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Unterfrauner I, Bragatto-Hess N, Studhalter T, Farshad M, Uçkay I. General skin and nasal decolonization with octenisan® set before and after elective orthopedic surgery in selected patients at elevated risk for revision surgery and surgical site infections-a single-center, unblinded, superiority, randomized controlled trial (BALGDEC trial). Trials 2024; 25:461. [PMID: 38978089 PMCID: PMC11229206 DOI: 10.1186/s13063-024-08173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/05/2023] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND The preoperative body surface and nasal decolonization may reduce the risk of surgical site infections (SSI) but yields conflicting results in the current orthopedic literature. METHODS We perform a single-center, randomized-controlled, superiority trial in favor of the preoperative decolonization using a commercial product (octenidine® set). We will randomize a total number of 1000 adult elective orthopedic patients with a high risk for SSI and/or wound complications (age ≥ 80 years, chronic immune-suppression, American Society of Anesthesiologists score 3-4 points) between a decolonization (octenisan® wash lotion 1 × per day and octenisan® md nasal gel 2-3 × per day; during 5 days) and no decolonization. Decolonized patients will additionally fill a questionnaire regarding the practical difficulties, the completeness, and the adverse events of decolonization. The primary outcomes are SSI and revision surgeries for postoperative wound problems until 6 weeks postoperatively (or 1 year for surgeries with implants or bone). Secondary outcomes are unplanned revision surgeries for non-infectious problems and all adverse events. With 95% event-free surgeries in the decolonization arm versus 90% in the control arm, we formally need 2 × 474 elective orthopedic surgeries included during 2 years. DISCUSSION In selected adult orthopedic patients with a high risk for SSI, the presurgical decolonization may reduce postoperative wound problems, including SSI. TRIAL REGISTRATION ClinicalTrial.gov NCT05647252. Registered on 9 December 2022. PROTOCOL VERSION 2 (5 December 2022).
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Affiliation(s)
- Ines Unterfrauner
- Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Nadja Bragatto-Hess
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Thorsten Studhalter
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Medical Direction, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich, 8008, Switzerland
| | - Ilker Uçkay
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
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Uçkay I, Bomberg H, Risch M, Müller D, Betz M, Farshad M. Broad-spectrum antibiotic prophylaxis in tumor and infected orthopedic surgery-the prospective-randomized, microbiologist-blinded, stratified, superiority trials: BAPTIST Trials. Trials 2024; 25:69. [PMID: 38243311 PMCID: PMC10799415 DOI: 10.1186/s13063-023-07605-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). METHODS We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is "remission" at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries. DISCUSSION In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime. TRIAL REGISTRATION ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022).
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Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Hagen Bomberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Markus Risch
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Daniel Müller
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Haug F, Waibel FWA, Lisy M, Winkler E, Uçkay I, Schöni M. The impact of the length of total and intravenous systemic antibiotic therapy for the remission of diabetic foot infections. Int J Infect Dis 2022; 120:179-186. [PMID: 35358726 DOI: 10.1016/j.ijid.2022.03.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE We investigated the impact of the total length of systemic antibiotic therapy (ABT) and its initial intravenous (IV) part on clinical failure (CF) and microbiological failure (MF) in diabetic foot infections (DFIs). METHODS In this single-center, retrospective, unmatched case-control study, we included DFI episodes treated with a combined surgical-antibiotic approach. RESULTS We included 721 DFI episodes, 537 with osteomyelitis (DFO). CF occurred in 191 (26.5%) and MF in 42 (5.8%) episodes. Multivariate Cox regression analysis showed that a short ABT of 8-21 days (hazard ratio [HR] 0.4; 95% CI 0.2-0.7) was inversely associated with CF. This was also applicable for IV ABT with relatively short durations of 2-7 days (HR 0.5; 95% CI 0.3-0.8) or 8-14 days (HR 0.6; 95% CI 0.4-0.9). We failed to detect a minimal threshold of total or IV ABT predictive for CF or MF. CONCLUSIONS Compared with total ABT of more than 84 days and IV therapy of more than 14 days, shorter total and IV ABT yielded no enhanced risk of CF or MF. Considering the "bias by indication" that is inherent to retrospective DFI studies, the best study design concerning the duration of ABT would be a stratified, prospective randomized trial, which is currently under way in our medical center.
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Affiliation(s)
- Florian Haug
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland.
| | - Felix W A Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Marcus Lisy
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Elin Winkler
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Switzerland; Infectiology, Balgrist University Hospital, University of Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
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Almeida RP, Mokete L, Sikhauli N, Sekeitto AR, Pietrzak J. The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review. EFORT Open Rev 2021; 6:872-880. [PMID: 34760287 PMCID: PMC8559557 DOI: 10.1302/2058-5241.6.200054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive. PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics. Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI. Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described. The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.
Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054
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Affiliation(s)
- Richard Peter Almeida
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Lipalo Mokete
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Nkhodiseni Sikhauli
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Allan Roy Sekeitto
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jurek Pietrzak
- Arthroplasty Unit, Division of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Al-Hilli Z, Wilkerson A. Breast Surgery: Management of Postoperative Complications Following Operations for Breast Cancer. Surg Clin North Am 2021; 101:845-863. [PMID: 34537147 DOI: 10.1016/j.suc.2021.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Breast cancer surgery is associated with low rates of surgical morbidity. Postoperative complications related to breast surgery include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, persistent postsurgical pain, Mondor disease, fat necrosis, reduced tactile sensation after mastectomy, and venous thromboembolism. Postoperative complications related to axillary surgery include seroma, infection, lymphedema, nerve injury, and reduced shoulder/arm mobility. The overall rate of complication related to axilla surgery may be confounded by the type of breast surgery performed. The management of postoperative complications related to oncologic breast and axillary surgery independent of reconstruction is reviewed here.
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Affiliation(s)
- Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA.
| | - Avia Wilkerson
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue /A80, Cleveland, OH 44195, USA
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Kewcharoen J, Kanitsoraphan C, Thangjui S, Leesutipornchai T, Saowapa S, Pokawattana A, Navaravong L. Postimplantation pocket hematoma increases risk of cardiac implantable electronic device infection: A meta-analysis. J Arrhythm 2021; 37:635-644. [PMID: 34141016 PMCID: PMC8207394 DOI: 10.1002/joa3.12516] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/31/2020] [Accepted: 01/21/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Several studies have shown an inconsistent relationship between postimplantation pocket hematoma and cardiac implantable electronic device (CIED) infection. In this study, we performed a systematic review and meta-analysis to explore the effect of postimplantation hematoma and the risk of CIED infection. METHODS We searched the databases of MEDLINE and EMBASE from inception to March 2020. Included studies were cohort studies, case-control studies, cross-sectional studies, and randomized controlled trials that reported incidence of postimplantation pocket hematoma and CIED infection during the follow-up period. CIED infection was defined as either a device-related local or systemic infection. Data from each study were combined using the random effects, generic inverse variance method of Der Simonian and Laird to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Fourteen studies were included in final analysis, involving a total of 28 319 participants. In random-effect model, we found that postimplantation pocket hematoma significantly increases the risk of overall CIED infection (OR = 6.30, 95% CI: 3.87-10.24, I 2 = 49.3%). There was no publication bias observed in the funnel plot as well as no small-study effect observed in Egger's test. CONCLUSIONS Our meta-analysis demonstrated that postimplantation pocket hematoma significantly increases the risk of CIED infection. Precaution should be taken during device implantation to reduce postimplantation hematoma and subsequent CIED infection.
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Affiliation(s)
- Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency ProgramHonoluluHIUSA
| | | | | | | | - Sakditad Saowapa
- Faculty of MedicineRamathibodi HospitalMahidol UniversityBangkokThailand
| | | | - Leenhapong Navaravong
- Division of Cardiovascular MedicineUniversity of Utah School of MedicineSalt Lake CityUTUSA
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Uçkay I, Holy D, Betz M, Sauer R, Huber T, Burkhard J. Osteoarticular infections: a specific program for older patients? Aging Clin Exp Res 2021; 33:703-710. [PMID: 31494913 DOI: 10.1007/s40520-019-01329-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND With the increasing number of elderly patients, arthroplasties, fractures and diabetic foot infections, the worldwide number of osteoarticular infections (OAI) among the elderly is concomitantly expected to rise. AIMS We explore existing scientific knowledge about OAI in the frail elderly population. METHODS We performed a literature search linking OAIs to geriatric patients and comparing elderly patients (> 65 years) with average adults (range 18-65 years). RESULTS In this literature, financial aspects, comparison of diverse therapies on quality of life, reimbursement policies, or specific guidelines or nursing recommendations are missing. Age itself was not an independent factor related to particular pathogens, prevention of OAI, nursing care, and outcomes of OAI. However, geriatric patients were significantly more exposed to adverse events of therapy. They had more co-morbidities and more conservative surgery for OAI. CONCLUSION Available literature regarding OAI management among elderly patients is sparse. In recent evaluations, age itself does not seem an independent factor related to particular epidemiology, pathogens, prevention, nursing care, rehabilitation and therapeutic outcomes of OAI. Future clinical research will concern more conservative surgical indications, but certainly reduce inappropriate antibiotic use.
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Affiliation(s)
- Ilker Uçkay
- Infectiology, Balgrist University Hospital, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, Zurich, Switzerland.
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Regina Sauer
- Nursing Care, Balgrist University Hospital, Zurich, Switzerland
| | - Tanja Huber
- Pharmacy, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Burkhard
- Infection Control, Balgrist University Hospital, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
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Sandy-Hodgetts K, Carville K, Santamaria N, Parsons R, Leslie GD. The Perth Surgical Wound Dehiscence Risk Assessment Tool (PSWDRAT): development and prospective validation in the clinical setting. J Wound Care 2019; 28:332-344. [PMID: 31166854 DOI: 10.12968/jowc.2019.28.6.332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The worldwide volume of surgery today is considerable and postoperative wound healing plays a significant part in facilitating a patient's recovery and rehabilitation. While contemporary surgical procedures are relatively safe, complications such as surgical wound dehiscence (SWD) or breakdown of the incision site may occur despite advances in surgical techniques, infection control practices and wound care. SWD impacts on patient mortality and morbidity and significantly contributes to prolonged hospital stay. Preoperative identification of patients at risk of SWD may be valuable in reducing the risk of postoperative wound complications. METHOD A three-phase study was undertaken to determine risk factors associated with SWD, develop a preoperative patient risk assessment tool and to prospectively validate the tool in a clinical setting. Phases 1 and 2 were retrospective case control studies. Phase 1 determined variables associated with SWD and these informed the development of a risk assessment tool. Univariate analysis and multiple logistic regression were applied to identify predictors of surgical risk. Phase 2 used the receiver operator curve statistic to determine the predictive power of the tool. Phase 3 involved a prospective consecutive case series validation to test the inter-rater reliability and predictive power of the tool. RESULTS In addition to those already identified in the literature, one independent risk predictor for SWD was identified: previous surgery in the same anatomical location (p<0.001, odds ratio [OR] 4). Multiple combined factors were integrated into the tool and included: age (p<0.019, OR 3), diabetes (p<0.624, OR 2), obesity (p<0.94, OR 1.4), smoking (p<0.387, OR 2), cardiovascular disease (p<0.381 OR 3) and peripheral arterial disease (p<0.501, OR 3). The predictive power of the tool yielded 71% in a combined data sample. CONCLUSION Patients with previous surgery in the same anatomical location were four times more likely to incur a dehiscence. Identification of at-risk patients for complications postoperatively is integral to reducing SWD occurrence and improving health-related outcomes following surgery.
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Affiliation(s)
- Kylie Sandy-Hodgetts
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Medicine, University of Western Australia, UWA Department of Obstetrics, King Edward Memorial Hospital, Perth, Western Australia
| | - Keryln Carville
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Medicine, University of Western Australia, UWA Department of Obstetrics, King Edward Memorial Hospital, Perth, Western Australia
| | - Nick Santamaria
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Medicine, University of Western Australia, UWA Department of Obstetrics, King Edward Memorial Hospital, Perth, Western Australia
| | - Richard Parsons
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Medicine, University of Western Australia, UWA Department of Obstetrics, King Edward Memorial Hospital, Perth, Western Australia
| | - Gavin D Leslie
- Burn Injury Research Unit, School of Biomedical Sciences, Faculty of Medicine, University of Western Australia, UWA Department of Obstetrics, King Edward Memorial Hospital, Perth, Western Australia
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Wuarin L, Abbas M, Harbarth S, Waibel F, Holy D, Burkhard J, Uçkay I. Changing perioperative prophylaxis during antibiotic therapy and iterative debridement for orthopedic infections? PLoS One 2019; 14:e0226674. [PMID: 31851708 PMCID: PMC6919616 DOI: 10.1371/journal.pone.0226674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022] Open
Abstract
Background Perioperative antibiotic prophylaxis in non-infected orthopedic surgery is evident, in contrast to prophylaxis during surgery for infection. Epidemiological data are lacking for this particular situation. Methods and findings It is a single-center cohort on iterative surgical site infections (SSIs) in infected orthopedic patients. We included 2480 first episodes of orthopedic infections (median age 56 years and 833 immune-suppressed): implant-related infections (n = 648), osteoarticular infections (1153), and 1327 soft tissue infections. The median number of debridement was 1 (range, 1–15 interventions). Overall, 1617 infections (65%) were debrided once compared to 862 cases that were operated multiple times (35%). Upon iterative intraoperative tissue sampling, we detected pathogens in 507 cases (507/862; 59%), of which 241 (242/507; 48%) corresponded to the initial species at the first debridement. We witnessed 265 new SSIs (11% of the cohort) that were resistant to current antibiotic therapy in 174 cases (7% of the cohort). In multivariate analysis, iterative surgical debridements that were performed under current antibiotic administration were associated with new SSIs (odds ratio 1.6, 95%CI 1.2–2.2); mostly occurring after the 2nd debridement. However, we failed to define an ideal hypothetic prophylaxis during antibiotic therapy to prevent further SSIs. Conclusions Selection of new pathogens resistant to ongoing antibiotic therapy occurs frequently during iterative debridement in orthopedic infections, especially after the 2nd debridement. The new pathogens are however unpredictable. The prevention, if feasible, probably relies on surgical performance and wise indications for re-debridement instead of new maximal prophylactic antibiotic coverage in addition to current therapeutic regimens.
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Affiliation(s)
- Lydia Wuarin
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Mohamed Abbas
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
| | - Felix Waibel
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Dominique Holy
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, Zurich, Switzerland
| | - Jan Burkhard
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, Zurich, Switzerland
| | - Ilker Uçkay
- Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals, Geneva, Switzerland
- Department of Orthopedic Surgery, Balgrist University Hospital, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, Zurich, Switzerland
- Infectiology and Infection Control, Balgrist University Hospital, Zurich, Switzerland
- Unit for Clinical and Applied Research, Balgrist University Hospital, Zurich, Switzerland
- * E-mail:
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Nylon sutures versus skin staples in foot and ankle surgery: is there a clinical difference? Musculoskelet Surg 2019; 104:163-169. [PMID: 31055725 DOI: 10.1007/s12306-019-00605-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Staple sutures have already been proven as a good alternative to nylon sutures for wound closure in hip and knee surgeries. One such advantage to using staple sutures is the significant decrease in surgical time. In foot surgeries, staple sutures are still considered critical and are only used sporadically. OBJECTIVE The aim of this retrospective study was to compare nylon sutures and skin staples for wound closure in foot and ankle surgeries with respect to complications and patient satisfaction. METHODS A total of 61 patients underwent different operations in the fore-, mid-, and hindfoot areas, which were performed by a single surgeon. Twenty-nine patients received staple wound closures, while 32 patients received nylon suture closures using the Donati back-and-forth technique. Incision length, surgery time, in-patient stay, and wound complications were recorded. Furthermore, a patient survey using the verbal numeric rating scale (VNRS) for subjective pain and cosmetic results at the time of stitch removal (14 days) and after a 6-week follow-up was conducted. RESULTS A significant between-group difference was found for surgery time (p = .041) and VNRS for pain (p < .001), with better results seen for staple sutures. Four patients with staple sutures and five with nylon sutures experienced wound dehiscence 14 days postoperatively. However, all patients had completely healed wounds at their 6-week follow-up. No revisional surgeries were necessary. CONCLUSION The present results indicate that a skin staple wound closure is a considerable alternative to the nylon suture closure in foot and ankle surgeries. Nevertheless, further prospective randomized trials must cement these insights.
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Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Endocrinol Diabetes Metab 2019; 2:e00059. [PMID: 31008367 PMCID: PMC6458464 DOI: 10.1002/edm2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/28/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
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Affiliation(s)
- Anne Rossel
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Dan Lebowitz
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Karim Gariani
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Service of Diabetology and EndocrinologyGeneva University HospitalsGenevaSwitzerland
| | - Mohamed Abbas
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
| | - Benjamin Kressmann
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Mathieu Assal
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- La Colline Hirslanden ClinicGenevaSwitzerland
| | - Philippe Tscholl
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| | - Dimitrios Stafylakis
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Ilker Uçkay
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
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Gariani K, Lebowitz D, von Dach E, Kressmann B, Lipsky BA, Uçkay I. Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors. Diabetes Obes Metab 2019; 21:244-251. [PMID: 30129109 DOI: 10.1111/dom.13507] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/30/2018] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Abstract
AIM To determine the most appropriate duration of antibiotic therapy for diabetic foot infections (DFIs). METHODS Using a clinical pathway for adult patients with DFIs (retrospective cohort analysis), we created a cluster-controlled Cox regression model to assess factors related to remission of infection, emphasizing antibiotic-related variables. We excluded total amputations as a result of DFI and DFI episodes with a follow-up time of <2 months. RESULTS Among 1018 DFI episodes in 482 patients, we identified 392 episodes of osteomyelitis, 626 soft tissue infections, 246 large abscesses, 322 episodes of cellulitis and 335 episodes of necrosis; 313 cases involved revascularization. Patients underwent surgical debridement for 824 episodes (81%), of which 596 (59%) required amputation. The median total duration of antibiotic therapy was 20 days. After a median follow-up of 3 years, 251 of the episodes (24.7%) were followed by ≥1 additional episode(s). Comparing patients with and without additional episodes, risk of recurrence was lower in those who underwent amputation, had type 1 diabetes, or underwent revascularization. On multivariate analysis including the entire study population, risk of remission was inversely associated with type 1 diabetes (hazard ratio [HR] 0.3, 95% confidence interval [CI] 0.2-0.6). Neither duration of antibiotic therapy nor parenteral treatment affected risk of recurrence (HR 1.0, 95% CI 0.99-1.01 for both). Similarly, neither >3 weeks versus <3 weeks of therapy, nor >1 week versus <1 week of intravenous treatment affected recurrence. In stratified analyses for both soft tissue DFIs or osteomyelitis separately, we did not observe associations of antibiotic duration with microbiological or clinical recurrences of DFI. The HRs were 1.0 (95% CI 0.6-1.8) for an antibiotic duration >3 weeks overall and 0.6 (95% CI 0.2-1.3) for osteomyelitis cases only. Plotting of duration of antibiotic therapy failed to identify any optimal threshold for preventing recurrences. CONCLUSIONS Our analysis found no threshold for the optimal duration or route of administration of antibiotic therapy to prevent recurrences of DFI. These limited data might support possibly shorter treatment duration for patients with DFI.
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Affiliation(s)
- Karim Gariani
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Service of Diabetology and Endocrinology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dan Lebowitz
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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13
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Uçkay I, von Dach E, Perez C, Agostinho A, Garnerin P, Lipsky BA, Hoffmeyer P, Pittet D. One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial. Mayo Clin Proc 2017; 92:1061-1069. [PMID: 28602435 DOI: 10.1016/j.mayocp.2017.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/01/2017] [Accepted: 03/15/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis. PATIENTS AND METHODS From May 1, 2011, through December 24, 2014, hospitalized patients with septic bursitis at University of Geneva Hospitals were randomized (1:1) to receive 1- vs 2-stage bursectomy. All the patients received postsurgical oral antibiotic drug therapy for 7 days. RESULTS Of 164 enrolled patients, 130 had bursitis of the elbow and 34 of the patella. The surgical approach used was 1-stage in 79 patients and 2-stage in 85. Overall, there were 22 treatment failures: 8 of 79 patients (10%) in the 1-stage arm and 14 of 85 (16%) in the 2-stage arm (Pearson χ2 test; P=.23). Recurrent infection was caused by the same pathogen in 7 patients (4%) and by a different pathogen in 5 (3%). Outcomes were better in the 1- vs 2-stage arm for wound dehiscence for elbow bursitis (1 of 66 vs 9 of 64; Fisher exact test P=.03), median length of hospital stay (4.5 vs 6.0 days), nurses' workload (605 vs 1055 points), and total costs (Sw₣6881 vs Sw₣11,178; all P<.01). CONCLUSION For adults with moderate to severe septic bursitis requiring hospital admission, bursectomy with primary closure, together with antibiotic drug therapy for 7 days, was safe, effective, and resource saving. Using a 2-stage approach may be associated with a higher rate of wound dehiscence for olecranon bursitis than the 1-stage approach. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01406652.
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Affiliation(s)
- Ilker Uçkay
- Orthopaedic Surgery Service, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Service of Infectious Diseases, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Infection Control Program, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Elodie von Dach
- Infection Control Program, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Cédric Perez
- Orthopaedic Surgery Service, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Americo Agostinho
- Orthopaedic Surgery Service, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Infection Control Program, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Philippe Garnerin
- Service of Anesthesiology, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Pierre Hoffmeyer
- Orthopaedic Surgery Service, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Didier Pittet
- Service of Infectious Diseases, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Infection Control Program, Medico-Economic Control, University of Geneva Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland; WHO Collaboration Center on Patient Safety, Geneva, Switzerland
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Miller TJ, Jeong HS, Davis K, Matthew A, Lysikowski J, Cho MJ, Reed G, Kenkel JM. Evaluation of the American Society of Anesthesiologists Physical Status classification system in risk assessment for plastic and reconstructive surgery patients. Aesthet Surg J 2014; 34:448-56. [PMID: 24676415 DOI: 10.1177/1090820x14525394] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The American Society of Anesthesiologists Physical Status (ASA-PS) classification is a ranking system that quantifies patient health before anesthesia and surgery. Some surgical disciplines apply the ASA-PS to gauge a patient's likelihood of developing postoperative complications. OBJECTIVE In this study, the authors analyze whether ASA-PS scores can successfully predict risk for postoperative complications in plastic and reconstructive operations. METHODS The authors retrospectively reviewed the charts of 1801 patient procedures and selected for inclusion 1794 complex plastic and reconstructive operations that took place at 1 of several academic medical institutions between January 2008 and January 2012. ASA-PS scores, patient comorbidities, and postoperative complications were analyzed. Percentile data were treated with tests for proportions. Nonpercentile data were analyzed through comparison of means (t test). Low-risk (ASA 1-2) and high-risk (ASA 3+) groups were compared with simple odds ratios. RESULTS For the 1430 women and 364 men in the patient cohort (average age, 49.5 years), the overall complication rate was 27.7%. When patients with complications were compared to those without, body mass index, operation time, recent major surgery, diabetes, hypertension, renal disease, cancer, and oral contraceptive use were statistically significant. After high-risk (n = 398) and low-risk (n = 1396) groups were identified, infection, delayed wound healing, deep vein thrombosis, and overall complications had significantly increased incidence in the high risk group. Notably, deep vein thrombosis displayed the highest odds ratio (4.17) and a complication rate increase from 0.93% to 3.77%. CONCLUSIONS ASA-PS scores can be used either as substitutes for or as adjuncts to questionnaire-based risk assessment methods in plastic surgery. In addition to deducing significant findings for deep vein thrombosis incidence, ASA-PS scores hold important predictive associations for multiple non-venous thromboembolism complications, providing a broader measurement for postoperative complication risks. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Travis J Miller
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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15
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Slade Shantz JA, Vernon J, Morshed S, Leiter J, Stranges G. Sutures versus staples for wound closure in orthopaedic surgery: a pilot randomized controlled trial. Patient Saf Surg 2013; 7:6. [PMID: 23394586 PMCID: PMC3598732 DOI: 10.1186/1754-9493-7-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 02/01/2013] [Indexed: 11/24/2022] Open
Abstract
Background In the spectrum of surgical decision-making, wound closure material is often an afterthought. However, the findings of a recent meta-analysis suggest that the rate of surgical site infections (SSIs) is increased by using staples to close surgical wounds. Less clear is the effect of closure material on the incidence of non-infectious wound complications. The aim of this study was to compare sutures and staples in terms of: incidence of wound complications to determine the sample size for a definitive trial comparing wound closure methods. Methods Eligible adult orthopaedic patients were randomized to have wounds closed with sutures or staples. Time for skin closure was recorded. Wounds were assessed for complications for six weeks. The incidence of complications was compared using Fisher’s exact test. Time to close and pain with removal of closure material were compared using a Student’s t-test. Results The total number of patients reporting a wound complication was 59 of 148 patients completing six-week followup (41%), with no differennce between sutures and staples (RR = 0.77, CI = 0.52–1.14). The time to close wounds was shorter in the staple group (mean=4.8 min, CI = 2.6–7.1) than the suture group (mean=12 min, CI = 7.9–16). Patients in the staple group (mean=3.7, CI =2.8–4.6) reported more pain with removal than suture group (mean=2.5, CI =1.6–3.4). Conclusions This study suggests that 42% of patients report a wound complication with no difference between sutures and staples. It was demonstrated that suturing skin requires more time and staples are more painful to remove. Trial registration Clinicaltrials.gov identifier NCT01146236 (registered June 14, 2010)
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Affiliation(s)
- Jesse A Slade Shantz
- Orthopedic Trauma Institute, University of California, 2550 23rd Street, Building 9, 2nd Floor, 94110, San Francisco, CA, USA.
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Ribeiro JC, Santos CBD, Bellusse GC, Rezende VDF, Galvão CM. Ocorrência e fatores de risco para infecção de sítio cirúrgico em cirurgias ortopédicas. ACTA PAUL ENFERM 2013. [DOI: 10.1590/s0103-21002013000400009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Analisar a ocorrência e os fatores de risco para infecção de sítio cirúrgico em pacientes submetidos a cirurgias ortopédicas. MÉTODOS: Estudo transversal prospectivo com 93 pacientes submetidos a cirurgias ortopédicas eletivas e limpas. RESULTADOS: A infecção de sítio cirúrgico foi diagnosticada em 16 pacientes (17,2%). Na análise dos dados, após ajuste do modelo de regressão logística binária, apenas a variável tempo total de internação mostrou-se com relação estatisticamente significativa com a presença ou não de infecção. CONCLUSÃO: A ocorrência de infecção de sítio cirúrgico em cirurgia ortopédica foi mais elevada, sendo 75% dos casos diagnosticados após a alta hospitalar, resultado que reforça a necessidade da vigilância pós-alta.
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