New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective

Meta-Analysis of Clinical Trials Comparing Cefazolin to Cefuroxime, Ceftriaxone, and Cefamandole for Surgical Site Infection Prevention

Surgical site infections are among the most prevalent and costly healthcare-associated infections, resulting in poor patient outcomes and even death. Cefazolin is a first-generation cephalosporin antibiotic that is widely used for surgical prophylaxis in a variety of surgical disciplines. Although previous studies showed that cefazolin is effective in preventing surgical site infections, other agents, such as cefuroxime and ceftriaxone, were used excessively for surgical patients. The present analysis included only clinical trials comparing the efficacy of cefazolin to cefuroxime, ceftriaxone, and cefamandole in lowering SSIs using PubMed, Google Scholar, and ClinicalTrials.gov. Review Manager software (RevMan version 5.4) was used to conduct the meta-analyses. A total of 12,446 patients were included in the study. Among these patients, 6327 patients received cefazolin and 6119 patients received cefamandole, cefuroxime, or ceftriaxone. Our analysis showed that cefazolin is as effective as cefuroxime, cefamandole, and ceftriaxone in preventing surgical site infections. Hence, our findings have provided evidence for the use of cefazolin before surgeries because of its efficacy, as previous studies showed that it is inexpensive and safer than other agents.

Effect of oral antimicrobial prophylaxis on surgical site infection after elective colorectal surgery: multicentre, randomised, double blind, placebo controlled trial

OBJECTIVE

To investigate whether oral antimicrobial prophylaxis as an adjunct to intravenous antibiotic prophylaxis reduces surgical site infections after elective colorectal surgery.

DESIGN

Multicentre, randomised, double blind, placebo controlled trial.

SETTING

11 university and non-university hospitals in France between 25 May 2016 and 8 August 2019.

PARTICIPANTS

926 adults scheduled for elective colorectal surgery.

INTERVENTION

Patients were randomised to receive either a single 1 g dose of ornidazole (n=463) or placebo (n=463) orally 12 hours before surgery, in addition to intravenous antimicrobial prophylaxis before surgical incision.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients with surgical site infection within 30 days after surgery. Secondary outcomes included individual types of surgical site infections and major postoperative complications (Clavien-Dindo classification grade 3 or higher) within 30 days after surgery.

RESULTS

Of the 960 patients who were enrolled, 926 (96%) were included in the analysis. The mean age of participants was 63 years and 554 (60%) were men. Surgical site infection within 30 days after surgery occurred in 60 of 463 patients (13%) in the oral prophylaxis group and 100 of 463 (22%) in the placebo group (absolute difference -8.6%, 95% confidence interval -13.5% to -3.8%; relative risk 0.60, 95% confidence interval 0.45 to 0.80). The proportion of patients with deep infections was 4.8% in the oral prophylaxis group and 8.0% in the placebo group (absolute difference -3.2%, 95% confidence interval -6.4% to -0.1%). The proportion of patients with organ space infections was 5.0% in the oral prophylaxis group and 8.4% in the placebo group (absolute difference -3.4%, -6.7% to -0.2%). Major postoperative complications occurred in 9.1% patients in the oral prophylaxis group and 13.6% in the placebo group (absolute difference -4.5%, -8.6% to -0.5%).

CONCLUSION

Among adults undergoing elective colorectal surgery, the addition of a single 1 g dose of ornidazole compared with placebo before surgery significantly reduced surgical site infections.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02618720.

Antiseptic Skin Preparation Agents to Prevent Surgical Site Infection in Colorectal Surgery: A 3-Armed Randomized Controlled Trial

BACKGROUND

There is much debate surrounding the ideal antiseptic skin preparation agent to reduce postoperative surgical site infection. International guidelines suggest that chlorhexidine- and alcohol-containing compounds have superior efficacy. However, there are minimal clinical trials specifically looking at skin preparation agents for colorectal surgery.

OBJECTIVE

The aim of this study was to compare the efficacy of chlorhexidine in alcohol versus povidone-iodine in alcohol versus povidone-iodine in aqueous solution for the prevention of surgical site infection in colorectal surgery.

DESIGN

This is a prospective, 3-armed, randomized controlled trial.

SETTING

This study was conducted at the 800-bed John Hunter Hospital and Newcastle Private Hospital, with all subspecialty services in New South Wales, Australia.

PATIENTS

All eligible, consenting adults undergoing colorectal surgery between July 2015 and December 2018 were included.

INTERVENTIONS

Patients were andomized to receive preincision skin preparation with one of the following: chlorhexidine in 70% alcohol, povidone-iodine in 70% alcohol, or povidone-iodine in aqueous solution.

MAIN OUTCOME MEASURE

The primary measure was surgical site infection within 30 days.

RESULTS

A total of 482 patients were randomized to chlorhexidine in alcohol, povidone-iodine in alcohol, or aqueous povidone-iodine. The overall surgical site infection rate was 22% (107/482). There was no difference in rates of surgical site infection: 20.6% (29/141), 22.8% (44/193), and 23.0% (34/148), respectively ( p = 0.5267). There was no difference in complication rates: 54.6% (77/141), 46.1% (89/193), and 49.3% (73/148), respectively ( p = 0.1762). The median length of stay was 6 days in all 3 groups.

LIMITATIONS

This is a subset analysis of a larger clinical trial for all forms of incisional surgery (the NewSKIN Prep trial), and noninferiority cannot be assessed. Changes in government regulations resulted in a change from 0.5% chlorhexidine in 70% ethanol to 2% chlorhexidine in 70% ethanol during the trial.

CONCLUSION

This large, prospective, randomized clinical trial appears to indicate that there is no difference in surgical site infection, complications, or length of stay among the 3 commonest forms of skin preparation in colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B875 .New Zealand Clinical Trials registry: ACTRN12615000021572Agentes antisépticos para la preparación de la piel para prevenir la infección del sitio quirúrgico en la cirugía colorrectal: un ensayo clínico aleatorizado de tres grupos.

ANTECEDENTES

Existe un gran debate en torno al agente de preparación de la piel antiséptico ideal para reducir la infección posoperatoria del sitio quirúrgico. Las pautas internacionales sugieren que los compuestos que contienen clorhexidina y alcohol tienen una eficacia. Sin embargo, existen ensayos clínicos mínimos que analizan específicamente los agentes de preparación de la piel para la cirugía colorrectal.

OBJETIVO

Comparar la eficacia de la clorhexidina en alcohol versus povidona yodada en alcohol versus povidona yodada en solución acuosa para la prevención de la infección del sitio quirúrgico en cirugía colorrectal.

DISEO

Este es un ensayo controlado aleatorio prospectivo de tres brazos.

AJUSTE

Este estudio se realizó en el Hospital John Hunter de 800 camas y el Hospital Privado de Newcastle con todos los servicios de subespecialidad en Nueva Gales del Sur, Australia.

PACIENTES

Se incluyeron todos los adultos elegibles que dieron su consentimiento para someterse a una cirugía colorrectal entre julio de 2015 y diciembre de 2018.

INTERVENCIONES

Aleatorizados para recibir una preparación para la piel previa a la incisión con uno de: clorhexidina en alcohol al 70%, povidona yodada en alcohol al 70% o povidona yodada en solución acuosa.

MEDIDA DE RESULTADO PRINCIPAL

La medida principal fue la infección del sitio quirúrgico dentro de los 30 días.

RESULTADOS

Un total de 482 pacientes fueron aleatorizados para recibir clorhexidina en alcohol, povidona yodada en alcohol o povidona yodada acuosa. La tasa global de infección del sitio quirúrgico fue del 22% (107/482). No hubo diferencias en las tasas de infección del sitio quirúrgico; 20,6% (29/141), 22,8% (44/193) y 23,0% (34/148) respectivamente; p = 0,5267. No hubo diferencia en las tasas de complicaciones; 54,6% (77/141), 46,1% (89/193) y 49,3% (73/148) respectivamente; p = 0,1762. La duración media de la estancia hospitalaria fue de 6,0 días en los tres grupos.

LIMITACIONES

Este es un análisis de subconjunto de un ensayo clínico más grande para todas las formas de cirugía incisional (el ensayo NewSKIN Prep) y no se puede evaluar la no inferioridad. Los cambios en las regulaciones gubernamentales dieron como resultado un cambio de clorhexidina al 0,5% en etanol al 70% a clorhexidina al 2% en etanol al 70% durante la prueba.

CONCLUSINES

Este gran ensayo clínico prospectivo y aleatorizado parece indicar que no hay diferencia en la infección del sitio quirúrgico, las complicaciones o la duración de la estancia entre las 3 formas más comunes de preparación de la piel en la cirugía colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B875 . (Traducción-Dr. Gonzalo Hagerman )Este ensayo se registró de forma prospectiva en el registro de ensayos clínicos de Australia Nueva Zelanda el 15/01/2015: ACTRN12615000021572.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Interaction of basic diseases and low red blood cell count as critical murderer of wound infection after osteosarcoma resection: Wound infection after osteosarcoma resection

BACKGROUND

Surgical wound infection is one of the common complications in patients after osteosarcoma resection. It is imperative to grasp the risk factors comprehensively. Therefore, this study aimed to explore the risk factors of wound infection and deeply analyze the correlation between risk factors and wound infection.

METHODS

The study subjects were 101 patients who underwent osteosarcoma resection between April 2018 and August 2021. The diagnosis of postoperative wound infection was confirmed by postoperative observation of the incision, ultrasound imaging, and pathogenic examination. This study included a series of potential factors, mainly laboratory examination indicators and patients' general information. The statistical methods had Pearson Chi-square test, Spearman-rho correlation test, multifactorial linear regression model, logistic regression analysis, and receiver operating characteristic (ROC) curve.

RESULTS

Pearson Chi-square test and Spearman correlation test showed that red blood cell (RBC) count (P = .033) and basic diseases (P = .020) were significantly correlated with a surgical wound infection after osteosarcoma resection. Logistic regression analysis manifested that basic disease (OR = 0.121, 95% CI: 0.015-0.960, P = .046) and RBC (OR = 0.296, 95% CI: 0.093-0.944, P = .040) have a clear correlation with whether the patients have surgical wound infection after osteosarcoma resection. And the interaction of basic diseases and RBC could diagnose the surgical wound infection sensitively and accurately (AUC = 0.700, P = .014, 95% CI = 0.564-0.836) via the ROC analysis.

CONCLUSION

Patients with basic diseases and low RBC were risk factors for surgical wound infection after osteosarcoma resection.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

Irrigation Solutions in Total Joint Arthroplasty

INTRODUCTION

Despite advancements in the field of adult reconstruction, prosthetic joint infection (PJI) remains a common and devastating complication of total joint arthroplasty. Eradication of these infections can often prove difficult, and they remain a source of considerable morbidity and mortality. This clinical review paper will focus on some of the more commonly used irrigation solutions; povidone-iodine (PI), chlorhexidine (CHG), acetic acid (AA), hydrogen peroxide (HP), antibiotic irrigations, taurolidine, and polyhexanide-betaine (PB).

SUMMARY OF THE EVIDENCE

Significant research has been performed on the prevention of PJI, including use of intraoperative joint irrigation solutions. Several solutions have been theorized to aid in infection prevention, but no evidence-based practice guidelines in this area of orthopaedics have been established. There is a paucity of prospective randomized control trials to compare the efficacy of these joint irrigation solutions.

CONCLUSIONS

The authors present a review regarding seven major categories of commonly used intraoperative joint irrigation solutions. The current literature fails to demonstrate a clear consensus for a preferred solution and concentration for povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, antibiotic irrigations, taurolidine, and polyhexanide-betaine. Prospective, randomized control trials directly comparing these different irrigation solutions are needed.

Peri-Operative Method of Applying Chlorhexidine and Iodine as Skin Preparation Solutions: Does It Matter? A Literature Review

Background: Surgical site infection (SSI) is an adverse event that can lead to increased pain, increased cost, risk of death, and decreased patient satisfaction. Studies have investigated the best solutions to prevent SSI. Chlorhexidine has been suggested as the most efficacious antiseptic. However, scant data exist on application of antiseptic solutions and effectiveness of concentric versus back-and-forth strokes. Because a specific method may result in better outcomes, we aimed to review the literature to compare these two techniques. Methods: PubMed-indexed articles were reviewed using specific keywords, including "back-and-forth," "concentric circle," "chlorhexidine," "iodine," "surgical site infection," "antiseptic," and "skin preparation." Because data showing the correlation between SSI and application method of skin preparation solutions were scant, studies that described skin preparation method but analyzed other types of infection, bacteremia, or colonization were also included in this review. Results: No consensus was found regarding the application method. Two articles showed the superiority of chlorhexidine applied using the back-and-forth technique, whereas one demonstrated the superiority of iodine applied in concentric circles. Conclusions: The method of applying antiseptic solution may be just as important as the choice of solution. More studies are needed to assess method of antiseptic application.

Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis

BACKGROUND

A combination of chlorhexidine gluconate and alcohol (CHG-alcohol) is recommended for surgical skin preparation to prevent surgical site infection (SSI). Although more than 1 per cent CHG-alcohol is recommended to prevent catheter-related bloodstream infections, there is no consensus regarding the concentration of the CHG compound for the prevention of SSI.

METHODS

A systematic review and meta-analysis was performed. Four electronic databases were searched on 5 November 2020. SSI rates were compared between CHG-alcohol and povidone-iodine (PVP-I) according to the concentration of CHG (0.5 per cent, 2.0 per cent, 2.5 per cent, and 4.0 per cent).

RESULTS

In total, 106 of 2716 screened articles were retrieved for full-text review. The risk ratios (RRs) of SSI for 0.5 per cent (6 studies) and 2.0 per cent (4 studies) CHG-alcohol were significantly lower than those for PVP-I (RR = 0.71, 95 per cent confidence interval (c.i.) 0.52 to 0.97; RR = 0.52, 95 per cent c.i 0.31 to 0.86 respectively); however, no significant difference was observed in the compounds with a CHG concentration of more than 2.0 per cent.

CONCLUSIONS

This meta-analysis is the first study that clarifies the usefulness of an alcohol-based CHG solution with a 0.5 per cent or higher CHG concentration for surgical skin preparation to prevent SSI.

Robbing Peter to Pay Paul: Chlorhexidine gluconate demonstrates short-term efficacy and long-term cytotoxicity

Wound cleansing agents are routine in wound care and preoperative preparation. Antiseptic activity intends to prevent contaminating microbes from establishing an infection while also raising concerns of cytotoxicity and delayed wound healing. We evaluated the cytotoxicity of five clinically used wound cleaning agents (saline, povidone iodine, Dove® and Dial® soaps, and chlorhexidine gluconate [CHG]) using both an ex vivo and in vivo human skin xenograft mouse model, in contrast to classical in vitro models that lack the structural and compositional heterogeneity of human skin. We further established an ex vivo wound contamination model inoculated with ~100 cells of Pseudomonas aeruginosa or Staphylococcus aureus to evaluate antimicrobial efficacy. Scanning electron microscopy and confocal microscopy were used to evaluate phenotypic and spatial characteristics of bacterial cells in wound tissue. CHG significantly reduced metabolic activity of the skin explants, while all treatments except saline affected local cellular viability. CHG cytotoxicity persisted and progressed over 14 days, impairing wound healing in vivo. Within the contamination model, CHG treatment resulted in a significant reduction of P. aeruginosa wound surface counts at 24 h post-treatment. However, this effect was transient and serial application of CHG had no effect on both P. aeruginosa or S. aureus microbial growth. Microscopy revealed that viable cells of P. aeruginosa reside deep within wound tissue post-CHG application, likely serving as a reservoir to re-populate the tissue to a high bioburden. We reveal concerning cytotoxicity and limited antimicrobial activity of CHG in human skin using clinically relevant models, with the ability to resolve spatial localization and temporal dynamics of tissue viability and microbial growth.

Current Status and Factors Associated with Clean Operating Rooms: A Survey of Hospitals in China

Background

Indoor air quality is controlled in the clean operating room (OR) to reduce the risk of surgical-site infections (SSIs). The aim of this study is to assess the usage and management of clean ORs in China and to identify factors associated with the risk of SSIs.

Methods

An online survey was distributed to hospitals in China from August 5 to September 5, 2018 via the WeChat account of the Shanghai International Forum for Infection Control and Prevention. The questionnaire consisted of two parts: basic information (hospital type, level, and number of beds) and usage and management (number of ORs, usage time, maintenance mode, test frequency, compliance with current standards, and comfort of healthcare workers). The significance of factors associated with the cleanliness and maintenance of clean ORs was assessed by univariate and multivariate logistic regression analyses.

Results

Among 1,308 responding hospitals, 25.7% failed to comply with current standards. “Maintenance mode” had a significant effect on compliance with current standards for clean ORs (p < 0.0001) and “professional” maintenance was superior to “outsource or no” maintenance (odds ratio = 0.511, 95% confidence interval = 0.367–0.711). There was a significant difference in the comfort of healthcare workers in clean ORs that complied with current standards vs. those that did not (39.92% [388/972] vs. 64.28% [216/336], respectively, p < 0.0001). Humidity was the chief complaint among healthcare workers.

Conclusion

Maintenance of clean ORs was significantly associated with the compliance of current standards. Noncompliance with current standards was associated with greater risks of SSIs. Maintenance of ORs for prevention of SSIs should consider the costs and benefits.

Systematic literature review on surgical site preparation in paediatric surgery

Background

Surgical site infections (SSIs) in children represent a common and serious postoperative complication. Surgical skin preparation is an essential preventive measure in every surgical procedure. The most commonly used antiseptic agents for surgical skin preparation are chlorhexidine gluconate and iodophors in alcohol-based solutions. In adult patients the use of chlorhexidine-containing antiseptic solutions for preoperative skin preparation has been advocated to reduce SSI rates. Our objective was to conduct a systematic literature review on use of antiseptic agents for surgical skin preparation in children less than 16 years of age.

Methods

A systematic review of MEDLINE, EMBASE, CINAHL and CENTRAL was performed using both MeSH and free text terms and using the relevant Cochrane filter to identify full text randomized trials (RCTs) and comparative observational studies. Interventions of interest were the choice of main agent in antiseptic solutions (chlorhexidine/povidone-iodine/alcohol) compared with each other or with other antiseptic agents. Primary outcome was the reported rate of surgical site infections.

Results

In total 8 studies were included in the review; 2 RCTs and 6 observational studies. Observational studies generally did not primarily investigate the association of different antiseptics with subsequent SSI. The identified randomised controlled trials included only 61 children in total, and were of low quality. Consequently, we did not conduct a formal meta-analysis. Since the publication of a comprehensive systematic review of perioperative measures for the prevention of SSI in 2016, no randomized controlled trials comparing antiseptic agents for surgical skin preparation in paediatric surgery have been conducted.

Conclusion

Robust evidence on the optimal skin antisepsis to reduce SSIs in children is lacking. Direct extrapolation of effects from trials involving adults is not appropriate as physiologic characteristics and risk factors for SSIs differ between adults and children. It is therefore essential to conduct high quality RCT investigating interventions to identify optimal measures to reduce SSI rates in children.

Trial registration

Prospero registration (CRD42020166193).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03502-z.

Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ² = 0.246; χ² = 69.75; p < 0.001; I² = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

The Utility of Perioperative Products for the Prevention of Surgical Site Infections in Total Knee Arthroplasty and Lower Extremity Arthroplasty: A Systematic Review

Surgical site infections (SSIs) are among the most prevalent and devastating complications following lower extremity total joint arthroplasty (TJA). Strategies to reduce the rates can be divided into preoperative, perioperatives, and postoperative measures. A multicenter trial is underway to evaluate the efficacy of implementing a bundled care program for SSI prevention in lower extremity TJA including: (1) nasal decolonization; (2) surgical skin antisepsis; (3) antimicrobial incise draping; (4) temperature management; and (5) negative-pressure wound therapy for selected high-risk patients. The purposes of this systematic review were to provide a background and then to summarize the available evidence pertaining to each of these SSI-reduction strategies with special emphasis on total knee arthroplasty. A systematic review of the literature was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. Five individual literature searches were performed to identify studies evaluating nasal decolonization temperature management, surgical skin antisepsis, antimicrobial incise draping, and negative-pressure wound therapy. The highest level of evidence reports was used in each product review, and if there were insufficient arthroplasty papers on the particular topic, then papers were further culled from the surgical specialties to form the basis for the review. There was sufficient literature to assess all of the various prophylactic and preventative techniques. All five products used in the bundled program were supported for use as prophylactic agents or for the direct reduction of SSIs in both level I and II studies. This systematic review showed that various pre-, intra-, and postoperative strategies are efficacious in decreasing the risks of SSIs following lower extremity TJA procedures. Thus, including them in the armamentarium for SSI-reduction strategies for hip and knee arthroplasty surgeons should decrease the incidence of infections. We expect that the combined use of these products in an upcoming study will support these findings and may further enhance the reduction of total knee arthroplasty SSIs in a synergistic manner.

What have we learned from the surveys of the AEC, AECP and the Observatory of Infection in Surgery? Compliance with postoperative infection prevention measures and comparison with the AEC recommendations

Before planning improvement strategies, it is crucial to know the degree of implementation of preventative measures for postoperative infection. The aggregated results of 3 surveys carried out by the Observatory of Infection in Surgery to members of 11 associations of surgeons and perioperative nurses are presented. The questions were aimed to determine the knowledge of the scientific evidence, personal beliefs and the actual use of the main measures. Of 2295 respondents, 45.1% did not receive feedback on the infection rate of their unit. Insufficient knowledge of some of the main prevention recommendations and some disturbing rates of use were observed. The preferred strategies to improve compliance with preventive guidelines and their degree of implementation were investigated. A gap between scientific evidence and clinical practice in the prevention of infection in different surgical specialties was confirmed.

Optimizing skin antisepsis for neonatal surgery: A quality improvement initiative

PURPOSE

Surgical site infections (SSIs) are a significant determinant of morbidity in the Neonatal Intensive Care Unit (NICU). Chlorhexidine gluconate/isopropyl alcohol (CHG-IPA) skin prep has demonstrated superiority over Povidone-Iodine (PI) in preventing SSIs in adults, however FDA labeling discourages CHG use in infants <2 months. This project aimed to i) create evidence for safe CHG skin antisepsis in neonates; and ii) evaluate the safety and effectiveness of CHG skin prep for neonatal surgery.

METHODS

A literature review was conducted to assess the safety and effectiveness of neonatal CHG skin antisepsis. Following stakeholder engagement, a CHG surgical skin prep protocol and validated neonatal skin integrity tool to assess prep-associated skin injury were implemented in 50 consecutive, eligible neonates ≥1500 g and ≥34 weeks post conceptual age undergoing abdominal or thoracic surgery. SSI rates were compared to a matched, historical PI skin prep cohort.

RESULTS

2%CHG-70%IPA or 0.5%CHG-70%IPA were used based on gestational age cutoffs. None of the CHG patients experienced adverse skin prep outcomes while 8% developed SSIs, compared to 14% in the historical PI cohort.

CONCLUSION

This project engaged NICU stakeholders in quality improvement work and informed the implementation of a safe and effective CHG skin prep protocol for neonatal surgery. LOE: IV.

The Impact of Care Bundles on the Incidence of Surgical Site Infections: A Systematic Review

OBJECTIVE

This systematic review assesses the effects of care bundles on the incidence of surgical site infections (SSIs).

DATA SOURCES

The search was conducted between February and May 2021, using PubMed, CINAHL, SCOPUS, Cochrane, and EMBASE databases.

STUDY SELECTION

Studies were included if they used systematic review methodology, were in English, used a quantitative design, and explored the use of care bundles for SSI prevention. A total of 35 studies met the inclusion criteria, and 26 provided data conducive to meta-analysis.

DATA EXTRACTION

Data were extracted using a predesigned extraction tool, and analysis was undertaken using RevMan (Cochrane, London, UK). Quality appraisal was undertaken using evidence-based librarianship.

DATA SYNTHESIS

The mean sample size was 7,982 (median, 840) participants. There was a statistically significant difference in SSI incidence in favor of using a care bundle (SSI incidence 4%, 703/17,549 in the care bundle group vs 7%, 1,157/17,162 in the usual care group). The odds ratio was 0.55 (95% confidence interval, 0.41-0.73; P < .00001), suggesting that there is a 45% reduction in the odds of SSI development for the care bundle group. The mean validity score for all studies was 84% (SD, 0.04%).

CONCLUSIONS

The results indicate that implementing care bundles reduced SSI incidence. However, because there was clinically important variation in the composition of and compliance with care bundles, additional research with standardized care bundles is needed to confirm this finding.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

Contemporary use of antimicrobial prophylaxis for surgical patients: An observational cohort study

BACKGROUND

Antimicrobial prophylaxis is commonly used to prevent surgical site infection (SSI), despite concerns of overuse leading to antimicrobial resistance. However, it is unclear how often antimicrobials are used and whether guidelines are followed.

OBJECTIVES

To describe contemporary clinical practice for antimicrobial prophylaxis including guideline compliance, the rate of postoperative infection and associated side effects.

DESIGN

A prospective, multicentre, observational cohort study.

SETTING

Twelve United Kingdom National Health Service hospitals.

PARTICIPANTS

One thousand one hundred and sixteen patients, aged at least 18 years undergoing specific colo-rectal, obstetric, gynaecological, urological or orthopaedic surgical procedures.

EXPOSURE

Compliance with guidelines for antimicrobial prophylaxis.

OUTCOMES

The primary outcome was SSI within 30 days after surgery. Secondary outcomes were number of doses of antimicrobials for prophylaxis and to treat infection, incidence of antimicrobial-related side effects and mortality within 30 days after surgery. Data are presented as number with percentage (%) or median with interquartile range [IQR].Results of logistic regression analyses are presented as odds ratio/rate ratio (OR/RR) with 95% confidence intervals (95% CIs).

RESULTS

1102 out of 1106 (99.6%) patients received antimicrobial prophylaxis, which was compliant with local guidelines in 929 out of 1102 (84.3%) cases. 2169 out of 51 28 (42.3%) doses of antimicrobials were administered as prophylaxis (median 1 [1 to 2] dose) and 2959 out of 5128 (57.7%) were administered to treat an infection (median 21 [11 to 28] doses). 56 patients (5.2%) developed SSI. Antimicrobial prophylaxis administered according to local guidelines was not associated with a lower incidence of SSI compared with administration outside guidelines [OR 0.90 (0.35 to 2.29); P  = 0.823]. 23 out of 1072 (2.2%) patients experienced a side effect of antimicrobial therapy. 7 out of 1082 (0.6%) patients died. The median hospital stay was 3 [1 to 5] days.

CONCLUSION

Antimicrobial prophylaxis was administered for almost all the surgical procedures under investigation. However, this was not always compliant with guidelines. Further research is required to determine whether the amount of prophylactic antimicrobials could be safely and effectively reduced without increasing the incidence of SSI.

Are preoperative oral antibiotics effective in reducing the incidence of anastomotic leakage after colorectal cancer surgery? Study protocol for a prospective, multicentre, randomized controlled study

Introduction

The optimal preoperative preparation for elective colorectal cancer surgery has been debated in academic circles for decades. Previously, several expert teams have conducted studies on whether preoperative mechanical bowel preparation and oral antibiotics can effectively reduce the incidence of postoperative complications, such as surgical site infections and anastomotic leakage. Most of the results of these studies have suggested that preoperative mechanical bowel preparation for elective colon surgery has no significant effect on the occurrence of surgical site infections and anastomotic leakage.

Methods/design

This study will examine whether oral antibiotic bowel preparation (OABP) influences the incidence of anastomotic leakage after surgery in a prospective, multicentre, randomized controlled trial that will enrol 1500 patients who require colon surgery. The primary endpoint, incidence of anastomotic leakage, is based on 2.3% in the OABP ± mechanical bowel preparation (MBP) group in the study by Morris et al. Patients will be randomized (1:1) into two groups: the test group will be given antibiotics (both neomycin 1 g and metronidazole 0.9 g) the day before surgery, and the control group will not receive any special intestinal preparation before surgery, including oral antibiotics or mechanical intestinal preparation. All study-related clinical data, such as general patient information, past medical history, laboratory examination, imaging results, and surgery details, will be recorded before surgery and during the time of hospitalization. The occurrence of postoperative fistulas, including anastomotic leakage, will be recorded as the main severe postoperative adverse event and will represent the primary endpoint.

Ethics and dissemination

Ethics approval was obtained from the Chinese Ethics Committee of Registering Clinical Trials (ChiECRCT20200173). The results of this study will be disseminated at several research conferences and as published articles in peer-reviewed journals. Protocol was revised on November 22, 2021, version 4.0.

Trial registration

ChiCTR2000035550. Registered on 13 Aug 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06235-7.

Clinical study of a new skin antiseptic olanexidine gluconate in gastrointestinal cancer surgery

Background

Surgical site infection (SSI) is a common complication of gastrointestinal surgery. Olanexidine gluconate (OLG) is a novel skin antiseptic that is effective against a wide range of bacteria. The purpose of this study was to evaluate the bactericidal efficacy of OLG in gastrointestinal cancer surgery.

Methods

This retrospective study included a total of 281 patients who underwent gastrointestinal cancer surgery (stomach or colon). The patients were divided into two groups: 223 patients were treated with OLG (OLG group), and 58 patients were treated with povidone-iodine (PVP-I) (control group). The efficacy and safety outcomes were measured as the rate of SSI within 30 days after surgery. In addition, we conducted subgroup analyses according to the surgical approach (open or laparoscopic) or primary lesion (stomach or colon).

Results

There was a significant difference in the rate of SSI between the control group and OLG group (10.3% vs. 2.7%; p = 0.02). There was a significant difference in the SSI rate in terms of superficial infection (8.6% vs. 2.2%; p = 0.0345) but not in deep infection (1.7% vs. 0.5%; p = 0.371). There was no significant difference between the control group and OLG group in the overall rate of adverse skin reactions (5.2% vs. 1.8%; p = 0.157).

Conclusion

This retrospective study demonstrates that OLG is more effective than PVP-I in preventing SSI during gastrointestinal cancer surgery.

Mitochondrial Side Effects of Surgical Prophylactic Antibiotics Ceftriaxone and Rifaximin Lead to Bowel Mucosal Damage

Despite their clinical effectiveness, a growing body of evidence has shown that many classes of antibiotics lead to mitochondrial dysfunction. Ceftriaxone and Rifaximin are first choice perioperative antibiotics in gastrointestinal surgery targeting fundamental processes of intestinal bacteria; however, may also have negative consequences for the host cells. In this study, we investigated their direct effect on mitochondrial functions in vitro, together with their impact on ileum, colon and liver tissue. Additionally, their impact on the gastrointestinal microbiome was studied in vivo, in a rat model. Rifaximin significantly impaired the oxidative phosphorylation capacity (OxPhos) and leak respiration in the ileal mucosa, in line with increased oxidative tissue damage and histological changes following treatment. Ceftriaxone prophylaxis led to similar changes in the colon mucosa. The composition and diversity of bacterial communities differed extensively in response to antibiotic pre-treatment. However, the relative abundances of the toxin producing species were not increased. We have confirmed the harmful effects of prophylactic doses of Rifaximin and Ceftriaxone on the intestinal mucosa and that these effects were related to the mitochondrial dysfunction. These experiments raise awareness of mitochondrial side effects of these antibiotics that may be of clinical importance when evaluating their adverse effects on bowel mucosa.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Hold the Antibiotics: Are Preoperative Antibiotics Unnecessary in the Treatment of Pediatric Supracondylar Humerus Fractures?

BACKGROUND

Supracondylar humerus (SCH) fracture is the most common elbow injury in children and often treated with closed reduction and percutaneous pinning (CRPP). There is little published evidence supporting or refuting the use of perioperative prophylactic antibiotics for SCH CRPP in the pediatric population. The purpose of this study is to evaluate the rate of surgical site infection for patients with and without preoperative antibiotics.

METHODS

A retrospective chart review was conducted of patients less than or equal to 16 years from 2012 to 2018 who underwent primary CRPP. Open fractures, multilimbed polytraumas, and immunodeficient patients were excluded. Infection rates were compared using a noninferiority test assuming a 3% infection rate and a predefined noninferiority margin of 4%. A total of 255 patients were needed to adequately power the study.

RESULTS

Of the 1253 cases identified, 845 met eligibility criteria. A total of 337 received antibiotics, and 508 did not. Preoperative nerve injury (P=0.0244) and sterilization technique (P<0.0001) were associated with antibiotic use: 4 patients developed an infection; there were successfully treated superficial infections, and 1 was a deep infection requiring a formal debridement. There were 8 patients that had a recorded mal-union, and 6 patients required additional procedures; 1 patient had a postoperative compartment syndrome on postoperation day 1. The infection rates among patients treated with and without antibiotics were 0.60% and 0.40%, respectively. The absence of antibiotics was not clinically inferior to using antibiotics (P=0.003).

CONCLUSIONS

Infection remains a rare complication following CRPP of SCH fractures. According to our current data, not giving perioperative antibiotics was not inferior to using perioperative antibiotics for preventing superficial or deep infection in patients undergoing CRPP of SCH fractures. With the increase in attention to antibiotic stewardship, it is important to eliminate unnecessary antibiotic use while continuing to maintain a low rate of surgical site infection.

LEVEL OF EVIDENCE

Level IV-case series. This is a therapeutic study that investigates the results from a case series.

Antiseptic Skin Agents to Prevent Surgical Site Infection After Incisional Surgery: A Randomized, Three-armed Combined Non-inferiority and Superiority Clinical Trial (NEWSkin Prep Study)

OBJECTIVE

To compare SSI rates between the skin preparation agents: PI-Aq, povidone-iodine with alcohol (PI-Alc), and chlorhexidine with alcohol (C-Alc).

BACKGROUND

Guidelines suggest that alcohol-containing chlorhexidine solutions are the gold standard for skin preparation before surgery. It remains difficult to determine whether it is the chlorhexidine component or the addition of alcohol that confers the most benefit.

METHODS

We conducted a multicenter, prospective, combined non-inferiority (PI-Alc vs C-Alc) and superiority (PI-Alc vs PI-Aq) randomized clinical trial. Participants were randomized 1:1:1 to receive either C-Alc, PI-Alc, or PI-Aq. The primary outcome was SSI rate as defined by the Centers for Disease Control. Secondary outcomes were complication rates, length of hospital stay, readmissions, and skin reactions.

RESULTS

Between January 2015 and December 2018, 3213 patients were randomized (C-Alc: 1076, PI-Alc: 1075, and PI-Aq: 1062). Mean age of participants was 57% and 55% were female. SSI rates were: C-Alc 11.09%, PI-Alc 10.88%, and PI-Aq 12.56%. PI-Alc was found to be non-inferior to C-Alc (mean difference, -0.21%; 95% confidence interval, -2.85 to 2.44; P = 0.0009 non-inferiority), whereas PI-Alc was not superior to PI-Aq (mean difference, -1.68%; 95% confidence interval, -4.40 to 1.05; P = 0.2302). There were no differences seen in secondary outcomes between groups and no treatment related adverse events or deaths occurred.

CONCLUSIONS

PI-Alc is non-inferior to C-Alc and not superior to PI-Aq. This is at odds with current guidelines that suggest alcohol-based chlorhexidine solutions should routinely be used for surgical skin preparation.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ANZCTRN12615000021571. www.anzctr.org.au.

Perioperative oral care can prevent surgical site infection after colorectal cancer surgery: A multicenter, retrospective study of 1,926 cases analyzed by propensity score matching

BACKGROUND

Surgical site infection is a common postoperative complication of colorectal cancer surgery, and surgical site infection increases medical costs, prolongs hospitalization, and worsens long-term prognosis. Perioperative oral care has been reported to be effective in preventing postoperative pneumonia, although there are only a few reports on its effectiveness in preventing surgical site infection. This study aimed to determine the role of perioperative oral care in surgical site infection prevention after colorectal cancer surgery.

METHODS

In this study, 1,926 patients with colorectal cancer from 8 institutions were enrolled; 808 patients (oral care group) received perioperative oral care at the hospital's dental clinic, and 1,118 (control group) did not receive perioperative oral care. The data were matched by propensity score to reduce bias. Ultimately, a total of 1,480 patients were included in the analysis.

RESULTS

The incidence of surgical site infection was significantly lower in the oral care group than in the control group (8.4% vs 15.7%, P < .001). Multivariate logistic regression analysis revealed 4 independent risk factors for surgical site infection: low albumin level, rectal cancer, blood loss, and lack of perioperative oral care. Lack of perioperative oral care had an odds ratio of 2.100 (95% confidence interval 1.510-2.930, P < .001).

CONCLUSION

These results suggest that perioperative oral care can reduce the incidence of surgical site infection after colorectal cancer resection. Perioperative oral care may have an important role in the future perioperative management of colorectal cancer as a safe and effective method of surgical site infection prevention, although further validation in prospective studies is needed.

Effect of Antimicrobial Prophylaxis Duration on Health Care-Associated Infections After Clean Orthopedic Surgery: A Cluster Randomized Trial

IMPORTANCE

Postoperative health care-associated infections are associated with a greater deterioration in patients' general health status and social and economic burden, with at least 1 occurring in approximately 4% of acute care hospital patients. Antimicrobial prophylaxis prevents surgical site infections in various orthopedic procedures; however, its relationship with health care-associated infections remains unknown.

OBJECTIVE

To examine whether a shorter antimicrobial prophylaxis duration of less than 24 hours after surgery is not inferior to a longer duration in preventing health care-associated infections after clean orthopedic surgery.

DESIGN, SETTING, AND PARTICIPANTS

This open-label, multicenter, cluster randomized, noninferiority clinical trial was conducted in 5 tertiary referral hospitals in greater Tokyo metropolitan area, Japan, from May to December 2018. Adult patients undergoing clean orthopedic surgery were recruited until the planned number of participants was achieved (500 participants per group). Statistical analysis was conducted from July to December 2019.

INTERVENTIONS

Antimicrobial prophylaxis was discontinued within 24 hours after surgery in group 24 and 24 to 48 hours after surgery in group 48. Group allocation was switched every 2 or 4 months according to the facility-based cluster rule. Study-group assignments were masked from participants.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of health care-associated infections requiring antibiotic therapies within 30 days after surgery. The noninferiority margin was 4%.

RESULTS

Of the 1211 participants who underwent cluster allocation, 633 participants were in group 24 (median [IQR] age, 73 [61-80] years; 250 men [39.5%] and 383 women [60.5%]), 578 participants were in group 48 (median [IQR] age, 74 [62-81] years; 204 men [35.3%] and 374 women [64.7%]), and all were eligible for the intention-to-treat analyses. Health care-associated infections occurred in 29 patients (4.6%) in group 24 and 38 patients (6.6%) in group 48. Intention-to-treat analyses showed a risk difference of -1.99 percentage points (95% CI, -5.05 to 1.06 percentage points; P < .001 for noninferiority) between groups, indicating noninferiority. Results of adjusted intention-to-treat, per-protocol, and per designated procedure population analyses supported this result, without a risk of antibiotic resistance and prolonged hospitalization.

CONCLUSIONS AND RELEVANCE

This cluster randomized trial found noninferiority of a shorter antimicrobial prophylaxis duration in preventing health care-associated infections without an increase in antibiotic resistance risk. These findings lend support to the global movement against antimicrobial resistance and provide additional information on adequate antimicrobial prophylaxis for clean orthopedic surgery.

TRIAL REGISTRATION

Identifier: UMIN000030929.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Glycemic Control Regimens in the Prevention of Surgical Site Infections: A Meta-Analysis of Randomized Clinical Trials

Background

Increased risk of surgical site infections (SSIs) caused by hyperglycemia makes it necessary to follow perioperative glucose lowering strategies to reduce postoperative complications. A meta-analysis was conducted to understand the efficacy of intensive vs. conventional blood glucose lowering regimens on the incidence of SSIs and hypoglycemia from various randomized controlled studies (RCTs).

Materials and Methods

A systematic literature review was conducted using MEDLINE and Central databases for RCTs that involved intensive (lower blood glucose target levels) vs. conventional (higher blood glucose target levels) strategies in patients undergoing various types of surgeries. The primary outcomes were SSIs or postoperative wound infections. Hypoglycemia and mortality outcomes were also studied. A random-effects model was used to calculate the pooled risk ratio (RR), and subgroup analyses were performed.

Results

A total of 29 RCTs were included in the meta-analysis with the information from 14,126 patients. A reduction in overall incidence of SSIs was found (RR 0.63, 0.50-0.80, p = 0.0002, I 2= 56%). Subgroup analyses showed that intensive insulin regimens decreased the risk of SSIs in patients with diabetes, in cardiac and abdominal surgical procedures, and during the intraoperative and postoperative phases of surgery. However, the risk of hypoglycemia and mortality was increased in the intensive group compared to the conventional group.

Conclusion

The results of the meta-analysis provide support for the use of intensive insulin regimens during the perioperative phase for decreasing the incidence of SSIs in certain patient populations and surgical categories.

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

BACKGROUND

The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness.

METHODS

A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days.

RESULTS

Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations.

CONCLUSION

Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.

Scaling up Quality Improvement for Surgical Teams (QIST)—avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS

Background

The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement.

Methods

We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019.

Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative.

Results

There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52–2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42–2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively.

Conclusions

Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS.

Trial registration

Prospectively registered on 15 February 2018, ISRCTN11085475

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01193-9.

Study protocol for a cluster randomised trial of sterile glove and instrument change at the time of wound closure to reduce surgical site infection in low- and middle-income countries (CHEETAH)

Background

Surgical site infection (SSI) represents a major burden for patients, doctors, and health systems around the world. The aim of this trial is to assess whether the practice of using separate sterile gloves and instruments to close wounds at the end of surgery compared to current routine hospital practice can reduce surgical site infection at 30-days post-surgery for patients undergoing clean-contaminated, contaminated, or dirty abdominal surgery.

Methods

This study protocol describes a pragmatic, international, multi-centre, 2-arm, cluster randomised controlled trial, with an internal pilot. Clusters are defined as hospitals within low- and middle-income countries (LMICs) defined by the Development Assistance Committee (DAC) Official Development Assistance (ODA) list, where there are at least 4 eligible hospitals per country. Hospitals (clusters) must be in LMICs where glove and instrument change are not currently routine practice. Patients (adults and children) undergoing emergency or elective abdominal surgery for a clean-contaminated, contaminated, or dirty operation are eligible for inclusion. Before closing the abdominal wall, surgeons and the scrub nurse will change gloves and use separate, sterile instruments (intervention), versus no changing gloves or using separate, sterile instruments (standard practice, control). The primary outcome is SSI within 30 days after surgery, using the Centre for Disease Control (CDC) criteria. Secondary outcomes are SSI before point of hospital discharge, and readmission, reoperation, length of hospital stay, return to normal activities, and death up to 30-days after surgery. A 12-month internal pilot, including 12 clusters and approximately 600 participants, aims to assess adherence to allocation and follow-up of patients. The main trial is powered to detect a minimum reduction in the primary outcome from 16 to 12%. A total of 12,800 participants will be recruited from 64 clusters (hospitals) each including at least 200 participants.

Discussion

Change of gloves and sterile instruments prior to fascial closure in abdominal surgery is a low-cost, simple, intraoperative intervention which involves all members of the surgical and scrub team. If effective at reducing SSI, this practice could be readily implemented across all contexts. The findings of this trial will inform future guideline updates from international healthcare organisations, including the World Health Organization.

Trial registration

ClinicalTrials.gov NCT03980652. Registered on 9 July 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06102-5.

Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.

Winds of Change in Antibiotic Therapy following Orthognathic Surgery

Background and objectives: This retrospective cohort study aimed to compare three postoperative antibiotic protocols of different durations on surgical-site-infection (SSI) rates following orthognathic surgery for the correction of jaw deformities. Materials and methods: An analysis on data collected from the medical files of 209 patients who underwent orthognathic surgery between 2010 and 2019 was conducted. The patients were divided into three groups according to the postoperative antibiotic protocol—Group 1 (24 h), Group 2 (2–3 days), and Group 3 (>3 days). Dependent and independent variables were collected, analyzed, and compared between the three groups. Results: Group 1 included 30 patients (14.3%), Group 2 included 123 patients (58.9%), and Group 3 included 56 patients (26.8%). The vast majority of the postoperative antibiotics were amoxicillinand clavulanic acid (87.1%). The duration of the surgery and the use of a feeding tube were significantly different between Groups 1 and 3 (p < 0.001 and p = 0.005, respectively). There was no significant difference in SSI rates between the three groups (p = 0.642). The use of antibiotics beyond the immediate postoperative period provides no increased benefit regarding infection prevention. Conclusions: In young and healthy patients undergoing orthognathic surgery, a 24hregimen of postoperative antibiotics may be sufficient.

Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review

Surgical site infection occurs with high frequency in gastrointestinal surgery, contributing to the high incidence of morbidity and mortality. The accepted practice worldwide for the prevention of surgical site infection is providing single- or multiple-dose antimicrobial prophylaxis. However, most suitable antibiotic and optimal duration of prophylaxis are still debated. The aim of the systematic review is to assess the efficacy of antimicrobial prophylaxis in controlling surgical site infection rate following esophagogastric surgery. PubMed and Cochrane databases were systematically searched until 31 October 2021, for randomized controlled trials comparing different antimicrobial regimens in prevention surgical site infections. Risk of bias of studies was assessed with standard methods. Overall, eight studies concerning gastric surgery and one study about esophageal surgery met inclusion criteria. No significant differences were detected between single- and multiple-dose antibiotic prophylaxis. Most trials assessed the performance of cephalosporins or inhibitor of bacterial beta-lactamase. Antimicrobial prophylaxis (AMP) is effective in reducing the incidence of surgical site infection. Multiple-dose antimicrobial prophylaxis is not recommended for patients undergoing gastric surgery. Further randomized controlled trials are needed to determine the efficacy and safety of antimicrobial prophylaxis in esophageal cancer patients.

Oncologic colorectal surgical site infection: oral or not oral antibiotic preparation, that is the question

PURPOSE

Surgical wound infection is the most frequent postoperative complication in abdominal surgery, especially at the colorectal level. The aim of this study is analysing the results of mechanical colon preparation combined with oral antibiotic versus mechanical colon preparation without antibiotic therapy in patients with colorectal cancer undergoing elective surgery.

METHODS

This retrospective cohort study had been developed from November 2017 to February 2020. We have included a total of 281 consecutive patients undergoing elective colon and rectal oncological surgeries by the same surgical group using laparoscopic and open approaches. Transanal minimally invasive surgery (TAMIS) and transanal total mesorectal excision (TaTME) approaches were excluded. Exposed patients undergoing colon and rectal cancer surgery received mechanical bowel preparation and oral antibiotics with three doses of neomycin 1 g and erythromycin 500 mg the day before surgery.

RESULTS

The primary outcome was reduction in surgical wound infection rates before and after starting the oral antibiotic therapy from 17 to 6% (p < 0.05). As a secondary analysis, we evaluated the anastomotic dehiscence rate, corresponding with a decrease from 12 to 3% (p < 0.05).

CONCLUSION

Mechanical bowel preparation combined with oral antibiotic therapy is still not unanimously carried out in all the medical hospitals. In this report, we show that mechanical bowel preparation in combination with oral antibiotic reduces the risk of surgical wound infection and anastomotic leakage in patients undergoing colon and rectal cancer surgery.

Clean and Confident: Impact of Sterile Instrument Processing Workshops on Knowledge and Confidence in Five Low- and Middle-Income Countries

Background: Proper sterilization of surgical instruments is essential for safe surgery, yet re-processing methods in low-resource settings can fall short of standards. Training of Trainers (TOT) workshops in Ethiopia and El Salvador instructed participants in sterile processing concepts and prepared participants to teach others. This study examines participants' knowledge and confidence post-TOT workshop, and moreover discusses subsequent non-TOT workshops and observed sterile processing practices. Methods: Five TOT workshops were conducted between 2018 and 2020 in Ethiopia and Central America. Participant trainers then led nine non-TOT workshops in El Salvador, Guatemala, Honduras, and Nicaragua. Interactive sessions covered instrument cleaning, packaging, disinfection, sterilization, and transportation. Participants completed pre- and post-tests, demonstrated skill competencies, and shared feedback. Peri-operative sterile processing metrics were also observed in Ethiopian hospitals pre- and post-workshops. Results: Ninety-five trainees participated in TOT workshops, whereas 169 participated in non-TOT workshops. Knowledge on a 10-point scale increased substantially after all training sessions (+2.3 ± 2.8, +2.9 ± 1.7, and 2.7 ± 2.5 after Ethiopian, Central American, and non-TOT workshops, respectively; all p < 0.05). Scores on tests of sterile processing theory also increased (Ethiopian TOT, +68% ± 92%; Central American TOT, +26% ± 20%; p < 0.01). Most respondents felt "very confident" about teaching (Ethiopian TOT, 72%; Central American TOT, 83%; non-TOT, 70%), whereas fewer participants felt "very confident" enacting change (Ethiopian TOT, 36%; Central American TOT, 58%; non-TOT, 38%). Reasons included resource scarcity and inadequate support. Nonetheless, observed instrument compliance improved after Ethiopian TOT workshops (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21-1.78; p < 0.01). Conclusions: Sterile processing workshops can improve knowledge, confidence, and sterility compliance in selected low- and middle-income countries. Training of Trainers models empower participants to adapt programs locally, enhancing sterile processing knowledge in different communities. However, national guidelines, physical and administrative resources, and long-term follow-up must improve to ensure effective sterile processing.

Topical antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: a systematic review and meta-analysis

Background

Topical antibiotics are widely prescribed as prophylaxis for surgical site infection (SSI). Despite giving high drug concentrations at local wound sites, their efficacy remains controversial. This study is a systematic review and meta-analysis designed to compare the efficacy and safety of topical antibiotics with non-antibiotic agents in preventing SSI.

Methods

Randomized controlled trials (RCTs) comparing topical antibiotics in patients with clean and clean-contaminated postsurgical wounds were included. Relevant trials published before 30 September 2020, were searched in the PubMed, Embase, and Cochrane databases, without language restrictions. The primary outcome was the incidence of SSIs, presented as the event rate. The secondary outcome was the incidence of contact dermatitis (safety outcome). Data were synthesized using the random-effects model, with the results expressed as risk ratio (RR) with 95 per cent confidence intervals (c.i.).

Results

Thirteen RCTs were included. The incidence of SSIs and contact dermatitis showed no significant difference between topical antibiotics and non-antibiotic agents (RR 0.89, 95 per cent c.i. 0.59 to 1.32 (P = 0.56, I² = 48 per cent); and RR 2.79, 95 per cent c.i. 0.51 to 15.19 (P = 0.24, I² = 0 per cent), respectively). In the subgroup analyses, a reduction in SSIs was also not observed in dermatological (RR 0.77, 95 per cent c.i. 0.39 to 1.55; P = 0.46, I² = 65 per cent), ocular (RR 0.08, 95 per cent c.i. 0.00 to 1.52; P = 0.09), spinal (RR 1.34, 95 per cent c.i. 0.65 to 2.77; P = 0.43, I² = 0 per cent), orthopaedic (RR 0.69, 95 per cent c.i. 0.37 to 1.29; P = 0.25, I² = 0 per cent), or cardiothoracic surgeries (RR 1.60, 95 per cent c.i. 0.79 to 3.25; P = 0.19).

Conclusion

Given the current evidence, the routine application of topical antibiotics to surgical wounds did not reduce the incidence of SSI. Further trials are needed to assess their effectiveness in high-risk surgeries or in selected patient groups.

Clinical application of skin antisepsis using aqueous olanexidine: a scoping review

Surgical site infections (SSIs) and catheter‐related bloodstream infections (CRBSIs) caused by bacteria from surfaces poorly disinfected with chlorhexidine gluconate (CHG) and povidone‐iodine (PVP‐I) are increasing. Olanexidine gluconate (OLG) was developed in 2015 in Japan to prevent SSI and CRBSI caused by bacteria resistant to CHG and PVP‐I. This scoping review aimed to identify the knowledge gap between what is known and what is not known about the disinfection efficacy of OLG. We searched MEDLINE through PubMed, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform search database, ClinicalTrials.gov, and the Web‐based database of Japanese medical articles for works published to July 18, 2021. Manual reference searches were also carried out. A total of 131 studies were screened. Forty‐seven studies were included in this review and classified into two major categories: studies on pharmacological effects and spectrum (n = 29) and studies on clinical and adverse effects (n = 18). Olanexidine gluconate showed bactericidal activity against methicillin‐resistant Staphylococcus aureus and vancomycin‐resistant enterococci, in addition to common Gram‐positive and Gram‐negative bacteria. In clinical settings, although there is limited evidence on SSI prevention, 1.5% OLG might be more effective than 10% PVP‐I and 1% CHG in preventing SSI. However, the clinical usefulness of OLG is unclear due to the limited number of clinical studies. Also, clinical research is limited to studies targeting SSI prevention, and there are no clinical studies on CRBSI. Further clinical studies are needed on SSI and CRBSI prevention.

Efficacy of mupirocin, neomycin and octenidine for nasal Staphylococcus aureus decolonisation: a retrospective cohort study

BACKGROUND

Periprosthetic joint infection (PJI) causes significant morbidity. Methicillin sensitive Staphylococcus aureus (MSSA) is the most frequent organism, and the majority are endogenous. Decolonisation reduces PJIs but there is a paucity of evidence comparing treatments. Aims; compare 3 nasal decolonisation treatments at (1) achieving MSSA decolonisation, (2) preventing PJI.

METHODS

Our hospital prospectively collected data on our MSSA decolonisation programme since 2013, including; all MSSA carriers, treatment received, MSSA status at time of surgery and all PJIs. Prior to 2017 MSSA carriers received nasal mupirocin or neomycin, from August 2017 until August 2019 nasal octenidine was used.

RESULTS

During the study period 15,958 primary hip and knee replacements were performed. 3200 (20.1%) were MSSA positive at preoperative screening and received decolonisation treatment, 698 mupirocin, 1210 neomycin and 1221 octenidine. Mupirocin (89.1%) and neomycin (90.9%) were more effective at decolonisation than octenidine (50.0%, P < 0.0001). There was no difference in PJI rates (P = 0.452).

CONCLUSIONS

Mupirocin and neomycin are more effective than octenidine at MSSA decolonisation. There was poor correlation between the MSSA status after treatment (on day of surgery) and PJI rates. Further research is needed to compare alternative MSSA decolonisation treatments.

Survey of Prophylactic use of Antibiotics among Indian Neurosurgeons

Background

Despite recommendations and guidelines, surgical antibiotic prophylaxis protocol for neurosurgical cases is not uniformly followed.

Objective

To report trends in the use of prophylactic antibiotics by Indian neurosurgeons for non-trauma neurosurgical cases.

Materials and Methods

An email survey consisting of 17 questions was sent in 2018 to 2,175 surgical members with a registered email in the Neurological Society of India (NSI) registry. Three reminders were sent at 3-month intervals. The results were analyzed for the number, type, and duration of antibiotic use for different surgical procedures. The differences in the antibiotic policy in different practice settings were also studied.

Results

The response rate was less than 5% (103 responses). Almost all (98.1%) surgeons used prophylactic antibiotics. A single antibiotic was most used for cranial surgeries (85%) and least for spine surgeries with instrumentation (64%) (P = 0.001). One dose or 1 day of antibiotics was used by the least number of responders (29%) for spinal instrumentation surgeries and the most responders (66.7%) for spinal surgery without instrumentation (P < 0.0001). Surgeons working in corporate teaching hospitals or non-teaching hospitals were more likely to use antibiotics for longer duration than surgeons working in government/trust teaching hospitals.

Conclusions

Substantial numbers of surgeons use prophylactic antibiotics for more than 1 day with a higher proportion of surgeons working in corporate teaching and non-teaching hospitals pursuing such a policy.

Changes in the gut bacterial communities in colon cancer surgery patients: an observational study

Background

Colon surgery has been shown to modulate the intestinal microbiota. Our objective was to characterize these changes using state-of-the-art next generation sequencing techniques.

Methods

We performed a single-centre prospective observational cohort study to evaluate the changes in the gut microbiota, i.e., taxon distribution, before and after elective oncologic colon surgery in adult patients with different antimicrobial prophylaxis regimens (standard prophylaxis with cefuroxime/metronidazole versus carbapenems for extended-spectrum beta-lactamase-producing Enterobacterales [ESBL-E] carriers). We obtained rectal samples on the day of surgery, intraoperative luminal samples, and rectal or stoma samples 3 days after surgery. We performed metataxonomic analysis based on sequencing of the bacterial 16S rRNA gene marker. Similarities and differences between bacterial communities were assessed using Bray–Curtis similarity, visualised using principal coordinates analysis and statistically tested by PERMANOVA. Comparison of taxa relative abundance was performed using ANCOM.

Results

We included 27 patients between March 27, 2019 and September 17, 2019. The median age was 63.6 years (IQR 56.4–76.3) and 44% were females. Most (81%) patients received standard perioperative prophylaxis as they were not ESBL carriers. There was no significant association between ESBL carriage and differences in gut microbiome. We observed large and significant increases in the genus Enterococcus between the preoperative/intraoperative samples and the postoperative sample, mainly driven by Enterococcus faecalis. There were significant differences in the postoperative microbiome between patients who received standard prophylaxis and carbapenems, specifically in the family Erysipelotrichaceae.

Conclusion

This hypothesis-generating study showed rapid changes in the rectal microbiota following colon cancer surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13099-021-00477-7.