for preoperative skin antisepsis resulted in a significantly lower risk of surgical-site infection after cesarean delivery than did the use of iodine-alcohol. (Funded by the National Institutes of Health and Washington University School of Medicine in St. Louis; ClinicalTrials.gov number, NCT01472549.).

A Novel Prevention Bundle to Reduce Surgical Site Infections in Pediatric Spinal Fusion Patients

BACKGROUND

The Surgical Care Improvement Project bundle emphasizes operative infection prevention practices. Despite implementing the Surgical Care Improvement Project bundle in 2008, spinal fusion surgical site infections (SF-SSI) continued to be prevalent for this low-volume, high-risk surgery.

OBJECTIVE

To design a combined pre-, peri-, and postoperative bundle (PPPB) that would lead to sustained reductions in SF-SSI rates.

DESIGN

Quality improvement project, before-after trial with cost-effectiveness analysis.

SETTING

Children’s hospital.

PATIENTS

All spinal fusion patients, 2008–2015.

INTERVENTION

A multidisciplinary team developed the PPPB composed of Surgical Care Improvement Project elements plus improved wound care practices, nursing standard of care, dedicated nursing unit, dermatology assessment tool and consultation, nursing education tool using “teach back” technique, and a “Back Home” kit. SF-SSI rates were compared before (2008–2010) and after (2011-February 2015) implementation of PPPB. PPPB compliance was monitored.

RESULTS

A total of 224 SF surgeries were performed from 2008 to February 2015. Pre-PPPB analysis revealed median time to SF-SSI of 28 days, secondary to skin and bowel flora. Mean 3-year pre-PPPB SF-SSI rate per 100 SF surgeries was 8.2 (8/98) (2008: 13.3 [4/30], 2009: 2.7 [1/37], 2010: 9.7 [3/31]). Mean SF-SSI rate after PPPB was 2.4 (3/126) (January 2011-February 2015); there was a 71% reduction in mean SSI rate (P=.0695). No SF-SSI occurred in neuromuscular patients (P=.008) after PPPB. Compliance with PPPB elements has been 100%.

CONCLUSIONS

PPPB led to sustained improvement in SF-SSI rates over 50 months. The PPPB could be reproduced for other surgeries.

Infect Control Hosp Epidemiol 2016;37:527–534

Moving Closer to Zero: Effect of "Just in Time" Dosing of Prophylactic Antibiotics on Surgical Site Infections

Background

A local quality initiative to improve compliance with surgical antibiotic prophylaxis measures resulted in a high percentage of patients receiving antibiotics within minutes of surgical incision. Studies examining the association between timing of prophylaxis and the risk for surgical site infection (SSI) have produced heterogeneous results.

Objective

To examine risk factors for SSI, including "just in time" dosing of antibiotic prophylaxis (dose administered within 5 minutes of incision).

Methods

This was a retrospective matched case-control study. Case patients developed SSI in the 30 days following a clean or clean-contaminated surgical procedure. Control patients did not develop SSI following similar procedures and were matched to ensure comparable baseline risk. We assessed the rate of guideline-compliant antibiotic prophylaxis and calculated odds ratios (ORs) to determine the association of patient covariates with the risk for SSI.

Results

Forty case patients and 104 controls were included in the study. The rate of appropriate prophylaxis was high in both groups (98% and 94% for case and control groups, respectively). Approximately 15% of case and control patients received antibiotic prophylaxis within 5 minutes of incision, thus, "just in time" dosing did not appear to increase the risk for SSI (OR, 0.814; 95% CI, 0.274-2.415). There was a nonsignificant association between receipt of vancomycin and SSI (OR, 2.844; 95% CI, 0.926-8.737).

Conclusion

"Just in time" dosing of prophylactic antibiotics was not associated with increased risk for SSI. Further study is needed to clarify the impact of antibiotic choice on the risk for subsequent SSI.

Surgical Site Infection following Cesarean Delivery: Patient, Provider, and Procedure-Specific Risk Factors

OBJECTIVE

This study aims to identify risk factors for cesarean delivery (CD) surgical site infection (SSI). study design: Retrospective analysis of 2,739 CDs performed at the University of Pittsburgh in 2011. CD SSIs were defined using National Healthcare Safety Network (NHSN) criteria. Chi-square test and t-test were used for bivariate analyses and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

Of 2,739 CDs, 178 (6.5%) were complicated by SSI. Patients with a SSI were more likely to have Medicaid, have resident physicians perform the CD, an American Society of Anesthesiologists (ASA) class of ≥ 3, chorioamnionitis, tobacco use, and labor before CD. In multivariable analysis, labor (odds ratio [OR], 2.35; 95% confidence interval [95% CI], 1.65-3.38), chorioamnionitis (OR, 2.24; 95% CI, 1.25-3.83), resident teaching service (OR, 2.15; 95% CI, 1.54-3.00), tobacco use (OR, 1.70; 95% CI, 1.04-2.70), ASA class ≥ 3 (OR, 1.61; 95% CI, 1.06-2.39), and CDs performed for nonreassuring fetal status (OR, 0.43; 95% CI, 0.26-0.67) were significantly associated with CD SSI.

CONCLUSION

Multiple patient, provider, and procedure-specific risk factors contribute to CD SSI risk which may be targeted in infection-control efforts.

Preadmission Application of 2% Chlorhexidine Gluconate (CHG): Enhancing Patient Compliance While Maximizing Skin Surface Concentrations

OBJECTIVE

Surgical site infections (SSIs) are responsible for significant morbidity and mortality. Preadmission skin antisepsis, while controversial, has gained acceptance as a strategy for reducing the risk of SSI. In this study, we analyze the benefit of an electronic alert system for enhancing compliance to preadmission application of 2% chlorhexidine gluconate (CHG).

DESIGN, SETTING, AND PARTICIPANTS

Following informed consent, 100 healthy volunteers in an academic, tertiary care medical center were randomized to 5 chlorhexidine gluconate (CHG) skin application groups: 1, 2, 3, 4, or 5 consecutive applications. Participants were further randomized into 2 subgroups: with or without electronic alert. Skin surface concentrations of CHG (μg/mL) were analyzed using a colorimetric assay at 5 separate anatomic sites.

INTERVENTION

Preadmission application of chlorhexidine gluconate, 2%

RESULTS

Mean composite skin surface CHG concentrations in volunteer participants receiving EA following 1, 2, 3, 4, and 5 applications were 1,040.5, 1,334.4, 1,278.2, 1,643.9, and 1,803.1 µg/mL, respectively, while composite skin surface concentrations in the no-EA group were 913.8, 1,240.0, 1,249.8, 1,194.4, and 1,364.2 µg/mL, respectively (ANOVA, P<.001). Composite ratios (CHG concentration/minimum inhibitory concentration required to inhibit the growth of 90% of organisms [MIC90]) for 1, 2, 3, 4, or 5 applications using the 2% CHG cloth were 208.1, 266.8, 255.6, 328.8, and 360.6, respectively, representing CHG skin concentrations effective against staphylococcal surgical pathogens. The use of an electronic alert system resulted in significant increase in skin concentrations of CHG in the 4- and 5-application groups (P<.04 and P<.007, respectively).

CONCLUSION

The findings of this study suggest an evidence-based standardized process that includes use of an Internet-based electronic alert system to improve patient compliance while maximizing skin surface concentrations effective against MRSA and other staphylococcal surgical pathogens.

Infect. Control Hosp. Epidemiol. 2016;37(3):254–259

Risk factors for surgical site infections after neurosurgery: A focus on the postoperative period

BACKGROUND

Surgical site infection (SSI) after neurosurgery has potentially devastating consequences.

METHODS

A prospective cohort study was conducted over a period of 24 months in a university center. All adult patients undergoing neurosurgical procedures, with exception of open skull fractures, were included. Multivariate logistic regression analysis was used to identify independent risk factors.

RESULTS

We included 949 patients. Among them, 43 were diagnosed with SSI (4.5%). A significant reduction in postneurosurgical SSI from 5.8% in 2009 to 3.0% in 2010 (P = .04) was observed. During that period, an active surveillance with regular feedback was established. The most common microorganisms isolated from SSI were Staphylococcus aureus (23%), Enterobacteriaceae (21%), and Propionibacterium acnes (12%). We identified the following independent risk factors for SSI postcranial surgery: intensive care unit (ICU) length of stay ≥7 days (odds ratio [OR] = 6.1; 95% confidence interval [CI], 1.7-21.7), duration of drainage ≥3 days (OR = 3.3; 95% CI, 1.1-11), and cerebrospinal fluid leakage (OR = 5.6; 95% CI, 1.1-30). For SSIs postspinal surgery, we identified the following: ICU length of stay ≥7 days (OR = 7.2; 95% CI, 1.6-32.1), coinfection (OR = 9.9; 95% CI, 2.2-43.4), and duration of drainage ≥3 days (OR = 5.7; 95% CI, 1.5-22).

CONCLUSION

Active surveillance with regular feedback proved effective in reducing SSI rates. The postoperative period is associated with overlooked risk factors for neurosurgical SSI. Infection control measures targeting this period are therefore promising.

An evaluation of surgical site infection surveillance methods for colon surgery and hysterectomy in Colorado hospitals

Surgical site infection (SSI) surveillance techniques for colon surgery and hysterectomy among Colorado infection preventionists were characterized through an online survey. Considerable variation was found in SSI surveillance practices, specifically varying use of triggers for SSI review, including laboratory values, healthcare personnel communication, and postoperative visits.

Triclosan-coated sutures reduce the risk of surgical site infections: a systematic review and meta-analysis

OBJECTIVE To analyze available evidence on the effectiveness of triclosan-coated sutures (TCSs) in reducing the risk of surgical site infection (SSI). DESIGN Systematic review and meta-analysis. METHODS A systematic search of both randomized (RCTs) and nonrandomized (non-RCT) studies was performed on PubMed Medline, OVID, EMBASE, and SCOPUS, without restrictions in language and publication type. Random-effects models were utilized and pooled estimates were reported as the relative risk (RR) ratio with 95% confidence interval (CI). Tests for heterogeneity as well as meta-regression, subgroup, and sensitivity analyses were performed. RESULTS A total of 29 studies (22 RCTs, 7 non-RCTs) were included in the meta-analysis. The overall RR of acquiring an SSI was 0.65 (95% CI: 0.55-0.77; I2=42.4%, P=.01) in favor of TCS use. The pooled RR was particularly lower for the abdominal surgery group (RR: 0.56; 95% CI: 0.41-0.77) and was robust to sensitivity analysis. Meta-regression analysis revealed that study design, in part, may explain heterogeneity (P=.03). The pooled RR subgroup meta-analyses for randomized controlled trials (RCTs) and non-RCTs were 0.74 (95% CI: 0.61-0.89) and 0.53 (95% CI: 0.42-0.66), respectively, both of which favored the use of TCSs. CONCLUSION The random-effects meta-analysis based on RCTs suggests that TCSs reduced the risk of SSI by 26% among patients undergoing surgery. This effect was particularly evident among those who underwent abdominal surgery.

Cardiac Implantable Electronic Device Infection: From an Infection Prevention Perspective

A cardiac implantable electronic device (CIED) is indicated for patients with severely reduced ejection fraction or with life-threatening cardiac arrhythmias. Infection related to a CIED is one of the most feared complications of this life-saving device. The rate of CIED infection has been estimated to be between 2 and 25; though evidence shows that this rate continues to rise with increasing expenditure to the patient as well as healthcare systems. Multiple risk factors have been attributed to the increased rates of CIED infection and host comorbidities as well as procedure related risks. Infection prevention efforts are being developed as defined bundles in numerous hospitals around the country given the increased morbidity and mortality from CIED related infections. This paper aims at reviewing the various infection prevention measures employed at hospitals and also highlights the areas that have relatively less established evidence for efficacy.

Reducing the risk of surgical site infection using a multidisciplinary approach: an integrative review

PURPOSE

To identify and describe the strategies and processes used by multidisciplinary teams of health care professionals to reduce surgical site infections (SSIs).

MATERIALS AND METHODS

An integrative review of the research literature was undertaken. Searches were conducted in April 2015. Following review of the included studies, data were abstracted using summary tables and the methodological quality of each study assessed using the Standards for Quality Improvement Reporting Excellence guidelines by two reviewers. Discrepancies were dealt with through consensus. Inductive content analysis was used to identify and describe the strategies/processes used by multidisciplinary health care teams to prevent SSI.

RESULTS AND DISCUSSION

In total, 13 studies met the inclusion criteria. Of these, 12 studies used quantitative methods, while a single study used qualitative interviews. The majority of the studies were conducted in North America. All quantitative studies evaluated multifaceted quality-improvement interventions aimed at preventing SSI in patients undergoing surgery. Across the 13 studies reviewed, the following multidisciplinary team-based approaches were enacted: using a bundled approach, sharing responsibility, and, adhering to best practice. The majority of studies described team collaborations that were circumscribed by role. None of the reviewed studies used strategies that included the input of allied health professionals or patient participation in SSI prevention.

CONCLUSION

Patient-centered interventions aimed at increasing patient participation in SSI prevention and evaluating the contributions of allied health professionals in team-based SSI prevention requires future research.

Vigilância pós-alta por telefone: validação e aplicação de instrumento para cirurgias vídeo-assistidas

RESUMOObjetivo:validar instrumento para vigilância pós-alta por contato telefônico de cirurgias vídeo-assistidas.Método:estudo multi-métodos com elaboração, validação e aplicação de instrumento. A validação foi realizada por peritos considerando pertinência, clareza e abrangência do conteúdo, sob cálculo do índice de validade de conteúdo, sendo válidas as questões com 80% de concordância. Para aplicação do instrumento, a amostra foi composta por 68 mulheres submetidas à cirurgia vídeo-assistidas sendo realizada análise descritiva.Resultados:houve discordância entre peritos na primeira avaliação e o instrumento foi reformulado obtendo-se concordância na segunda avaliação. A taxa de resposta ao contato telefônico foi de 88,2% (60/68). Queixas de dor abdominal, sangramento e edema incisional foram mais frequentes. Nenhuma apresentou infecção.Conclusão:o instrumento foi validado, aplicado e encontra-se disponível para utilização.

Gap analysis of infection control practices in low- and middle-income countries

BACKGROUND

Healthcare-associated infection rates are higher in low- and middle-income countries compared with high-income countries, resulting in relatively larger incidence of patient mortality and disability and additional healthcare costs.

OBJECTIVE

To use the Infection Control Assessment Tool to assess gaps in infection control (IC) practices in the participating countries.

METHODS

Six international sites located in Argentina, Greece, Hungary, India, Nepal, and South Africa provided information on the health facility and the surgical modules relating to IC programs, surgical antibiotic use and surgical equipment procedures, surgical area practices, sterilization and disinfection of equipment and intravenous fluid, and hand hygiene. Modules were scored for each country.

RESULTS

The 6 international sites completed 5 modules. Of 121 completed sections, scores of less than 50% of the recommended IC practices were received in 23 (19%) and scores from 50% to 75% were received in 43 (36%). IC programs had various limitations in many sites and surveillance of healthcare-associated infections was not consistently performed. Lack of administration of perioperative antibiotics, inadequate sterilization and disinfection of equipment, and paucity of hand hygiene were found even in a high-income country. There was also a lack of clearly written defined policies and procedures across many facilities.

CONCLUSIONS

Our results indicate that adherence to recommended IC practices is suboptimal. Opportunities for improvement of IC practices exist in several areas, including hospital-wide IC programs and surveillance, antibiotic stewardship, written and posted guidelines and policies across a range of topics, surgical instrument sterilization procedures, and improved hand hygiene.

Swabbing Surgical Sites Does Not Improve the Detection of Staphylococcus aureus Carriage in High-Risk Surgical Patients

BACKGROUND

A major risk factor for the development of surgical site infections is Staphylococcus aureus carriage. Compared with non-carriers, S. aureus carriers have up to a 14-fold greater risk for post-surgical infections. Pre-operative screening for S. aureus carriage is controversial. Yet, targeted screening in high-risk patients or from clinically relevant sites may be beneficial. We aimed to determine whether S. aureus detection in high-risk surgical patients would be increased by culturing surgical sites, in addition to the nares, vs. nares-only culturing.

METHODS

Adults undergoing pre-operative evaluations in orthopedic and neurosurgical clinics were eligible for participation. For each subject, specimens were collected from the anterior nares and from the proposed surgical site. Samples were inoculated onto methicillin-resistant S. aureus-selective chromogenic agar plates and blood agar plates.

RESULTS

Of 150 subjects, 80 (53.3%) were women and 70 (46.7%) men. The mean age was 61 years and 77/150 (51.3%) had a BMI≥30. Culture results were available for 147/150 subjects. Of the 147 surgical site cultures, 54 (36.7%), 51 (34.7%), and 28 (19.0%) were collected from knee, hip, and lumbar sites, respectively; the remaining 14 (9.5%) were from cervical, thoracic, or infra-clavicular sites. Overall, 35/147 (23.8%) nasal cultures grew S. aureus; 29/147 (19.7%) grew methicillin-susceptible S. aureus (MSSA), and 6/147 (4.1%) grew methicillin-resistant S. aureus (MRSA). Only 2/147 (1.4%) surgical site cultures grew S. aureus; both grew MSSA and MSSA was cultured also from the nasal swabs of these subjects. Using nasal culture+surgical site culture as "true positive," the percentage of additional S. aureus carriers detected by the addition of surgical site screening was zero as compared to nasal screening alone.

CONCLUSIONS

The detection of S. aureus carriage in high-risk surgical patients is not improved by swabbing surgical sites in addition to the nares.

Procedure-specific surgical site infection incidence varies widely within certain National Healthcare Safety Network surgery groups

BACKGROUND

The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories.

METHODS

This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; bile duct, liver or pancreas [BILI]; breast; colon; and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida, and New York from January 2009-September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. The 90-day SSI rates were calculated using ICD-9-CM diagnosis codes.

RESULTS

There were 62,901 amputation surgeries, 33,358 BILI surgeries, 72,058 breast surgeries, 125,689 colon surgeries, and 85,745 hernia surgeries in 349,298 people. The 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas, and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (P < .0001 for each) compared with open liver procedures (11.1% SSI).

CONCLUSION

The 90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed to make valid comparisons between hospitals.

Seasonal Variation of Common Surgical Site Infections: Does Season Matter?

OBJECTIVE

To evaluate seasonal variation in the rate of surgical site infections (SSI) following commonly performed surgical procedures.

DESIGN

Retrospective cohort study.

METHODS

We analyzed 6 years (January 1, 2007, through December 31, 2012) of data from the 15 most commonly performed procedures in 20 hospitals in the Duke Infection Control Outreach Network. We defined summer as July through September. First, we performed 3 separate Poisson regression analyses (unadjusted, multivariable, and polynomial) to estimate prevalence rates and prevalence rate ratios of SSI following procedures performed in summer versus nonsummer months. Then, we stratified our results to obtain estimates based on procedure type and organism type. Finally, we performed a sensitivity analysis to test the robustness of our findings.

RESULTS

We identified 4,543 SSI following 441,428 surgical procedures (overall prevalence rate, 1.03/100 procedures). The rate of SSI was significantly higher during the summer compared with the remainder of the year (1.11/100 procedures vs 1.00/100 procedures; prevalence rate ratio, 1.11 [95% CI, 1.04-1.19]; P=.002). Stratum-specific SSI calculations revealed higher SSI rates during the summer for both spinal (P=.03) and nonspinal (P=.004) procedures and revealed higher rates during the summer for SSI due to either gram-positive cocci (P=.006) or gram-negative bacilli (P=.004). Multivariable regression analysis and sensitivity analyses confirmed our findings.

CONCLUSIONS

The rate of SSI following commonly performed surgical procedures was higher during the summer compared with the remainder of the year. Summer SSI rates remained elevated after stratification by organism and spinal versus nonspinal surgery, and rates did not change after controlling for other known SSI risk factors.

Wound Care

Wound care requires an understanding of normal wound healing, causes of delays of wound healing, and the management of wounds. Every wound must be treated as an individual with regard to cause, chronicity, location, and level of microbial contamination, as well as patient factors that affect wound healing. Knowledge of wound care products available and when negative pressure wound therapy and drain placement is appropriate can improve outcomes with wound healing. Inappropriate product use can cause delays in healing. As a wound healing progresses, management of a wound and the bandage material used must evolve.

A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates

Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).

A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates

Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).

Efficacy of skin and nasal povidone-iodine preparation against mupirocin-resistant methicillin-resistant Staphylococcus aureus and S. aureus within the anterior nares

Mupirocin decolonization of nasal Staphylococcus aureus prior to surgery decreases surgical-site infections; however, treatment requires 5 days, compliance is low, and resistance occurs. In 2010, 3M Company introduced povidone-iodine (PVP-I)-based skin and nasal antiseptic (Skin and Nasal Prep [SNP]). SNP has rapid, broad-spectrum antimicrobial activity. We tested SNP's efficacy using full-thickness tissue (porcine mucosal [PM] and human skin) explant models and human subjects. Prior to or following infection with methicillin-resistant Staphylococcus aureus (MRSA) (mupirocin sensitive and resistant), explants were treated with Betadine ophthalmic preparation (Bet), SNP, or mupirocin (Bactroban nasal ointment [BN]) or left untreated. One hour posttreatment, explants were washed with phosphate-buffered saline (PBS) plus 2% mucin. One, 6, or 12 h later, bacteria were recovered and enumerated. Alternatively, following baseline sampling, human subjects applied two consecutive applications of SNP or saline to their anterior nares. One, 6, and 12 h after application of the preparation (postprep), nasal swabs were obtained, and S. aureus was enumerated. We observed that treatment of infected PM or human skin explants with SNP resulted in >2.0 log10 CFU reduction in MRSA, regardless of mupirocin sensitivity, which was significantly different from the values for BN- and Bet-treated explants and untreated controls 1 h, 6 h, and 12 h after being washed with PBS plus mucin. Swabbing the anterior nares of human subjects with SNP significantly reduced resident S. aureus compared to saline 1, 6, and 12 h postprep. Finally, pretreatment of PM explants with SNP, followed by a mucin rinse prior to infection, completely prevented MRSA infection. We conclude that SNP may be an attractive alternative for reducing the bioburden of anterior nares prior to surgery.