American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224:59-74. [PMID: 27915053 DOI: 10.1016/j.jamcollsurg.2016.10.029]

Implementation of a Wisconsin Division of Public Health Surgical Site Infection Prevention Champion Initiative

Approximately 900 surgical site infections (SSIs) were reported to the Wisconsin Division of Public Health annually from 2013 to 2015, representing the most prevalent reported health care-associated infection in the state. Personnel at the Wisconsin Division of Public Health launched an SSI prevention initiative in May 2015 using a surgical care champion to provide surgical team peer-to-peer guidance through voluntary, nonregulatory, fee-exempt onsite visits that included presentations regarding the evidence-based surgical care bundle, tours of the OR and central processing areas, and one-on-one discussions with surgeons. The surgical care champion visited 10 facilities from August to December 2015, and at those facilities, SSIs decreased from 83 in 2015 to 47 in 2016 and the overall SSI standardized infection ratio decreased by 45% from 1.61 to 0.88 (P = .002), suggesting a statewide SSI prevention champion model can help lead to improved patient outcomes.

Perioperative Antibiotics for Clean Hand Surgery: A National Study

PURPOSE

Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated.

METHODS

We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis.

RESULTS

Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million.

CONCLUSIONS

In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Implementation of an abdominal closure bundle to reduce surgical site infection in patients on a gynecologic oncology service undergoing exploratory laparotomy

OBJECTIVE

Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. This study investigated whether implementation of an abdominal closure bundle reduces surgical site infection rates. We aimed to identify sub-populations that would benefit the most from this intervention.

METHODS

We conducted a retrospective cohort study of all patients that underwent exploratory laparotomy by a Gynecologic Oncologist from January 1, 2011 to April 1, 2017. The abdominal closure bundle was implemented on May 6, 2014. SSI rates were assessed overall and within subgroups.

RESULTS

875 patients were included in the analysis. Overall, SSI rate was reduced, albeit not significantly, from 48/471 (10.2%) to 32/404 (7.9%) (p=0.148) with implementation of the closing bundle. In patients that underwent a tumor debulking procedure, SSI was noted in 36/277 (13.0%) in the pre-bundle group and 14/208 (6.7%) in the post-bundle cohort (p=0.017). In patients with malignant pathology, the pre-bundle cohort had an SSI rate of 38/282 (13.5%), which reduced to 18/215 (8.4%) in the post-bundle group (p=0.049). In patients with FIGO stage III or IV disease, the SSI rate was reduced from 21/114 (18.4%) to 8/87 (8.4%) with implantation of the closure bundle (p=0.028). In patients with intra-operative ascites, SSI rate decreased from 19/119 (15.9%) pre-bundle to 4/104 (3.8%) in the post-bundle group (p=0.002).

CONCLUSIONS

Implementation of an abdominal closure bundle was not associated with a significant reduction in overall SSI rate. However, multiple subpopulations associated with advanced gynecologic cancer benefited from this intervention.

Break Scrub to Take That Phone Call?

BACKGROUND

The American College of Surgeons reports that 60% of the hundreds of thousands of surgical site infections occurring annually are preventable. The practice of surgeons taking phone calls while remaining sterile in the operating field is often accomplished by interposing a sterile disposable towel between the phone and their glove. After completing the call, surgeons resume operating. The purpose of our study was to test the conceptual idea of whether bacteria transmit from an inanimate object, such as a telephone, to the gloves of a surgeon through a sterile disposable towel.

STUDY DESIGN

Glo Germ (Glo Germ Co), an ultraviolet light-enhanced particle powder sized to mimic bacteria, was placed on an inanimate surface and held with a sterile disposable operating room towel covering a sterile surgical glove. The glove was then inspected for Glo Germ using an ultraviolet light. Additionally, 18 operating room telephones were cultured and then held with a Sterile Disposable OR Towel (Medline Industries Inc) covering a sterile surgical glove. The surgical gloves were then cultured to determine if bacteria had transmitted from the telephone through the towel and onto the sterile glove.

RESULTS

The Glo Germ powder readily transmitted through the towel to the gloves. Median colony-forming units (CFU) on the cultured telephones for the 17 samples was 10, ranging from 1 to 35 CFUs. Of these 17 samples, 47% had transmission from the telephone to the glove, which was significantly greater than 0% (95% CI 26% to 69%, p < 0.001).

CONCLUSIONS

Sterile disposable operating room towels do not provide an effective barrier between bacteria present on operating room telephones and the otherwise sterile gloves of a surgeon.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Study Design:

This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format.

Results:

Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning.

Conclusion:

This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery

BACKGROUND

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery.

METHODS

A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded.

RESULTS

A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028).

CONCLUSIONS

The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

A Multi-Component Strategy to Decrease Wound Complications after Open Infra-Inguinal Re-Vascularization

BACKGROUND

Wound complications remain a significant source of morbidity for patients undergoing open infra-inguinal re-vascularization. The purpose of this study was to determine the impact of several infection-control strategies on post-operative wound complications after open infra-inguinal re-vascularization.

METHODS

A retrospective cohort study was conducted among all patients who underwent an open infra-inguinal re-vascularization procedure before and after 2014. Since 2014, we have implemented strategies to reduce post-operative wound complications, including: (1) Decreasing the use of incisional skin staples, (2) increasing the use of negative pressure wound therapy (NPWT) dressings, and (3) implementing an outpatient elective decontamination protocol for methicillin-resistant Staphylococcus aureus. "Pre-era" is defined as the period between January 2012 and December 2013, before the implementation of infection control strategies; "Post-era" is between January 2015 and August 2016, after implementation. The primary outcome of interest is 30-day wound complications (infection or dehiscence). Multi-variable logistic regression analysis was used to identify significant predictors of wound-related complications between the two cohorts. Propensity score adjustment controlled for baseline patient characteristics, peri-operative variables, and surgeon experience.

RESULTS

A total of 338 open infra-inguinal procedures were performed: 175 in the pre-era and 163 in the post-era. Chlorhexidine skin preparation was used in the majority (321 [95%]) of cases. Comparing the periods, the post-era is characterized by a significant decrease in the use of groin staples (118 [67%] vs. 51 [31%], p < 0.001), and an increased application of NPWT dressings (6 [4%] vs. 66 [43%], p < 0.001). Thirty-five (37%) outpatient elective cases received the pre-operative decontamination protocol in the post-era. Compared with the pre-era, there was a decrease in the 30-day rate of wound complications (68 [39%] to 42 [26%], p = 0.011), and infection-related re-admissions (31 [17.7%] to 21 [12.9%], p = 0.220). When adjusting for patient characteristics, operative variables, and surgeon experience, post-era had significantly lower wound complications (odds ratio [OR] 0.33, p = 0.002) and re-operations (OR 0.16, p = 0.007). Among outpatient elective cases, the decontamination protocol was also independently associated with these two outcomes (wound complications: OR 0.05, p = 0.006; re-operations: 0.06, p = 0.002). The use of groin staples was an independent predictor of deep groin infections (OR 248, p < 0.001) and re-operations (OR 8.16, p = 0.032).

CONCLUSIONS

Wound complications after open infra-inguinal re-vascularization have decreased significantly after the implementation of several infection-control strategies. Findings suggest that skin staples should be avoided in groin wounds, and anti-staphylococcal decontamination protocols decrease wound complications and prevent re-operations.

Procalcitonin: Usefulness in Acute Care Surgery and Trauma

BACKGROUND

Procalcitonin (PCT) is a serum biomarker currently suggested by the Surviving Sepsis Campaign to aid in determination of the appropriate duration of therapy in sepsis patients. We review the use of procalcitonin in patients after trauma or acute care surgery.

METHOD

A MEDLINE search via PubMed was performed using the combination of "procalcitonin" and "humans" and "injuries, trauma," "wounds and injuries," or "wounds." Studies of burn patients, children, other biomarkers, and non-acute care surgery were excluded.

RESULTS

Procalcitonin may be useful in identifying infection in trauma and post-operative acute care surgery. However, heterogenity exists among patients, and surgery and trauma alone elevate PCT even in the absence of infection.

CONCLUSIONS

Although trends in PCT concentrations may offer insight, no standard approach can be recommended currently.

Topical Vancomycin Reduces Surgical-Site Infections After Craniotomy: A Prospective, Controlled Study

BACKGROUND

Surgical-site infections (SSIs) are an important cause of morbidity and mortality in neurosurgical patients. Topical antibiotics are one potential method to reduce the incidence of these infections.

OBJECTIVE

To examine the efficacy of topical vancomycin applied within the wound during craniotomy in a large prospective cohort study at a major academic center.

METHODS

Three hundred fifty-five patients were studied prospectively in this cohort study; 205 patients received 1 g of topical vancomycin powder in the subgaleal space while 150 matched control patients did not. Patients otherwise received identical care. The primary outcome variable was SSI rate factored by cohort. Secondary analysis examined cost savings from vancomycin usage estimated from hospital costs associated with SSI in craniotomy patients.

RESULTS

The addition of topical vancomycin was associated with a significantly lower rate of SSI than standard of care alone (0.49% [1/205] vs 6% [9/150], P = .002). Based on the costs of revision surgery for infections, topical vancomycin usage was estimated to save $1367 446 per 1000 craniotomy patients. No adverse reactions occurred.

CONCLUSION

Topical vancomycin is a safe, effective, and cost-saving measure to prevent SSIs following craniotomy. These results have broad implications for standard of care in craniotomy.

Bundles Prevent Surgical Site Infections After Colorectal Surgery: Meta-analysis and Systematic Review

INTRODUCTION

Colorectal surgeries (CRS) have one of the highest rates of surgical site infections (SSIs) with rates 15 to >30%. Prevention "bundles" or sets of evidence-based interventions are structured ways to improve patient outcomes. The aim sof this study is to evaluate CRS SSI prevention bundles, bundle components, and implementation and compliance strategies.

METHODS

A meta-analysis of studies with pre- and post-implementation data was conducted to assess the impact of bundles on SSI rates (superficial, deep, and organ/space). Subgroup analysis of bundle components identified optimal bundle designs.

RESULTS

Thirty-five studies (51,413 patients) were identified and 23 (17,557 patients) were included in the meta-analysis. A SSI risk reduction of 40% (p < 0.001) was noted with 44% for superficial SSI (p < 0.001) and 34% for organ/space (p = 0.048). Bundles with sterile closure trays (58.6 vs 33.1%), MBP with oral antibiotics (55.4 vs 31.8%), and pre-closure glove changes (56.9 vs 28.5%) had significantly greater SSI risk reduction.

CONCLUSION

Bundles can effectively reduce the risk of SSIs after CRS, by fostering a cohesive environment, standardization, and reduction in operative variance. If implemented successfully and complied with, bundles can become vital to improving patients' surgical quality of care.

Incision Classification Accuracy: Do Residents Know How to Classify Them?

BACKGROUND

It is unclear whether surgical residents understand how to classify incisions, which may impact how closure is handled in the operating room. We hypothesized that surgical residents define incision class (IC) accurately compared with an attending NSQIP surgeon champion (SC).

METHODS

We evaluated our NSQIP database from April 1, 2015, to December 31, 2016, including cases in which a resident was present and IC was documented. Cases in which the resident, circulator, or surgical clinical rater disagreed on the IC were then reviewed by a blinded SC.

RESULTS

Residents were correct in 83.6% of the cases, with PGY 5 persons having the lowest accuracy. Class 3 incisions were most often misclassified (36%). A disproportionate number of misclassifications by PGY4 and PGY5-7 residents occurred in incision classes 2 and 3. Surgical site infections occurred in 7.4% of cases, ranging from 2.4% in IC 1 to 15.7% in IC 4 cases.

CONCLUSIONS

Although overall accuracy appears reasonable, it is of concern that incisions at higher risk of infection (contaminated) were least likely to be classified appropriately. Chief residents, who often are making the decisions on incision closure, were the least accurate in determining IC. This may have a deleterious impact on incision management, suggesting a need for directed resident education on IC and further investigation to determine its impact on site infection risk and patient outcomes.

Surgical Site Infection Reduction Bundle: Implementation and Challenges at Ventura County Medical Center

Surgical Site Infections (SSIs) are a significant cause of morbidity and increased cost in the postoperative patient occurring in 2–5 per cent of those undergoing inpatient surgery. Ventura County Medical Center (VCMC) initiated an SSI reduction bundle in 2013, to try to reduce the incidence of SSI. The bundle is a series of best practices including preoperative, perioperative, intraoperative, and postoperative components, as well as items focused on the staff and electronic medical record. VCMC started with a 6.1 per cent SSI rate in 2013. A consistent reduction in SSI rate followed each quarter after that for a rate of less than 2.0 per cent in early 2016. The most critical aspect of this process was the necessary collaboration between disparate departments and the ongoing investment of the staff to this challenging process; the people at the heart of the collaborative process were the key to its success.

Suture thread check test for detection of surgical site contamination: a prospective study

BACKGROUND

Surgical site infection (SSI) is a common complication of surgical procedures.

AIM

Our study aimed at investigating a new method based on assessment of suture thread colonization to identify patients developing an SSI.

MATERIALS AND METHODS

We prospectively enrolled 119 patients undergoing elective surgery. For each patient, a synthetic absorbable thread in Lactomer 9-1 (Polisorb Gauge 2) inserted in the surgical site at the end of surgery was sent to the microbiology laboratory after 48 h to assess colonization of its inner tract.

RESULTS

Forty (33.6% of cases) patients had a colonized thread. Antibiotic prophylaxis was administered to 66 of 79 patients who did not display a colonized thread and to 20 of the 40 patients with a colonized thread (83.5% versus 50%, respectively, P = 0.0002). An SSI was observed only in patients with a colonized thread (10% versus 0, P = 0.02). The microorganisms identified in colonized threads were the same identified in SSIs.

CONCLUSIONS

Since an SSI was found only in patients with colonized threads, the method described here may be valuable for identifying patients developing an SSI. Moreover, the method can also be useful for targeting efficient antibiotic therapy to the culprit microorganisms.

Multi-Institution Analysis of Infection Control Practices Identifies the Subset Associated with Best Surgical Site Infection Performance: A Texas Alliance for Surgical Quality Collaborative Project

BACKGROUND

In an effort to reduce surgical site infection (SSI) rates, a large number of infection control practices (ICPs), including operating room attire policies, have been recommended. However, few have proven benefits and many are costly, time-consuming, and detrimental to provider morale. The goal of this multi-institution study was to determine which ICPs are associated with lower postoperative SSI rates.

STUDY DESIGN

Twenty American College of Surgeons NSQIP and Texas Alliance for Surgical Quality-affiliated hospitals completed this Quality Improvement Assessment Board-approved study. Surgeon champions at each hospital ranked current surgery, anesthesia, and nursing adherence to 38 separate ICPs in 6 categories (attire, preoperative, intraoperative, preoperative, intraoperative, antibiotics, postoperative, and reporting) on 4-point scales for general surgery cases. These data were compared with the risk-adjusted general surgery SSI odds ratios contained in the July 2016 American College of Surgeons NSQIP hospital-level, risk-adjusted reports. Compliance rates were compared between the 7 best (median SSI odds ratio, 0.64; range, 0.56 to 0.70) and 7 worst (median SSI odds ratio, 1.16; range, 0.94 to 1.65) performers using ANOVA.

RESULTS

Nearly all hospitals reported maximal adherence to hair removal with clippers (Surgical Care Improvement Project measure Inf-6) and to best-practice prophylactic antibiotic metrics (Surgical Care Improvement Project measure Inf-1-3). Variable adherence was identified across many ICPs and more frequent compliance with 8 ICPs correlated with lower SSI odds ratios, including preoperative shower; skin preparation technique; using clean instruments, gowns, and gloves for wound closure and dressing changes; and transparent internal reporting of SSI data. Operating room attire ICPs, including coverage of nonscrubbed provider head and arm hair, did not correlate with SSI rates.

CONCLUSIONS

This analysis suggests that the subset of ICPs that focus on perioperative patient skin and wound hygiene and transparent display of SSI data, not operating room attire policies, correlated with SSI rates. Implementation of this subset of evidence-based ICPs may improve SSI rates at lower-performing hospitals.

Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery

OBJECTIVE

Surgical site infections (SSIs) can lead to substantial morbidity, prolonged hospitalization, increased costs, and death in patients undergoing colorectal procedures. We sought to investigate the effect of using an SSI reduction bundle on the rate of SSIs in gynecologic cancer patients undergoing colon surgery.

METHODS

We identified all gynecologic cancer patients who underwent colon resection at our institution from 2014 to 2016, during which time a service-wide SSI reduction bundle was introduced. The intervention included preoperative oral antibiotics with optional mechanical bowel preparation, skin preparation with antibacterial solution, and the use of a separate surgical closing tray. SSI rates were assessed within 30days post-surgery.

RESULTS

Of 233 identified patients, 115 had undergone colon surgery prior to (PRE) and 118 after (POST) the implementation of the intervention. A low anterior resection was the most common colon surgery in both cohorts. The incidence of SSI within 30days of surgery was 43/115 (37%) in the PRE and 14/118 (12%) in the POST cohorts (p≤0.001). Wound dehiscence was noted in 30/115 (26%) and 2/118 (2%) patients, respectively (p≤0.001). In patients whose operation took longer than 360min, 30-day SSI rates were 37% (28/76) and 12% (8/67), respectively (p≤0.001). In patients with an estimated blood loss >500cm³, SSI rates were 44% (27/62) and 15% (10/67), respectively (p≤0.001).

CONCLUSIONS

The implementation of an SSI reduction bundle was associated with a significant reduction in 30-day SSIs in these patients. The intervention remained effective in patients undergoing longer operations and in those with increased blood loss.

The role of antimicrobial sutures in preventing surgical site infection

INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patient's pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).

Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile

Objective

We aimed to measure the association between 2013 guideline concordant prophylactic antibiotic use prior to surgery and infection with Clostridium difficile.

Design

We conducted a retrospective case-control study by selecting patients who underwent a surgical procedure between January 1, 2012 and December 31, 2013.

Setting

Large urban community hospital.

Patients

Cases and controls were patients age 18+ years who underwent an eligible surgery (i.e., colorectal, neurosurgery, vascular/cardiac/thoracic, hysterectomy, abdominal/pelvic and orthopedic surgical procedures) within six months prior to infection diagnosis. Cases were diagnosed with C. difficile infection while controls were not.

Methods

The primary exposure was receiving (vs. not receiving) the recommended prophylactic antibiotic regimen, based on type and duration. Potential confounders included age, sex, length of hospital stay, comorbidities, type of surgery, and prior antibiotic use. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression.

Results

We enrolled 68 cases and 220 controls. The adjusted OR among surgical patients between developing C. difficile infection and not receiving the recommended prophylactic antibiotic regimen (usually receiving antimicrobial prophylaxis for more than 24 hours) was 6.7 (95% CI: 2.9–15.5). Independent risk factors for developing C. difficile infection included having severe comorbidities, receiving antibiotics within the previous 6 months, and undergoing orthopedic surgery.

Conclusions

Adherence to the recommended prophylactic antibiotics among surgical patients likely reduces the probability of being case of C. difficile. Antibiotic stewardship should be a priority in strategies to decrease the morbidity, mortality, and costs associated with C. difficile infection.

Atypical Wound Pathogens

BACKGROUND

Atypical wound pathogens may be so described because they are uncommon pathogens of soft tissue among human beings, or because they may be fastidious and difficult to recover/isolate in the laboratory.

METHODS

A review of pertinent English-language literature was performed.

RESULTS

These wound pathogens are a diverse lot, including aerobic and anaerobic gram-positive and gram-negative bacilli, non-tuberculous mycobacteria, and bacteria that cannot be characterized conventionally because they lack a cell wall (the Mycoplasmataceae). They are diverse with respect to their virulence, but many are opportunistic pathogens.

CONCLUSIONS

Among these atypical pathogens, clinical reports are most common of wound infections caused by Mycoplasma/Ureaplasma (sometimes as co-infecting agents), and the so-called rapidly growing non-tuberculous mycobacteria (Runyon Type IV; e.g., M. chelonae).

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.

Results of 167 consecutive cases of acetabular fractures using the Kocher-Langenbeck approach: a case series

Background

Acetabular fractures are quite challenging injuries for the orthopedic surgeon because of their low incidence and their deep and complex anatomy. The objective of this study was to evaluate surgeon-independent parameters that might influence radiographic outcome and early complication rates of high-energy acetabular fractures treated by open reduction and internal fixation via the Kocher-Langenbeck approach, the golden standard for posterior access.

Methods

One hundred sixty-seven consecutive patients (111 males and 56 females) with a mean age of 41.8 years and a mean follow-up period of 10 months were surgically treated by one experienced surgeon at a level I trauma center within 10 years. To quantify the radiographic outcome, the Matta, Brooker, and Epstein grades were used. Posttraumatic arthritis and avascular necrosis of the femoral head (defined as Helfet grades 3 or 4 and Ficat/Arlet stages 3 or 4, respectively) were evaluated. Furthermore, subgroup analyses according to fracture type, age, and gender were performed for each outcome measure and complication (infection, hemorrhagic shock, revision surgery, nerve damage, and need of a total hip arthroplasty).

Results

65 A1, 34 A2, 51 B1, and 17 B2 fractures were identified according to the AO/ASIF classification. Of all patients, reduction was rated anatomic in 63.5%, imperfect in 22.2%, and poor in 14.4%. Degenerative changes were observed in 49.7%; 37.9% were affected by heterotopic ossification, 21.6% by posttraumatic arthritis, and 5.4% by avascular necrosis of the femoral head. Fifteen percent were diagnosed with a nerve damage, and 4.8% sustained an infection. Total hip arthroplasty was performed in 10.2%. Revision surgery due to secondary loss of reduction, seroma/hematoma, and wound infection was indicated in 6.0%.

Conclusions

Fracture type, age, and gender are prognostic factors for the surgical outcome after ORIF of high-energy acetabular fractures.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-017-0563-6) contains supplementary material, which is available to authorized users.

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Perioperative hyperglycemia is a risk factor for surgical site infections (SSI). Although the recommended target blood glucose level (BG) is 140–180 mg/dL for critically ill patients, recent studies conducted in patients undergoing surgery showed a significant benefit of intensive insulin therapy for the management of perioperative hyperglycemia. The aim of the present review is to evaluate the benefits of strict glycemic control for reducing SSI in gastroenterological surgery. We carried out a post‐hoc analysis of the previously published data from research on the risk factors for SSI. The highest BG within 24 hours after surgery was evaluated. A total of 1555 patients were enrolled in the study. In multivariate analysis, a dose–response relationship between the level of hyperglycemia and the odds of SSI was demonstrated when compared with the reference group (≤150 mg/dL) (odds ratio [OR] = 1.68, 95% confidence interval [CI] 1.14–2.49 for 150–200 mg/dL; and OR = 2.15, 95% CI 1.40–3.29 for >200 mg/dL). Unexpectedly, hyperglycemia was not a significant risk factor for SSI among diabetes patients. By contrast, non‐diabetes patients with a BG of >150 mg/dL were found to have increased odds of SSI. In conclusion, a target BG of ≤150 mg/dL is recommended in patients without diabetes who undergo gastroenterological surgery. Additional study is required to determine an optimal target BG in diabetes patients. Because of the risk of hypoglycemia, a conventional protocol is indicated for patients admitted to the general ward where frequent glucose measurement is not assured.

Patients at High-Risk for Surgical Site Infection

BACKGROUND

Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes.

METHODS

Review of the pertinent English-language literature.

RESULTS

High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications.

CONCLUSIONS

Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.

Characterizing Surgical Site Infection Signals in Clinical Notes

Surgical site infections (SSIs) are the most common and costly of hospital acquired infections. An important step in reducing SSIs is accurate SSI detection, which enables measurement quality improvement, but currently remains expensive through manual chart review. Building off of previous work for automated and semi-automated SSI detection using expert-derived "strong features" from clinical notes, we hypothesized that additional SSI phrases may be contained in clinical notes. We systematically characterized phrases and expressions associated with SSIs. While 83% of expert-derived original terms overlapped with new terms and modifiers, an additional 362 modifiers associated with both positive and negative SSI signals were identified and 62 new base observations and actions were identified. Clinical note queries with the most common base terms revealed another 49 modifiers. Clinical notes contain a wide variety of expressions describing infections occurring among surgical specialties which may provide value in improving the performance of SSI detection algorithms.