Surgical site infection - a European perspective of incidence and economic burden

Early recognition of methicillin-resistant Staphylococcus aureus surgical site infections using risk and protective factors identified by a group of Italian surgeons through Delphi method

BACKGROUND

Surgical site infections (SSIs) constitute a major clinical problem in terms of morbidity, mortality, duration of hospital stay, and overall costs. The bacterial pathogens implicated most frequently are Streptococcus pyogenes (S. pyogenes) and Staphylococcus aureus (S. aureus). The incidence of methicillin-resistant S. aureus (MRSA) SSIs is increasing significantly. Since these infections have a significant impact on hospital budgets and patients' health, their diagnosis must be anticipated and therapy improved. The first step should be to evaluate risk factors for MRSA SSIs.

METHODS

Through a literature review, we identified possible major and minor risk factors for, and protective factors against MRSA SSIs. We then submitted statements on these factors to 228 Italian surgeons to determine, using the Delphi method, the degree of consensus regarding their importance. The consensus was rated as positive if >80% of the voters agreed with a statement and as negative if >80% of the voters disagreed. In other cases, no consensus was reached.

RESULTS

There was positive consensus that sepsis, >2 weeks of hospitalization, age >75 years, colonization by MRSA, and diabetes were major risk factors for MRSA SSIs. Other possible major risk factors, on which a consensus was not reached, e.g., prior antibiotic use, were considered minor risk factors. Other minor risk factors were identified. An adequate antibiotic prophylaxis, laparoscopic technique, and infection committee surveillance were considered protective factors against MRSA SSIs. All these factors might be used to build predictive criteria for identifying SSI due to MRSA.

CONCLUSIONS

In order to help to recognize and thus promptly initiate an adequate antibiotic therapy for MRSA SSIs, we designed a gradation of risk and protective factors. Validation, ideally prospective, of this score is now required. In the case of a SSI, if the risk that the infection is caused by MRSA is high, empiric antibiotic therapy should be started after debriding the wound and collecting material for culture.

Analyzing the risk factors influencing surgical site infections: the site of environmental factors

BACKGROUND

Addressing surgical site infection (SSI) is accomplished, in part, through studies that attempt to clarify the nature of many essential factors in the control of SSI. We sought to examine the link between multiple risk factors, including environmental factors, and SSI for prevention management.

METHODS

We conducted a longitudinal prospective study to identify SSIs in all patients who underwent interventions in 2014 in 8 selected hospitals on the Mediterranean coast of Spain. Risk factors related to the operating theatre included level of fungi and bacterial contamination, temperature and humidity, air renewal and differential air pressure. Patient-related variables included age, sex, comorbidity, nutrition level and transfusion. Other factors were antibiotic prophylaxis, electric versus manual shaving, American Society of Anaesthesiologists physical status classification, type of intervention, duration of the intervention and preoperative stay.

RESULTS

Superficial SSI was most often associated with environmental factors, such as environmental contamination by fungi (from 2 colony-forming units) and bacteria as well as surface contamination. When there was no contamination in the operating room, no SSI was detected. Factors that determined deep and organ/space SSI were more often associated with patient characteristics (age, sex, transfusion, nasogastric feeding and nutrition, as measured by the level of albumin in the blood), type of intervention and preoperative stay. Antibiotic prophylaxis and shaving with electric razor were protective factors for both types of infection, whereas the duration of the intervention and the classification of the intervention as "dirty" were shared risk factors.

CONCLUSION

Our results suggest the importance of environmental and surface contamination control to prevent SSI.

The Seasonal Variability in Surgical Site Infections and the Association With Warmer Weather: A Population-Based Investigation

OBJECTIVE To determine whether the seasonality of surgical site infections (SSIs) can be explained by changes in temperature. DESIGN Retrospective cohort analysis. SETTING The National Inpatient Sample database. PATIENTS All hospital discharges with a primary diagnosis of SSI from 1998 to 2011 were considered cases. Discharges with a primary or secondary diagnoses of specific surgeries commonly associated with SSIs from the previous and current month served as our "at risk" cohort. METHODS We modeled the national monthly count of SSI cases both nationally and stratified by region, sex, age, and type of institution. We used data from the National Climatic Data Center to estimate the monthly average temperatures for all hospital locations. We modeled the odds of having a primary diagnosis of SSI as a function of demographics, payer, location, patient severity, admission month, year, and the average temperature in the month of admission. RESULTS SSI incidence is highly seasonal, with the highest SSI incidence in August and the lowest in January. During the study period, there were 26.5% more cases in August than in January (95% CI, 23.3-29.7). Controlling for demographic and hospital-level characteristics, the odds of a primary SSI admission increased by roughly 2.1% per 2.8°C (5°F) increase in the average monthly temperature. Specifically, the highest temperature group, >32.2°C (>90°F), was associated with an increase in the odds of an SSI admission of 28.9% (95% CI, 20.2-38.3) compared to temperatures <4.4°C (<40°F). CONCLUSIONS At population level, SSI risk is highly seasonal and is associated with warmer weather. Infect Control Hosp Epidemiol 2017;38:809-816.

Do prophylactic antibiotics in gynecologic surgery prevent postoperative inflammatory complications? A systematic review

PURPOSE

The aim of this study was to systematically review the literature on antibiotic prophylaxis in gynaecologic surgeries to prevent inflammatory complications after gynaecological operations. The study was carried out as a systematic review.

METHODS

Only randomised controlled trials of women undergoing gynaecological surgery were included. The Medline and the Cochrane library databases were searched from 1966 to 2016. The trials must have investigated an antibiotic intervention to prevent an inflammatory complication after gynaecological surgery. Trials were excluded if they were not randomised, uncontrolled or included obstetrical surgery.

RESULTS

Prophylactic antibiotics prevent inflammatory complications after gynaecological surgery. Prophylactic antibiotics are more effective in surgery requiring access to the peritoneal cavity or the vagina. Cefotetan appears to be more capable in preventing the overall inflammatory complication rate than cefoxitin or cefazolin. No benefit has been shown for the combination of antibiotics as prophylaxis. No difference has been shown between the long-term and short-term use of antibiotics. There is no need for the primary use of an anaerobic antibacterial agent.

CONCLUSION

Antibiotics help to prevent postoperative inflammatory complications after major gynecologic surgeries.

The Effect of Antibiotic-Coated Sutures on the Incidence of Surgical Site Infections in Abdominal Closures: a Meta-Analysis

OBJECTIVE

This meta-analysis aims to determine if antibiotic-impregnated sutures for abdominal fascial closure prevent postoperative surgical site infections (SSIs), hernias, and/or dehiscence.

METHODS

MEDLINE and EMBASE databases (1946-2016) were searched. Randomized controlled trials comparing antibiotic-impregnated sutures to standard sutures for abdominal closure were eligible. Risk of bias was evaluated using the Cochrane Handbooks definitions.

RESULTS

Four-hundred fifty articles were reviewed; five eligible studies (N = 3117) were identified. All studies routinely used prophylactic antibiotics. Overall risk of SSI in the antibiotic-impregnated suture group was 10.4 vs. 13.0% in the control group. Pooled data showed no difference in SSI between suture types (odds ratio 0.79, 95% CI 0.57-1.09, P = 0.15, I ² = 44%). There was no evidence of subgroup effect by suture material (polydioxanone vs. polyglactin 910; P = 0.19) or by comparing colorectal surgery studies to others (P = 0.67). There was a high risk of bias in two studies, one for high loss to follow-up and one for not using an intent-to-treat analysis.

CONCLUSION

Our meta-analysis is the most comprehensive review on the utility of antibiotic-impregnated sutures in abdominal surgery to prevent SSI. We found no evidence to support routine use of these sutures.

Vaccine development to prevent Staphylococcus aureus surgical-site infections

BACKGROUND

Staphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.

METHODS

A review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.

RESULTS

A prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.

CONCLUSION

There is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.

Economic case for intraoperative interventions to prevent surgical-site infection

BACKGROUND

Surgical-site infection (SSI) occurs in 1-10 per cent of all patients undergoing surgery; rates can be higher depending on the type of surgery. The aim of this review was to establish whether (or not) surgical hand asepsis, intraoperative skin antisepsis and selected surgical dressings are cost-effective in SSI prevention, and to examine the quality of reporting.

METHODS

The authors searched MEDLINE via Ovid, CINAHL via EBSCO, Cochrane Central and Scopus databases systematically from 1990 to 2016. Included were RCTs and quasi-experimental studies published in English, evaluating the economic impact of interventions to prevent SSI relative to surgical hand and skin antisepsis, and wound dressings. Characteristics and results of included studies were extracted using a standard data collection tool. Study and reporting quality were assessed using SIGN and CHEERS checklists.

RESULTS

Across the three areas of SSI prevention, the combined searches identified 1214 articles. Of these, five health economic studies evaluating the cost-effectiveness of selected surgical dressings were eligible. Study authors concluded that the interventions being assessed were cost-effective, or were potentially cost-saving. Still, there is high uncertainty around the decision to adopt these dressings/devices in practice. The studies' reporting quality was reasonable; three reported at least 15 of the 24 CHEERS items appropriately. Assessment of methodological quality found that two studies were considered to be of high quality.

CONCLUSION

With few economic studies undertaken in this area, the cost-effectiveness of these strategies is unclear. Incorporating economic evaluations alongside RCTs will help towards evidence-informed decisions.

Prevention of postsurgical wound dehiscence after abdominal surgery with NPWT: a multicentre randomised controlled trial protocol

OBJECTIVE

The effectiveness of negative pressure wound therapy (NPWT) in the prevention of postoperative surgical wound dehiscence (SWD) is the subject of much debate and remains to be determined. This study will identify individuals at risk of postoperative SWD and trial the use of NPWT as a prophylactic measure against the occurrence of SWD, compared with a non-NPWT standard surgical dressing (SSD).

METHOD

A prospective multicentre randomised controlled trial comparing NPWT dressing against standard surgical dressings (SSD) will be conducted. An intention-to-treat (ITT) approach will be used for the trial.

AIMS

The primary outcome is the prevention of postoperative SWD up to and including day 30 postoperative. Secondary outcomes are: prevention of surgical site infection (SSI) and economic analysis of treatment groups.

CONCLUSION

This study will determine the effectiveness of NPWT in the prevention of postoperative abdominal SWD in a predefined level of risk population. This level 1 study will provide further data for abdominal SWD risk classification, which is anticipated to inform preventive postoperative management. The study design uses a prospective real-world scenario in order to identify clinically significant differences between the intervention and control groups.

TRIAL REGISTRATION

This trial was prospectively registered on 10 December 2012 with Australian and New Zealand Clinical Trials Network (ANZCTR): 12612001275853.

Skin antisepsis with chlorhexidine versus iodine for the prevention of surgical site infection: A systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is one of the most frequent health care-associated infections. One of the practices to reduce their incidence is preoperative skin antisepsis. Two of the most commonly active components used are chlorhexidine gluconate and povidone iodine. Of 3 reviews conducted between 2010 and 2012 comparing antiseptics, 2 were in favor of chlorhexidine; however, the latest was unable to draw conclusions.

PURPOSE

To verify whether recent evidence supports the hypothesis that chlorhexidine in preoperative antisepsis is more efficient than other antiseptics in reducing SSI rates.

PROCEDURES

We conducted a systematic review from 2000-2014 in all languages. The primary end point was SSI incidence and secondary skin bacterial colonization.

RESULTS

Nineteen studies were included. Meta-analysis were conducted for comparable studies for both outcomes. The results of the meta-analysis, including all of the studies in which chlorhexidine was compared with iodophor, were in favor of chlorhexidine for both SSI incidence (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.52-0.92) and bacterial skin colonization (RR, 0.45; 95% CI, 0.36-0.55).

CONCLUSIONS

There is moderate-quality evidence supporting the use of chlorhexidine for preoperative skin antisepsis and high-quality evidence that the use of chlorhexidine is associated with fewer positive skin cultures. Further rigorous trials will be welcomed to attain stronger evidence as to the best antiseptic to be used before surgery.

Goal-directed fluid therapy for reducing risk of surgical site infections following abdominal surgery - A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Surgical site infections (SSIs) become a key indicator of quality of care. This meta-analysis aimed to determine the effect of goal-directed fluid therapy (GDFT) on the risk of SSIs after abdominal surgery.

METHODS

MEDLINE, Embase, CINAHL, Scopus, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews were searched for randomized controlled trials (RCTs), from inception to May 2016 that compared the incidence of SSIs in abdominal surgical patients with or without GDFT treatment. . Data were pooled and risk ratio (RR) as well as weighted mean differences (WMD) with their 95% confidence intervals (CI) was calculated using either fixed or random effects models, depending on heterogeneity (I²).

RESULTS

A total of 29 eligible RCTs with 5317 patients were included in this analysis. GDFT significantly reduced the incidence of SSIs after abdominal surgery. The pooled RR was 0.74 (95% CI: 0.63 to 0.86) with low heterogeneity (I² = 4%). Length of hospital stay was significantly reduced in the GDFT group (WMD: -1.16 days, 95% CI: -1.92 to -0.40, p = 0.003; I² = 81%).

CONCLUSION

This systematic review suggests that perioperative GDFT is associated with a reduction in the incidence of SSIs after abdominal surgery.

Surgical wound dehiscence in an Australian community nursing service: time and cost to healing

OBJECTIVE

Surgical wound dehiscence (SWD) increases the length of hospital stay and impacts on patient wellbeing and health-care costs. Globally, the health-care costs associated with SWD are poorly reported and those reported are frequently associated with surgical site infection (SSI), rather than dehiscence of non-microbial cause. This retrospective study describes and reports on the costs and time to healing associated with a number of surgical patients who were referred to a community nursing service for treatment of an SWD following discharge from a metropolitan hospital, in Perth, Western Australia.

METHOD

Descriptive statistical analysis was carried out to describe the patient, wound and treatment characteristics. A costing analysis was conducted to investigate the cost of healing these wounds.

RESULTS

Among the 70 patients referred with a SWD, 55% were treated for an infected wound dehiscence which was a significant factor (p=0.001). Overall, the cost of treating the 70 patients with a SWD in a community nursing service was in excess of $56,000 Australian dollars (AUD) (£28,705) and did not include organisational overheads or travel costs for nurse visits. The management of infection contributed to 67% of the overall cost.

CONCLUSION

SWD remains an unquantified aspect of wound care from a prevalence and fiscal point of view. Further work needs to be done in the identification of SWD and which patients may be 'at risk'.

DECLARATION OF INTEREST

The authors declare they have no competing interests.

Outcome of Noncardiac Surgical Patients Admitted to a Multidisciplinary Intensive Care Unit

Context:

Surgical procedures carry significant morbidity and mortality depending on the type of surgery and patients. There is a dearth of evidence from India on the outcome of surgical patients admitted to an Intensive Care Unit (ICU).

Aims:

We aimed to describe the incidence and risk factors of postoperative complications and mortality in noncardiac surgical patients admitted to the ICU.

Settings and Design:

This was a prospective observational study on all perioperative patients admitted to a multidisciplinary ICU for 18 months.

Subjects and Methods:

Data on demography, admission Acute Physiology and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA) scores, perioperative course, type and duration of surgery, reason for ICU admission, ICU interventions, and perioperative complications were recorded. The primary outcomes analyzed were perioperative complications and mortality.

Results:

The study included 762 patients with a mean age of (mean ± standard deviation [SD]) 50.5 ± 18 years and a male (58.4%) preponderance. The mean (±SD) admission APACHE-II and SOFA scores were 15 (±5.0) and 4.26 (±2.6), respectively. The most common reason for ICU admission was elective mechanical ventilation 50%, followed by prolonged surgery 26.2% and hemodynamic instability 21.2%. Most (51.1%) patients belonged to American Society of Anaesthesiologists physical Status III or IV and Lee's surgical risk Category I and II (66.8%). The most common surgical procedures performed were gastro-intestinal (28.5%) followed by interventional Neuro-radiology (14.0%) and orthopedic (13.9%). Overall perioperative complications were observed in 51.4% (n = 392). Common complications observed were hemodynamic instability 24%, hypothermia 17.2%, sepsis 17.3%, poor glycemic control 11.2%, perioperative myocardial infarction 7.1%, cardiac arrest 0.13%, and acute kidney injury (AKI) 10.1%. The overall hospital mortality was 7.9%. Multivariate logistic regression analysis showed that admission APACHE-II score, sepsis, AKI, and ICU length of stay were independent predictors for mortality.

Conclusions:

High risk perioperative patients after noncardiac surgery have significant mortality and morbidity.

Bluebelle study (phase A): a mixed-methods feasibility study to inform an RCT of surgical wound dressing strategies

OBJECTIVES

Dressing primary surgical wounds is common, but the implications for surgical site infection (SSI) remain unknown. The Bluebelle study aimed to determine the feasibility of a randomised controlled trial (RCT) comparing 'simple', 'complex' or 'no' dressings on abdominal wounds, as prespecified in a funder's research brief. Bluebelle includes exploratory work (phase A) to inform a pilot version of the proposed RCT (phase B). Phase A aimed to investigate current dressing practices and perspectives on the proposed RCT, with a view to refining the forthcoming pilot.

DESIGN

Mixed methods, including semi-structured interviews and document analysis.

SETTING

6 UK hospitals.

PARTICIPANTS

51 patients and 92 clinical professionals from abdominal surgical specialities.

RESULTS

Professionals had variable interpretations of what constitutes a 'dressing', particularly with respect to 'glue'-a product listed under 'wound-closure products' in the British National Formulary, which some surgeons reportedly applied as a 'wound covering'. Areas of ambiguity arising from interviews informed development of pragmatic definitions, including specification of conditions under which glue constituted a 'dressing'. Professionals reported that 'simple' dressings were routinely used in practice, whereas 'complex' dressings were not. This raised questions about the relevance of comparison groups, prompting the design of a survey to determine the types/frequency of dressing use in abdominal surgery (reported elsewhere). This confirmed that complex dressings were rarely used, while 'glue as a dressing' was used relatively frequently. 'Complex dressings' were therefore substituted for 'glue as a dressing' (following an updated Cochrane review, which found insufficient evidence to determine the effectiveness of 'glue as a dressing'). Patients and professionals acknowledged uncertainty around dressing use and SSI prevention, but felt dressings may serve practical and/or psychological benefits. This steered development of additional outcome measures for the pilot.

CONCLUSIONS

Pre-trial qualitative research can highlight areas of ambiguity and inform new lines of enquiry in relation to prespecified research briefs, enabling adjustments to RCT design that enhance relevance to practice.

Incidence of surgical site infection in postoperative patients at a tertiary care centre in India

OBJECTIVE

A prospective observational was carried out to calculate the incidence of surgical site infections (SSI) along with the main risk factors and causative organisms in postoperative patients at a tertiary care setting in Mumbai.

METHOD

A total number of 1196 patients between June 2011 to March 2013 admitted to the general surgical ward or surgical ICU of our hospital were included in the study. Post laproscopy patients and organ space SSIs were excluded. Patient data were collected using a preformed pro forma and a wound Southampton score tabulated and checked repeatedly until suture removal of patient. Regular follow-up was maintained until at least 30 days postoperatively.

RESULTS

The study showed a SSI rate of 11%. Risk factors associated with a higher incidence of SSI were found to be age (>55 years), diabetes mellitus (especially uncontrolled sugar in the perioperative period), immunocompromised patients (mainly HIV and immunosuppressive therapy patients), surgeon skill (higher in senior professors compared with junior residents), nature of the cases, (emergency surgeries), placement of drains, wound class (highest in dirty wounds), type of closure (multilayer closure), prolonged duration of hospital stay, longer duration of surgery (>2 hours), type of surgery (highest in cholecystectomy). The highest rates of causative organisms for SSIs found were Staphylococcus aureus, Escherichia coli and Klebsiella ssp.

CONCLUSION

Prevention of SSIs requires a multipronged approach with particular emphasis on optimising preoperative issues, adhering religiously to strict protocols during the intraoperative period and addressing and optimising metabolic and nutritional status in postoperative period.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Focus on the prophylaxis, epidemiology and therapy of methicillin-resistant Staphylococcus aureus surgical site infections and a position paper on associated risk factors: the perspective of an Italian group of surgeons

BACKGROUND

The aim of this research was to study the epidemiology, microbiology, prophylaxis, and antibiotic therapy of surgical site infections (SSIs), especially those caused by methicillin-resistant Staphylococcus aureus (MRSA), and identify the risk factors for these infections. In Italy SSIs occur in about 5 % of all surgical procedures. They are predominantly caused by staphylococci, and 30 % of them are diagnosed after discharge. In every surgical specialty there are specific procedures more associated with SSIs.

METHODS

The authors conducted a systematic review of the literature on SSIs, especially MRSA infections, and used the Delphi method to identify risk factors for these resistant infections.

RESULTS

Risk factors associated with MRSA SSIs identified by the Delphi method were: patients from long-term care facilities, recent hospitalization (within the preceding 30 days), Charlson score > 5 points, chronic obstructive pulmonary disease and thoracic surgery, antibiotic therapy with beta-lactams (especially cephalosporins and carbapenem) and/or quinolones in the preceding 30 days, age 75 years or older, current duration of hospitalization >16 days, and surgery with prothesis implantation. Protective factors were adequate antibiotic prophylaxis, laparoscopic surgery and the presence of an active, in-hospital surveillance program for the control of infections. MRSA therapy, especially with agents that enable the patient's rapid discharge from hospital is described.

CONCLUSION

The prevention, identification and treatment of SSIs, especially those caused by MRSA, should be implemented in surgical units in order to improve clinical and economic outcomes.

Efficacy of triclosan-coated sutures for reducing risk of surgical site infection in adults: a meta-analysis of randomized clinical trials

BACKGROUND

Surgical site infection (SSI) is the third most frequent type of nosocomial infections. Triclosan-coated sutures are often used to reduce the risk of SSI, but studies examining this have given conflicting results. Therefore, this meta-analysis was performed to assess the efficacy of triclosan-coated sutures for reducing risk of SSI in adults.

METHODS

PubMed, EMBASE, Google Scholar, and ClinicalTrials.gov were searched to identify randomized clinical trials evaluating triclosan-coated sutures for preventing SSI on patients 18 y or older.

RESULTS

Thirteen randomized clinical trials involving 5256 participants were included. Triclosan-coated sutures were associated with lower risk of SSI than uncoated sutures across all surgeries (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.65-0.88, P < 0.001). Similar proportions of patients experienced wound dehiscence with either type of suture (RR 0.97, 95% CI 0.49-1.89, P = 0.92). Subgroup analysis showed lower risk of SSI with triclosan-coated sutures in abdominal surgeries (RR 0.70, 95% CI 0.50-0.99, P = 0.04) and group with prophylactic antibiotic (RR 0.79, 95% CI 0.63-0.99, P = 0.04). However, such risk reduction was not observed in cardiac surgeries, breast surgeries, or group without prophylactic antibiotic.

CONCLUSIONS

Triclosan-coated sutures can decrease the incidence of SSI in abdominal surgeries and might not interfere with wound healing process. Nevertheless, further studies are needed to examine whether triclosan-coated sutures are effective at preventing SSI in non-abdominal surgeries and to further study the interaction of antibiotic prophylaxis with triclosan-coated sutures.

Influence of Shorter Duration of Prophylactic Antibiotic Use on the Incidence of Surgical Site Infection Following Colorectal Cancer Surgery

Purpose

This study aimed to identify the risk factors for surgical site infections (SSIs) in patients undergoing colorectal cancer surgery and to determine whether significantly different SSI rates existed between the short prophylactic antibiotic use group (within 24 hours) and the long prophylactic antibiotic use group (beyond 24 hours).

Methods

The medical records of 327 patients who underwent colorectal resection due to colorectal cancer from January 2010 to May 2014 at a single center were retrospectively reviewed, and their characteristics as well as the surgical factors known to be risk factors for SSIs, were identified.

Results

Among the 327 patients, 45 patients (13.8%) developed SSIs. The patients were divided into two groups according to the duration of antibiotic use: group S (within 24 hours) and group L (beyond 24 hours). Of the 327 patients, 114 (34.9%) were in group S, and 213 (65.1%) were in group L. Twelve patients (10.5%) in group S developed SSIs while 33 patients (15.5%) in group L developed SSIs (P = 0.242). History of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were independent risk factors for SSIs.

Conclusion

This study shows that discontinuation of prophylactic antibiotics within 24 hours after colorectal surgery has no significant influence on the incidence of SSIs. This study also showed that history of diabetes mellitus and lung disease, long operation time, and perioperative transfusion were associated with increased SSI rates.

Post-surgical infections and perioperative antibiotics usage in pediatric genitourinary procedures

BACKGROUND

Post-surgical infections (PSIs) are a source of preventable perioperative morbidity. No guidelines exist for the use of perioperative antibiotics in pediatric urologic procedures.

OBJECTIVE

This study reports the rate of PSIs in non-endoscopic pediatric genitourinary procedures at our institution. Secondary aims evaluate the association of PSI with other perioperative variables, including wound class (WC) and perioperative antibiotic administration.

STUDY DESIGN

Data from consecutive non-endoscopic pediatric urologic procedures performed between August 2011 and April 2014 were examined retrospectively. The primary outcome was the rate of PSIs. PSIs were classified as superficial skin (SS) and deep/organ site (D/OS) according to Centers for Disease Control and Prevention guidelines, and urinary tract infection (UTI). PSIs were further stratified by WC1 and WC2 and perioperative antibiotic usage. A relative risk and chi-square analysis compared PSI rates between WC1 and WC2 procedures.

RESULTS

A total of 1185 unique patients with 1384 surgical sites were reviewed; 1192 surgical sites had follow-up for inclusion into the study. Ten total PSIs were identified, for an overall infection rate of 0.83%. Of these, six were SS, one was D/OS, and three were UTIs. The PSI rate for WC1 (885 sites) and WC2 (307 sites) procedures was 0.34% and 2.28%, respectively, p < 0.01. Relative risk of infection in WC2 procedures was 6.7 (CI 1.75-25.85, p = 0.0055). The rate of infections in WC1 procedures was similar between those receiving and not receiving perioperative antibiotics (0.35% vs. 0.33%). All WC2 procedures received antibiotics.

DISCUSSION

Post-surgical infections are associated with significant perioperative morbidity. In some studies, PSI can double hospital costs, and contribute to hospital length of stay, admission to intensive care units, and impact patient mortality. Our study demonstrates that the rate of PSI in WC1 operations is low, irrespective of whether the patient received perioperative antibiotics (0.35%) or no antibiotics (0.33%). WC2 operations were the larger source of morbidity with an infection rate of 2.28% and a 6.7 fold higher increase in relative risk.

CONCLUSIONS

WC1 procedures have a rate of infection around 0.3%, which is independent of the use of perioperative antibiotics. WC2 procedures have a higher rate of infection, with a relative risk of 6.7 for the development of PSI, and should be the target of guidelines for periprocedural prophylaxis.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS AND DISCUSSION

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

CONCLUSION

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

Diabetes mellitus is associated with increased risk of surgical site infections: A meta-analysis of prospective cohort studies

BACKGROUND AND OBJECTIVE

Observational studies have suggested an association between diabetes mellitus and the risk of surgical site infections (SSIs), but the results remain inconclusive. We conducted a meta-analysis of prospective cohort studies to elucidate the relationship between diabetes mellitus and SSIs.

METHODS

We searched PubMed, Embase, and Web of Science databases and reviewed the reference lists of the retrieved articles to identify relevant studies. Associations were tested in subgroups representing different patient characteristics and study quality criteria. The random-effect model was used to calculate the overall relative risk (RR).

RESULTS

Fourteen prospective cohort studies (N = 91,094 participants) were included in this meta-analysis, and the pooled crude RR was 2.02 (95% confidence interval, 1.68-2.43) with significant between-study heterogeneity observed (I(2) = 56.50%). Significant association was also detected after we derived adjusted RRs for studies not reporting the adjusted RRs and calculated the combined adjusted RR of the 14 studies (RR, 1.69; 95% confidence interval, 1.33-2.13). Results were consistent and statistically significant in all subgroups. Stratified analyses found the number of confounders adjusted for, sample size, and method of diabetes case ascertainment might be the potential sources of heterogeneity. Sensitivity analysis further demonstrated the robustness of the result.

CONCLUSIONS

This meta-analysis suggests diabetes mellitus is significantly associated with increased risk of SSIs. Future studies are encouraged to reveal the mechanisms underlying this association.

Antibiotic Susceptibility Pattern of Aerobic and Anaerobic Bacteria Isolated From Surgical Site Infection of Hospitalized Patients

BACKGROUND

Surgical Site Infections (SSIs) are infections of incision or deep tissue at operation sites. These infections prolong hospitalization, delay wound healing, and increase the overall cost and morbidity.

OBJECTIVES

This study aimed to investigate anaerobic and aerobic bacteria prevalence in surgical site infections and determinate antibiotic susceptibility pattern in these isolates.

MATERIALS AND METHODS

One hundred SSIs specimens were obtained by needle aspiration from purulent material in depth of infected site. These specimens were cultured and incubated in both aerobic and anaerobic condition. For detection of antibiotic susceptibility pattern in aerobic and anaerobic bacteria, we used disk diffusion, agar dilution, and E-test methods.

RESULTS

A total of 194 bacterial strains were isolated from 100 samples of surgical sites. Predominant aerobic and facultative anaerobic bacteria isolated from these specimens were the members of Enterobacteriaceae family (66, 34.03%) followed by Pseudomonas aeruginosa (26, 13.4%), Staphylococcus aureus (24, 12.37%), Acinetobacter spp. (18, 9.28%), Enterococcus spp. (16, 8.24%), coagulase negative Staphylococcus spp. (14, 7.22%) and nonhemolytic streptococci (2, 1.03%). Bacteroides fragilis (26, 13.4%), and Clostridium perfringens (2, 1.03%) were isolated as anaerobic bacteria. The most resistant bacteria among anaerobic isolates were B. fragilis. All Gram-positive isolates were susceptible to vancomycin and linezolid while most of Enterobacteriaceae showed sensitivity to imipenem.

CONCLUSIONS

Most SSIs specimens were polymicrobial and predominant anaerobic isolate was B. fragilis. Isolated aerobic and anaerobic strains showed high level of resistance to antibiotics.

Association between Triclosan-Coated Sutures for Abdominal Wall Closure and Incisional Surgical Site Infection after Open Surgery in Patients Presenting with Fecal Peritonitis: A Randomized Clinical Trial

BACKGROUND

A factor that may influence the incidence of surgical site infections (SSIs) is the suture used for closure of the abdominal wall because bacteria may adhere to the suture material. Sutures can be coated with antibacterial substances that may reduce the bacterial load in the incision.

OBJECTIVE

The aim of this study was to evaluate the effect of triclosan-coated sutures used in abdominal wall closure in patients with fecal peritonitis.

METHODS

A randomized study was performed. Inclusion criteria were intra-operative diagnosis of fecal peritonitis secondary to acute diverticulitis perforation, neoplastic tumor perforation, or colorectal anastomotic leak of previous elective colorectal resection. The patients were randomly assigned to either abdominal wall closure with triclosan-coated sutures (group 1) or sutures without triclosan (group 2).

RESULTS

Fifty patients were included in group 1 and 51 in group 2. The incisional SSI rate was 10% in group 1 and 35.3% in group 2 (p=0.004; odds ratio [OR]=0.204; 95% confidence interval [CI] 0.069-0.605). A significant reduction in SSIs caused by Escherichia coli and Enterococcus faecalis was observed in group 2.

CONCLUSION

The use of triclosan-coated sutures in fecal peritonitis surgery reduces the incidence of incisional SSI.

Nosocomial Infections and Epidemiology of Antibiotic Resistance in Teaching Hospitals in South East of Iran

Aim:

Antibiotic resistance as one of the most serious health threats worldwide leading to a high rate of morbidity and mortality. The aim of present study was to examine the prevalence of nosocomial infections (NIs) and pattern of antibiotic resistance in teaching hospitals in Iran

Methods:

This cross-sectional descriptive study was conducted in a period of one year in three teaching hospitals and all patients with suspected NIs symptoms were chooses. Among these patients who showed antibiotic resistance were included in the study. The samples for clinical test in laboratory were obtained with using standard methods and aseptic technique by trained personnel. Antibiotic susceptibility testing was performed by Kirby-Bauer’s disk diffusion method on Muller-Hinton agar (Hi Media, Mumbai, India) in accordance with the standards of the Clinical Laboratory Standards Institute.

Results:

During one year study, 561 patients with nosocomial infections were recognized and among them 340 patients (60.6%) showed some level of antibiotic resistance. The most common cause of NIs in present study was Acinetobacter and the most type of infection was respiratory system infections (52.7%). The highest resistance rate was against Ciprofloxacin (61.8%) followed by Imipenem (50.3%).

Conclusion:

Rate of NIs and antibiotics resistance is high in Iranian hospital. So Iranian health ministry should provide guideline and suitable programs for prevention of NIs and antibiotic therapy in hospitals.

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patient's recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English-only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at-risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.

Bacterial contamination of suction catheter tips during aortic valve replacement surgery: a prospective observational cohort study

Background

Bacterial mediastinitis is a severe complication after open heart surgery. The infection causes prolonged hospitalization and an increased mortality risk. Observations from orthopaedic surgery showed that the suction catheter used during surgery is commonly contaminated with bacteria. The aim of this study was to describe the prevalence of suction catheter contamination in cardiac surgery and to study if suction time influences the contamination risk.

Methods

Fifty suction catheter tips were collected during 25 aortic valve replacement operations. The suction tip was exchanged once during the operation (after aortotomy closure). The tips were subjected to bacterial contamination analysis.

Results

In 20 of the 25 investigated cases (80%), bacterial contamination was detected on one or both tips. The tip used during the beginning of the operation showed bacterial contamination in 13/25 cases (52%) and the second tip in 12/25 (48%). In 5/25 cases (20%) both tips were contaminated. There was no association between bacterial contamination and suction time. Coagulase-negative staphylococcus was the most commonly detected microorganism.

Conclusions

The suction device should be considered as a potential source of bacterial contamination in cardiac surgery. The results suggest that the suction catheter should be replaced before key moments like valve implantation and sternal closure.

Multi-Center Randomized Controlled Trial on the Effect of Triclosan-Coated Sutures on Surgical Site Infection after Colorectal Surgery

BACKGROUND

Surgical site infection (SSI) remains the most frequent complication after colorectal resection. The role of sutures coated with antimicrobial agents such as triclosan in reducing SSI is controversial.

METHODS

This was a multi-center randomized controlled trial with patients and outcome assessors blinded to treatment. The study was performed in four university referral hospitals. Patient candidates for elective colorectal resection were assigned randomly to abdominal incision closure with polyglactin 910 triclosan-coated sutures (triclosan group) or with polyglactin 910 without triclosan (control group). The primary outcome was the rate of SSI within 30 d after hospital discharge. The secondary outcomes were the overall rate of incision complications and length of hospital stay (LOS).

RESULTS

Two hundred eighty-one patients (triclosan group: 140; control group: 141) were analyzed after randomization. The rate of SSI was 12.9% (18/140) in the triclosan group versus 10.6% (15/141) in the control group (odds ratio: 1.24; 95% confidence interval: 0.60-2.57; p=0.564). Secondary outcome analysis showed an overall incision complication rate of 38.3% in the control group versus 45.7% in the triclosan group (odds ratio: 1.36; 95% confidence interval: 0.84-2.18; p=0.208). Median LOS was 11 d in both groups (p=0.55).

CONCLUSIONS

Surgical sutures coated with triclosan do not appear to be effective in reducing the rate of SSI.

Using double gloves in surgical procedures: a literature review

This article will present a critical review of the literature relating to the use of double gloves during surgery in order to identify best practice by using available resources and to improve health care. During surgery there is an increased risk of exposure to blood and, as a result, pathogens can be transferred through contact between the patient and surgical team. Health professionals working in the operating room are prone to frequent exposure to patients' blood and body fluids (Davanzo et al, 2008 ; Au et al, 2008 ; Myers et al, 2008). Several researchers have also demonstrated that the highest incidence of blood and body fluid exposure is in the operating room during surgical procedures (Ganczak et al, 2006 ; Myers et al, 2008 ; Naghavi and Sanati, 2009).

A preliminary study for the development of indices and the current state of surgical site infections (SSIs) in Korea: the Korean Surgical Site Infection Surveillance (KOSSIS) program

Purpose

We aimed to develop an effective system for surgical site infection (SSI) surveillance and examine the current domestic state of SSIs for common abdominal surgeries in Korea.

Methods

The Korean Surgical Site Infection Surveillance (KOSSIS) program was developed as an SSI surveillance system. A prospective multicenter study in nine university-affiliated or general hospitals was conducted for patients who underwent gastrectomy, cholecystectomy, appendectomy, colectomy, or proctectomy between August 16 and September 30 in 2012. Patients were monitored for up to 30 days by combining direct observation and a postdischarge surgeon survey. Data on SSIs were prospectively collected with KOSSIS secretarial support according to a common protocol. Operation-specific SSI rates were stratified according to risk factors and compared with data from the Korean Nosocomial Infections Surveillance System (KONIS) and National Healthcare Safety Network. A focus group interview was conducted with participating hospitals for feedback.

Results

A total of 1,088 operations were monitored: 207 gastrectomies, 318 cholecystectomies, 270 appendectomies, 197 colectomies, and 96 proctectomies. Operation-specific SSI rates determined by the KOSSIS program were substantially higher than those found in KONIS (7.73% [95% confidence interval, 4.5%-12.3%] vs. 3.4% for gastrectomies, 10.15% [95% confidence interval, 6.1%-15.2%] vs. 4.0% for colectomy, and 13.5% [95% confidence interval, 7.4%-22.0%] vs. 4.2% for proctectomy).

Conclusion

Despite a short surveillance period and heterogenous group of hospitals, our results suggest that KOSSIS could be a useful program to enhance SSI surveillance in Korea.

Metabolism gene signatures and surgical site infections in abdominal surgery

INTRODUCTION

Surgical site infections (SSI) represent a significant cause of morbidity in abdominal surgery. The objective of this study was to determine the gene expression signature in subcutaneous tissues in relation to SSI.

METHODS

To determine differences in gene expression, microarray analysis were performed from bulk tissue mRNA of subcutaneous tissues prospectively collected in 92 patients during open abdominal surgery. 10 patients (11%) developed incisional (superficial and deep) SSI.

RESULTS

Preoperative risk factors in patients with SSI were not significantly different from those in patients without wound infections. 1025 genes were differentially expressed between the groups, of which the AZGP1 and ALDH1A3 genes were the highest down- and upregulated ones. Hierarchical clustering demonstrated strong similarity within the respective groups (SSI vs. no-SSI) indicating inter-group distinctness. In a functional classification, genes controlling cell metabolism were mostly down-regulated in subcutaneous tissues of patients that subsequently developed SSI.

CONCLUSION

Altered expression of metabolism genes in subcutaneous tissues might constitute a risk factor for postoperative abdominal SSI.

The incidence and distribution of surgical site infection in mainland China: a meta-analysis of 84 prospective observational studies

Surgical site infection (SSI) is one of the most common surgical complications in the world, particularly in developing countries. This study aimed to estimate the incidence and distribution of SSI in mainland China. Eighty-four prospective observational studies (82 surveillance studies, 1 nested case control study, and 1 cohort study) were selected for inclusion in this meta-analysis. The average incidence of SSI in mainland China was 4.5% (95% CI: 3.1–5.8) from 2001 to 2012 and has decreased significantly in recent years. The remote western regions had a higher incidence of 4.6% (95% CI: 4.0–5.3). The most common surgical procedure was abdominal surgery (8.3%, 95% CI: 6.5–10.0). SSI occurred frequently in the elderly (5.1%, 95% CI: 2.2–8.0), patients confined to hospital for over 2 weeks (5.7%, 95% CI: 0.9–10.0), superficial incision wounds (5.6%, 95% CI: 4.4–6.8), dirty wounds (8.7%, 95% CI: 6.9–10.6), operations lasting for over 2 hours (7.3%, 95% CI: 4.9–9.7), general anaesthesia operations (4.7%, 95% CI: 2.7–6.6), emergency surgeries (5.9%, 95% CI: 4.2–7.7), and non-intra-medication operations (7.4%, 95% CI: 1.0–13.7).

Predominance of multi-drug resistant bacterial pathogens causing surgical site infections in Muhimbili National Hospital, Tanzania

Background

Surgical site infections (SSIs) remain a common and widespread problem contributing to a significant morbidity and mortality, attributed partly by the increase in antimicrobial resistance among the etiological agents. This study was done to determine the spectrum of bacterial isolates and their susceptibility patterns causing SSIs at Muhimbili National Hospital, Tanzania.

Methods

This descriptive cross sectional study was conducted between September, 2011 and February, 2012. Pus swabs or pus were cultured on blood agar (Oxoid, UK) and MacConkey agar (Oxoid, UK) and incubated aerobically at 37°C for 18–24 hours. Bacterial identification was done using API 20E and VITEK and antimicrobial susceptibility was determined by Kirby Bauer disc diffusion.

Results

Of the 100 patients, from whom wound swabs were collected, 90 (90%) had positive aerobic bacterial growth. A total of 147 pathogenic bacteria were isolated, including 114 (77.5%) gram negative and 33(22.5%) gram positive organisms. The most prevalent bacterial species were Pseudomonas aeruginosa (16.3%), followed by Staphylococcus aureus (12.2%) and Klebsiella pneumoniae (10.8%). Of the 18 S. aureus , 8 (44%) were methicillin resistant Staphylococcus aureus (MRSA) and three of them (17%) were carrying both MRSA and induced clindamycin resistance (ICR). Extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae were observed in 23 (79.3%) of the 29 isolates tested. Majority of Escherichia coli 12 (92.3%) and K. pneumoniae 11 (69%) isolates were ESBL producers. About 63% (93/147) were multiple-drug resistance (MDR) isolates, and the overall MDR among Gram positive and Gram negative bacteria was 60.6% (20/33) and 61.4%, (73/114), respectively. The prevalence of MDR for E. coli, A. baumannii and P. stuartii was 100% each. Majority (97%) of the Gram negative bacteria were resistant to more than four categories (classes) of antibiotics.

Conclusion

A high proportion (63%) of the isolates causing SSIs in this tertiary hospital were MDR, of which (90%) were resistant to more than four classes of antibiotics. In the light of these findings, an urgent and significant change in antibiotic prescription policy is required at this National hospital.

Efficacy of the novel topical antimicrobial agent PXL150 in a mouse model of surgical site infections

Antimicrobial peptides have recently emerged as a promising new group to be evaluated in the therapeutic intervention of infectious diseases. This study evaluated the anti-infectious effect of the short, synthetic, broad-spectrum antimicrobial peptide PXL150 in a mouse model of staphylococcal surgical site infections. We found that administration of PXL150, formulated in an aqueous solution or in a hydroxypropyl cellulose gel, significantly reduced the bacterial counts in the wound compared with placebo treatment, warranting further investigations of the potential of this peptide as a novel local treatment of microbial infections.

A prospective randomized controlled trial of subcutaneous passive drainage for the prevention of superficial surgical site infections in open and laparoscopic colorectal surgery

INTRODUCTION

A number of studies have evaluated the effects of subcutaneous drainage during digestive surgery. All of the previous studies assessed the usefulness of active-suctioning drain, including two randomized controlled studies which found no benefit for the placement of active-suctioning drains in digestive surgery. The utility of passive drainage has not been evaluated previously. The purpose of this study was to evaluate the efficacy of subcutaneous passive drainage system for preventing surgical site infections during major colorectal surgery.

PATIENTS AND METHODS

A total of 263 patients who underwent major colorectal surgery were enrolled in this study. Patients were randomly assigned to receive subcutaneous passive drainage or no drainage. The primary outcome measured was the incidence of superficial surgical site infections. The secondary outcomes measured were the development of hematomas, seromas, and wound dehiscence.

RESULTS

Finally, a total of 246 patients (124 underwent passive drainage, and 122 underwent no drainage) were included in the analysis after randomization. There was a significant difference in the incidence of superficial surgical site infections between patients assigned to the passive drainage and no drainage groups (3.2 % vs 9.8 %, respectively, P = 0.041). There were no cases that developed a hematoma, seroma, or wound dehiscence in either group. A subgroup analysis revealed that male gender, age ≥75 years, diabetes mellitus, American Society of Anesthesiologists (ASA) status ≥2, blood loss ≥100 ml, and open access were factors that were associated with a beneficial effect of subcutaneous passive drainage.

CONCLUSIONS

Subcutaneous passive drainage provides benefits over no drainage in patients undergoing major colorectal surgery.

Alcohol drinking does not affect postoperative surgical site infection or anastomotic leakage: a systematic review and meta-analysis

BACKGROUND

Alcohol abuse appears to increase postoperative complications, but clinical trials have reported conflicting results. The objective of this systematic review and meta-analysis is to clarify how alcohol drinking affects postoperative surgical site infection and anastomotic leakage and to determine the impact of perioperative alcohol intervention.

MATERIAL AND METHODS

The databases MEDLINE, EMBASE, and CENTRAL were searched. Observational studies assessing surgical site infection and anastomotic leakage for alcohol drinkers and randomized controlled trials (RCTs) studying perioperative alcohol interventions were included. Meta-analyses were performed with random effects models. Methodological quality was assessed by the Newcastle-Ottawa Scale and Cochrane methodology.

RESULTS

Fifteen observational studies and 2 RCTs were identified. Meta-analyses were performed for alcohol drinkers vs nondrinkers and moderate drinkers (≤ 2 U/day), respectively. No difference between alcohol drinkers and nondrinkers was found. When drinkers and moderate drinkers were compared, a significantly higher incidence of surgical site infection and anastomotic leakage was found in unadjusted studies. In the meta-analysis of studies adjusting for smoking and age, alcohol drinking did not significantly affect surgical site infection and anastomotic leakage. The RCTs did not show any effect of perioperative alcohol abstinence or pharmacological withdrawal treatment on outcome.

CONCLUSIONS

Alcohol drinking is not an independent risk factor for surgical site infection and anastomotic leakage. Interventions which aim to make patients quit alcohol or treat withdrawal symptoms do not seem to affect the surgical outcomes of interest.

Adhesiolysis-related morbidity in abdominal surgery

OBJECTIVE

To determine the incidence of bowel injury in operations requiring adhesiolysis and to assess the impact of adhesiolysis on the incidence of surgical complications, postoperative morbidity, and costs.

BACKGROUND

Morbidity of adhesiolysis during abdominal surgery seems an important health care problem, but the direct impact of adhesiolysis on inadvertent organ damage, morbidity, and costs is unknown.

METHODS

In a prospective cohort study, detailed data on adhesiolysis were gathered by direct observation during elective abdominal surgery. Comparison was made between surgical procedures with and without adhesiolysis on the incidence of inadvertent bowel defects. Secondary outcomes were the effect of adhesiolysis and bowel injury on surgical complications, other morbidity, and costs.

RESULTS

A total of 755 (out of 844) surgeries in 715 patients were included. Adhesiolysis was required in 475 (62.9%) of operations. Median adhesiolysis time was 20 minutes (range: 1-177). Fifty patients (10.5%) undergoing adhesiolysis inadvertently incurred bowel defect, compared with 0 (0%) without adhesiolysis (P < 0.001). In univariate and multivariate analyses, adhesiolysis was associated with an increase of sepsis incidence [odds ratio (OR): 5.12; 95% confidence interval (CI): 1.06-24.71], intra-abdominal complications (OR: 3.46; 95% CI: 1.49-8.05) and wound infection (OR: 2.45; 95% CI: 1.01-5.94), longer hospital stay (2.06 ± 1.06 days), and higher hospital costs [$18,579 (15,204-21,954) vs $14,063 (12,471-15,655)]. Mortality after adhesiolysis complicated by a bowel defect was 4 out of 50 (8%), compared with 7 out of 425 (1.6%) after uncomplicated adhesiolysis (OR: 5.19; 95% CI: 1.47-18.41).

CONCLUSIONS

Adhesiolysis and inadvertent bowel injury have a large negative effect on the convalescence after abdominal surgery. The awareness of adhesion-related morbidity during reoperation and the prevention of postsurgical adhesion deserve priority in research and clinical practice.

Moxifloxacin in complicated skin and skin structure infections (cSSSIs): A prospective, international, non-interventional, observational study

Introduction

ARTOS was an international, prospective, non-interventional, non-controlled observational study designed to determine the effectiveness, safety, and tolerability of moxifloxacin under daily-life conditions in patients with complicated skin and skin structure infections (cSSSIs) treated in Europe, the Middle East, and Asia–Pacific region.

Methods

Eligible patients included males and females who were hospitalized patients or outpatients requiring antibiotic therapy for cSSSIs and for whom the treating physician had elected to begin moxifloxacin therapy in accordance with its approved indications. Patients were assessed before therapy and then at one or two follow-up visits. Effectiveness was assessed with respect to improvement and resolution of signs and symptoms of cSSSIs and safety with respect to the nature and frequency of adverse events and adverse drug reactions.

Results

A total of 6,594 patients were enrolled of whom 5,444 had data available for analysis; 4,692 patients received sequential intravenous/oral (IV/PO) moxifloxacin and 752 exclusively IV therapy. A majority of patients were aged between 40 and 79 years and had one or more comorbid conditions. Post-surgical wound infection, skin abscess, and diabetic foot infection were the cSSSIs most frequently diagnosed and treated with moxifloxacin, with almost 90% of infections rated moderate or severe. Treating physicians chose sequential moxifloxacin 400 mg for most patients, switching from IV to PO after 3–4 days. On average, treatment was maintained for 10 days. Treatment with moxifloxacin was associated with rapid relief in symptoms, with 93.2% of patients experiencing either complete resolution of symptoms or improvement at follow-up. Moxifloxacin was well tolerated with adverse drug reactions occurring in only 2% of patients.

Conclusions

This study, conducted in a ‘real-world’ setting, confirms the effectiveness and safety of moxifloxacin in the treatment of a wide spectrum of cSSSIs seen in routine clinical practice.

Evaluating the clinical and economic burden of healthcare-associated infections during hospitalization for surgery in France

Over 4 million patients suffer nosocomial infections annually in the European Union. This study aimed to estimate the healthcare burden associated with healthcare-associated infections (HAIs) following surgery in France, and explore the potential impact of infection control strategies and interventions on the clinical and economic burden of disease. Data on the frequency of HAIs were gathered from the 2010 Programme de Médicalisation des Systèmes d'Information (PMSI), and cost data were taken from the 2009 Echelle Nationale de Coûts à Méthodologie Commune (ENCC). It was estimated that 3% of surgical procedures performed in 2010 in France resulted in infection, resulting in an annual cost of €57 892 715. Patients experiencing a HAI had a significantly increased mortality risk (4·15-fold) and an increased length of hospital stay (threefold). Scenario analysis in which HAI incidence following surgery was reduced by 8% (based on a study of the effectiveness of triclosan-coated sutures), suggested that, annually, 20 205 hospital days and €4 588 519 could be saved. Analyses of 20% and 30% reductions in incidence (based on an estimate of the number of preventable nosocomial infections) suggested that annual savings of €11 548 057 and €17 334 696, respectively, could be made. New infection control interventions which reduce HAI incidence during hospitalization for surgery have the potential to provide valuable cost savings to healthcare providers.

Safety in the operating theatre--a transition to systems-based care

All surgeons want the best, safest care for their patients, but providing this requires the complex coordination of multiple disciplines to ensure that all elements of care are timely, appropriate, and well organized. Quality-improvement initiatives are beginning to lead to improvements in the quality of care and coordination amongst teams in the operating room. As the population ages and patients present with more complex disease pathology, the demands for efficient systematization will increase. Although evidence suggests that postoperative mortality rates are declining, there is substantial room for improvement. Multiple quality metrics are used as surrogates for safe care, but surgical teams--including surgeons, anaesthetists, and nurses--must think beyond these simple interventions if they are to effectively communicate and coordinate in the face of increasing demands.