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Kurobe M, Sugihara T, Harada A, Kaji S, Uchida G, Kanamori D, Baba Y, Hiramatsu T, Ohashi S, Otsuka M. The Comparison of Postoperative Umbilical Port Site-Related Complications Between Transumbilical and Periumbilical Incision After Laparoscopic Surgery in Children. J Laparoendosc Adv Surg Tech A 2023; 33:807-813. [PMID: 37093029 DOI: 10.1089/lap.2022.0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
Introduction: No studies have directly compared postoperative umbilical port site (UPS)-related complications between transumbilical and periumbilical incisions (TUI and PUI) after laparoscopic surgery in children. Patients and Methods: We conducted a retrospective review of 324 children of ≤15 years of age who underwent laparoscopic repair (LR) for inguinal hernia, via either a TUI or PUI, between 2010 and 2020. UPS-related complications, such as wound infection and umbilical deformity, were compared between TUI and PUI. We also investigated the risk factors for the development of UPS-related complications after LR. Results: TUIs and PUIs were used for 228 and 96 children, respectively. The incidence rates of postoperative wound infection and umbilical deformity in the PUI group were higher in comparison to the TUI group; although not to a statistically significant extent (7.3% versus 5.3%, P = .451, 6.3% versus 4.8%, P = .593). One case of incisional hernia at the UPS was seen in the TUI group. In the univariate analysis, sex, age, weight for age Z-score, nutrition status, insertion and closure time, total operative time, American Society of Anesthesiologists score, blood loss, and comorbidities were not significantly associated with the development of UPS-related complications after LR. Conclusion: The incidence of UPS-related complications in TUI and PUI was not significantly different. Due to the low incidence of UPS-related complications, it was difficult to draw conclusions regarding contributing factors; however, meticulous care should be taken to avoid UPS-related complications when closing the UPS (Ethical approval No. 2019-24).
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Affiliation(s)
- Masashi Kurobe
- Department of Pediatric Surgery and Kawaguchi Municipal Medical Center, Kawaguchi, Japan
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Tetsuro Sugihara
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Atsushi Harada
- Department of Pediatric Surgery and Kawaguchi Municipal Medical Center, Kawaguchi, Japan
| | - Sayuri Kaji
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Goki Uchida
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Daisuke Kanamori
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Yuji Baba
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Tomomasa Hiramatsu
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Shinsuke Ohashi
- Division of Pediatric Surgery, Department of Surgery, The Jikei University, School of Medicine, Tokyo, Japan
| | - Masahiko Otsuka
- Department of Surgery, Kawaguchi Municipal Medical Center, Kawaguchi, Japan
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Costabella F, Patel KB, Adepoju AV, Singh P, Attia Hussein Mahmoud H, Zafar A, Patel T, Watekar NA, Mallesh N, Fawad M, Sathyarajan DT, Abbas K. Healthcare Cost and Outcomes Associated With Surgical Site Infection and Patient Outcomes in Low- and Middle-Income Countries. Cureus 2023; 15:e42493. [PMID: 37637579 PMCID: PMC10455046 DOI: 10.7759/cureus.42493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Surgical site infection (SSI) is a growing global concern. The principal explanation for this is its adverse clinical outcomes, such as morbidity and mortality. However, the link between the economic burden of SSIs and patient outcomes needs to be sufficiently characterized. This review aims to describe the financial implications of SSIs on patient outcomes in low- and middle-income countries (LMIC). Despite the heterogeneity in study designs from multiple LMIC countries, there is a significant correlation between SSI-associated healthcare costs from increased length of stay (LOS), readmissions, reoperations, and adverse patient outcomes. This varies based on the size, degree of infection, or other patient comorbidities. SSIs are much more prevalent in LMICs. The additional financial burden incurred in managing SSIs reinforces the need to prioritize practicing interventions to prevent this complication, which resource-limited health institutions are unequipped to do and consequently have significant adverse patient outcomes.
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Affiliation(s)
- Fernando Costabella
- Department of Pediatrics, Hospital General Dr. Manuel Gea Gonzalez, Mexico City, MEX
| | - Keval B Patel
- Department of Surgery, Narendra Modi Medical College, Ahmedabad, IND
| | | | - Purnima Singh
- College of Medicine, Gulf Medical University, Ajman, ARE
| | | | - Awais Zafar
- Department of Psychiatry, Sahiwal Medical College, Sahiwal, PAK
| | - Tirath Patel
- Department of Surgery, American University of Antigua, St. John, ATG
| | - Ninad A Watekar
- Department of Surgery, Davao Medical School Foundation, Davao, PHL
| | - Navya Mallesh
- Department of Surgery, St. Martinus University, Willemstad, CUW
| | - Moiz Fawad
- Department of Neurological Surgery, King Saud Hospital, Unaizah, SAU
| | - Dily T Sathyarajan
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Bengaluru, IND
- Department of Surgery, Government Medical College, Thrissur, IND
| | - Kiran Abbas
- Department of Community Health Sciences, Aga Khan University, Karachi, PAK
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Ţarcă E, Cojocaru E, Trandafir LM, Melinte Popescu MG, Luca AC, Butnariu LI, Hanganu E, Moscalu M, Ţarcă V, Stătescu L, Radu I, Melinte Popescu AS. Nosocomial Infections Affecting Newborns with Abdominal Wall Defects. Healthcare (Basel) 2023; 11:healthcare11081131. [PMID: 37107965 PMCID: PMC10137964 DOI: 10.3390/healthcare11081131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Abdominal wall defects are serious birth defects, with long periods of hospitalization and significant costs to the medical system. Nosocomial infection (NI) may be an additional risk factor that aggravates the evolution of newborns with such malformations. METHODS in order to analyze the factors that may lead to the occurrence of NI, we performed a retrospective study over a period of thirty-two years (1990-2021), in a tertiary children's hospital; 302 neonates with omphalocele and gastroschisis were eligible for the study. RESULTS a total of 33.7 % patients were infected with one or more of species of bacteria or fungi. These species were Enterobacteriaceae, Pseudomonas aeruginosa and Acinetobacter spp., Staphylococcus spp., Enterococcus spp. or Candida spp., but the rate of NI showed a significant decrease between the 1990-2010 and 2011-2021 period (p = 0.04). The increase in the number of surgeries was associated with the increase in the number of NI both for omphalocele and gastroschisis; in the case of gastroschisis, the age of over 6 h at the time of surgery increased the risk of infection (p = 0.052, marginal statistical significance). Additionally, for gastroschisis, the risk of NI was 4.56 times higher in the presence of anemia (p < 0.01) and 2.17 times higher for the patients developing acute renal failure (p = 0.02), and a hospitalization period longer than 14 days was found to increase the risk of NI 3.46-fold (p < 0.01); more than 4 days of TPN was found to increase the NI risk 2.37-fold (p = 0.015). Using a logistic regression model for patients with omphalocele, we found an increased risk of NI for those in blood group 0 (OR = 3.8, p = 0.02), in patients with a length of hospitalization (LH) of ≥14 days (OR = 6.7, p < 0.01) and in the presence of anemia (OR = 2.5, p = 0.04); all three independent variables in our model contributed 38.7% to the risk of NI. CONCLUSION although in the past 32 years we have seen transformational improvements in the outcome of abdominal wall defects, there are still many factors that require special attention for corrections.
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Affiliation(s)
- Elena Ţarcă
- Department of Surgery II-Pediatric Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Elena Cojocaru
- Department of Morphofunctional Sciences I-Pathology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Laura Mihaela Trandafir
- Department of Mother and Child Medicine-Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Marian George Melinte Popescu
- Department of General Nursing, Faculty of Medicine and Biological Sciences, "Ştefan cel Mare" University of Suceava, 720229 Suceava, Romania
| | - Alina Costina Luca
- Department of Mother and Child Medicine-Pediatrics, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Lăcrămioara Ionela Butnariu
- Department of Medical Genetics, Faculty of Medicine, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Elena Hanganu
- Department of Biomedical Sciences, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Viorel Ţarcă
- Department of Preventive Medicine and Interdisciplinarity, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Laura Stătescu
- Department of Dermatology, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Iulian Radu
- Department of Surgery, "Grigore T. Popa" University of Medicine and Pharmacy, 700115 Iaşi, Romania
| | - Alina Sinziana Melinte Popescu
- Department of General Nursing, Faculty of Medicine and Biological Sciences, "Ştefan cel Mare" University of Suceava, 720229 Suceava, Romania
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Tandon S, Ensor ND, Pacilli M, Laird AJ, Bortagaray JI, Stunden RJ, Nataraja RM. Tissue adhesive, adhesive tape, and sutures for skin closure of paediatric surgical wounds: prospective randomized clinical trial. Br J Surg 2022; 109:1087-1095. [PMID: 35913888 PMCID: PMC10364679 DOI: 10.1093/bjs/znac254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Tissue adhesive, adhesive tape, and sutures are used to close surgical incisions. However, it is unclear which produces the best results in children, and whether combination wound closure is better than sutures alone. METHODS In this parallel randomised controlled trial (ANZCTR: ACTRN12617000158369), children (aged 18 years or less) undergoing elective general surgical or urological procedures were randomized to skin closure with sutures alone, sutures and adhesive tape, or sutures and tissue adhesive. Participants were assessed 2 weeks, 6 weeks, and more than 6 months after operation. Outcomes included wound cosmesis (clinician- and parent-rated) assessed using four validated scales, parental satisfaction, and wound complication rates. RESULTS 295 patients (333 wounds) were recruited and 277 patients (314 wounds) were included in the analysis. Tissue adhesive wounds had poorer cosmesis at 6 weeks: median 10-point VAS score 7.7 with sutures alone, 7.5 with adhesive tape, and 7.0 with tissue adhesive (P = 0.014). Respective median scores on a 100-point VAS were 80.0, 77.2, and 73.8 (P = 0.010). This difference was not sustained at over 6 months. There was no difference in parent-rated wound cosmesis at 6 weeks (P = 0.690) and more than 6 months (P = 0.167): median score 9.0 with sutures alone, 10.0 with adhesive tape, and 10.0 with tissue adhesive at both stages. Parental satisfaction was similar at all points, with a median score of 5 (very satisfied) for all groups. There was one instance of wound dehiscence in the tissue adhesive group and no wound infections. CONCLUSION Short-term wound cosmesis was poorer with tissue adhesive although it is unclear whether this difference is sustained in the long-term. There were no differences between techniques for the study outcomes. REGISTRATION NUMBER ACTRN12617000158369 (ANZCTR) (https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372177&isReview=true).
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Affiliation(s)
- Sarthak Tandon
- Department of Paediatric Surgery, Urology and Surgical Simulation, Monash Children’s Hospital, Melbourne, Victoria, Australia
| | - Nicholas D Ensor
- Department of Paediatric Surgery, Urology and Surgical Simulation, Monash Children’s Hospital, Melbourne, Victoria, Australia
| | - Maurizio Pacilli
- Department of Paediatric Surgery, Urology and Surgical Simulation, Monash Children’s Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ashleigh J Laird
- Department of Paediatric Surgery, Urology and Surgical Simulation, Monash Children’s Hospital, Melbourne, Victoria, Australia
| | - Juan I Bortagaray
- Department of Paediatric Surgery, Urology and Surgical Simulation, Monash Children’s Hospital, Melbourne, Victoria, Australia
| | - Robert J Stunden
- Department of Paediatric Surgery, Urology and Surgical Simulation, Monash Children’s Hospital, Melbourne, Victoria, Australia
| | - Ramesh M Nataraja
- Correspondence to: Ramesh M. Nataraja, Monash Children’s Hospital and Monash University, Department of Paediatric Surgery, 246 Clayton Road, Clayton, Melbourne, Victoria, Australia, 3168 (e-mail: )
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Nthumba PM, Huang Y, Perdikis G, Kranzer K. Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2022; 23:501-515. [PMID: 35834578 DOI: 10.1089/sur.2022.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ2 = 0.246; χ2 = 69.75; p < 0.001; I2 = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.
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Affiliation(s)
- Peter M Nthumba
- Department of Plastic Surgery, AIC Kijabe Hospital, Kenya.,Department of Plastic Surgery, Vanderbilt Medical University Center, Nashville, Tennesse, USA
| | - Yongxu Huang
- Department of Plastic Surgery, Vanderbilt Medical University Center, Nashville, Tennesse, USA
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt Medical University Center, Nashville, Tennesse, USA
| | - Katharina Kranzer
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Biomedical Research and Training Institute, Harare, Zimbabwe.,Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Munich, Germany
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Tanaka K, Mikami T, Ebata Y, Kato H, Miyano G, Ishii J, Okazaki T. Umbilical microflora and pediatric surgery. Pediatr Surg Int 2022; 38:345-349. [PMID: 34586482 DOI: 10.1007/s00383-021-05026-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION In pediatric surgery, the umbilicus with humid environment prone to bacterial colonization has become the most common site of entrance into the peritoneum. However, the umbilical flora in children has never been reported. This study aimed to describe the characteristics of umbilical microflora in children before antiseptic skin preparation. PATIENTS AND METHODS We prospectively reviewed all children (age, ≤ 15 years) undergoing surgical procedures using umbilical access between April 2020 and June 2021. Before antiseptic skin preparation, culture swabs were taken from the umbilicus. Data on age, sex, and surgical procedure as well as microflora results and clinical findings were analyzed. RESULTS Overall, data on 123 children aged between 9 days and 15 years (median: 3 years) were obtained. In the umbilicus, the most frequent colonizing bacteria were coagulase-negative Staphylococcus species and Corynebacterium. The isolation of intestinal bacteria from children aged ≤ 3 years was significantly increased (P = 0.03). The results of the multidrug resistance test revealed that the bacteria from the umbilicus exhibited a high frequency of cefazolin (CEZ) resistance (46.1%). No postoperative surgical site infection was recorded in our study. CONCLUSIONS This prospective study is the first report to investigate the umbilical microflora in over 100 children. In this study, a large spectrum of both resident and transient microflora was cultured from the umbilicus. This umbilical microflora was similar to previous reports of adult microflora except in children aged ≤ 3 years. Our data suggest that in children ≤ 3 years, preoperative and postoperative antibiotics should be chosen by considering CEZ resistance and intestinal bacteria. The result of umbilical microflora would be useful to select the antibiotics for treatment of surgical site infection (SSI), and the culture swabs from the umbilicus before the operation for the children at high risk for SSI are highly recommended.
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Affiliation(s)
- Keiichiro Tanaka
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan.
| | - Takafumi Mikami
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Yu Ebata
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Haruki Kato
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Go Miyano
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Junya Ishii
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
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Yalamanchi P, Parent AL, Baetzel AE, Crowe SM, Gutting AA, Gisondo G, Portice LC, Thorne MC, Wagner DS, Bates KE, Tribble AC. Optimization of Antibiotic Prophylaxis Delivery for Pediatric Surgical Procedures. Pediatrics 2021; 148:peds.2020-001669. [PMID: 34272341 DOI: 10.1542/peds.2020-001669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To optimize prophylactic antibiotic timing and delivery across all surgeries performed at a single large pediatric tertiary care center. METHODS A multidisciplinary surgical quality team conducted a quality improvement initiative from July 2015 to December 2019 by using the A3 problem-solving method to identify and evaluate interventions for appropriate antibiotic administration. The primary outcome measure was the percentage of surgical encounters for pediatric patients with appropriate timing of antibiotic administration before surgical incision. Surgical site infection rates was the secondary outcome. Intervention effectiveness was assessed by using statistical process control. RESULTS A total of 32 192 eligible surgical cases for pediatric patients were completed during the study period. Identified barriers to timely perioperative antibiotic administration included failure to order antibiotics before the surgical date and lack of antibiotic availability in the operating room at the time of administration. Resulting sequential interventions included updating institutional guidelines to reflect procedure-specific antibiotic choices and clarifying timing of administration to optimize pharmacokinetics, creating a hard-stop antibiotic order within electronic health record case requests, optimizing pharmacy and nursing workflow, and implementing an automatic antibiotic prophylaxis timer in the operating room. Administration of prophylactic antibiotics during the recommended preincision time window significantly improved; the correct timing was recorded in 38.6% of preintervention cases versus 94.0% at the conclusion of rollout of the sequential interventions (P < .001). Surgical site infection rates remained stable. CONCLUSIONS Here we demonstrate utility of the A3 problem-solving schematic to successfully optimize prophylactic antibiotic timing and delivery in the surgical setting for pediatric patients by implementing systems-based interventions.
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Affiliation(s)
| | - Ashley L Parent
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Anne E Baetzel
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Susan M Crowe
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Andrew A Gutting
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Gino Gisondo
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Lynda C Portice
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Marc C Thorne
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Deborah S Wagner
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Katherine E Bates
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
| | - Alison C Tribble
- C.S. Mott Children's Hospital and University of Michigan, Ann Arbor, Michigan
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McNamara SA, Hirt PA, Weigelt MA, Nanda S, de Bedout V, Kirsner RS, Schachner LA. Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review. J Wound Care 2020; 29:321-334. [PMID: 32530778 DOI: 10.12968/jowc.2020.29.6.321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously. METHOD Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included 'wound care', 'wound management', 'paediatrics', 'children', 'skin substitutes', and 'grafts'. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: 'Apligraf', 'dermagraft', 'Manuka honey', 'antibiotic', 'timolol', and 'negative pressure wound therapy' (NPWT). RESULTS Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount. CONCLUSION Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.
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Affiliation(s)
- Stephanie A McNamara
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Penelope A Hirt
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Maximillian A Weigelt
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Sonali Nanda
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Valeria de Bedout
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Robert S Kirsner
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Lawrence A Schachner
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
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9
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Catania VD, Boscarelli A, Lauriti G, Morini F, Zani A. Risk Factors for Surgical Site Infection in Neonates: A Systematic Review of the Literature and Meta-Analysis. Front Pediatr 2019; 7:101. [PMID: 30984722 PMCID: PMC6449628 DOI: 10.3389/fped.2019.00101] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/05/2019] [Indexed: 12/17/2022] Open
Abstract
Purpose: Surgical site infections (SSI) contribute to postoperative morbidity and mortality in children. Our aim was to evaluate the prevalence and identify risk factors for SSI in neonates. Methods: Using a defined strategy, three investigators searched articles on neonatal SSI published since 2000. Studies on neonates and/or patients admitted to neonatal intensive care unit following cervical/thoracic/abdominal surgery were included. Risk factors were identified from comparative studies. Meta-analysis was conducted according to PRISMA guidelines using RevMan 5.3. Data are (mean ± SD) prevalence. Results: Systematic review-of 885 abstracts screened, 48 studies (27,760 neonates) were included. The incidence of SSI was 5.6% (1,564 patients). SSI was more frequent in males (61.8%), premature babies (77.4%), and following gastrointestinal surgery (95.4%). Meta-analysis-10 comparative studies (16,442 neonates; 946 SSI 5.7%) showed that predictive factors for SSI development were gestational age, birth weight, age at surgery, length of surgical procedure, number of procedure per patient, length of preoperative hospital stay, and preoperative sepsis. Conversely, preoperative antibiotic use was not significantly associated with development of SSI. Conclusions: Younger neonates and those undergoing abdominal procedures are at higher risk for SSI. Given the lack of evidence-based literature, prospective studies may help determine the risk factors for SSI in neonates.
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Affiliation(s)
- Vincenzo Davide Catania
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Alessandro Boscarelli
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giuseppe Lauriti
- Department of Pediatric Surgery, Spirito Santo Hospital and G. d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Francesco Morini
- Neonatal Surgery Unit, Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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von Schweinitz D, Ure B. Chirurgische Infektionen bei Kindern und Jugendlichen. KINDERCHIRURGIE 2019. [PMCID: PMC7123254 DOI: 10.1007/978-3-662-58202-2_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Der menschliche Organismus ist von einer unzähligen Menge von Mikroorganismen umgeben. Dringen diese Krankheitserreger in uns ein, dann laufen Wechselbeziehungen zwischen dem Eindringling und dem Wirtsorganismus ab. Krankheit resultiert, wenn die Mikroorganismen aufgrund ihrer verschiedenen Determinanten der Pathogenität und Virulenz den Wettlauf mit der Infektabwehr des Makroorganismus gewonnen haben. Mit diesem Problem hatten sich Chirurgen zu allen Zeiten auseinanderzusetzen und es hat bis heute nicht an Aktualität verloren.
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Affiliation(s)
- Dietrich von Schweinitz
- Kinderchirurgische Klinik und Poliklinik im Dr. von Haunerschen Kinderspital, LMU München, München, Germany
| | - Benno Ure
- Klinik für Kinderchirurgie, Medizinische Hochschule Hannover (MHH), Hannover, Germany
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Surgical site infections in neonates are independently associated with longer hospitalizations. J Perinatol 2017; 37:1130-1134. [PMID: 28749483 DOI: 10.1038/jp.2017.107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/17/2017] [Accepted: 05/22/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE There is limited data characterizing the risk and impact of surgical site infection (SSI) in neonates; this makes it difficult to identify factors that increase neonatal SSI risk and to determine how SSI affects outcomes in this special population. STUDY DESIGN The American College of Surgeons National Surgical Improvement Program Pediatric (NSQIP-P) collected data on children undergoing surgery at children's hospitals from 2012 to 2014. Neonates undergoing general surgical procedures were characterized with regard to demographic characteristics and comorbidities. Perioperative variables such as wound class, type of surgery and length of operation were also evaluated. RESULTS Seven thousand three hundred and seventy-nine neonates were identified in the NSQIP-P participant user file. The overall SSI rate was 2.6%. Only wound class and length of surgery were significantly associated with SSI. Furthermore, SSI was independently associated with longer length of stay, even after adjusting for covariates. CONCLUSIONS This is the largest study to date analyzing SSI in neonates. We found that perioperative variables have a more significant impact on SSI than patient factors, suggesting that operation-related characteristics are influencing SSI. Furthermore, neonates with SSI are more likely to have prolonged hospitalizations even after adjusting for patient comorbidities.
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Visser R, Milbrandt K, Lum Min S, Wiseman N, Hancock BJ, Morris M, Keijzer R. Applying vacuum to accomplish reduced wound infections in laparoscopic pediatric surgery. J Pediatr Surg 2017; 52:849-852. [PMID: 28245914 DOI: 10.1016/j.jpedsurg.2017.01.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The prevention of surgical site infections has received little attention in pediatric surgery. Negative pressure wound therapy is used to treat complex wounds. We hypothesized that this principle could reduce wound infection rates following laparoscopic surgery. We tested this in a randomized controlled trial. MATERIALS AND METHODS We randomized pediatric patients with an umbilical port site to a standard dressing or a vacuum dressing. The dressings were removed 48h after surgery. A nurse blinded for the treatment inspected the umbilical wound between post-operative days 7-10 for infection. Data comparison was performed using a Fisher exact test with p<0.05 defined as significant. RESULTS We recruited 90 patients over 2 years and randomized 44 to the vacuum dressing arm and 42 to the control arm. We observed a 2.8% (n=1/35) infection rate in the vacuum dressing group and 3.3% (n=1/30) in the control group (p=1.0). DISCUSSION We ended our study early when an interim analysis showed an impractical number of patients would be required to achieve sufficient power. We did not find a significant difference between the control and vacuum dressings in reducing post-operative wound infections. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Robin Visser
- Department of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kris Milbrandt
- Department of Surgery, Division of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics & Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suyin Lum Min
- Department of Surgery, Division of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics & Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nathan Wiseman
- Department of Surgery, Division of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics & Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Betty-Jean Hancock
- Department of Surgery, Division of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics & Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Melanie Morris
- Department of Surgery, Division of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics & Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Pediatric Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Pediatrics & Child Health and Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada.
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Surgical Site Infections Following Pediatric Ambulatory Surgery: An Epidemiologic Analysis. Infect Control Hosp Epidemiol 2016; 37:931-938. [DOI: 10.1017/ice.2016.98] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVETo identify surgical site infection (SSI) rates following pediatric ambulatory surgery, SSI outcomes and risk factors, and sensitivity and specificity of SSI administrative billing codes.DESIGNRetrospective chart review of pediatric ambulatory surgeries with International Classification of Disease, Ninth Revision (ICD-9) codes for SSI, and a systematic random sampling of 5% of surgeries without SSI ICD-9 codes, all adjudicated for SSI on the basis of an ambulatory-adapted National Healthcare Safety Network definition.SETTINGUrban pediatric tertiary care center April 1, 2009-March 31, 2014.METHODSSSI rates and sensitivity and specificity of ICD-9 codes were estimated using sampling design, and risk factors were analyzed in case–rest of cohort, and case-control, designs.RESULTSIn 15,448 pediatric ambulatory surgeries, 34 patients had ICD-9 codes for SSI and 25 met the adapted National Healthcare Safety Network criteria. One additional SSI was identified with systematic random sampling. The SSI rate following pediatric ambulatory surgery was 2.9 per 1,000 surgeries (95% CI, 1.2–6.9). Otolaryngology surgeries demonstrated significantly lower SSI rates compared with endocrine (P=.001), integumentary (P=.001), male genital (P<.0001), and respiratory (P=.01) surgeries. Almost half of patients with an SSI were admitted, 88% received antibiotics, and 15% returned to the operating room. No risk factors were associated with SSI. The sensitivity of ICD-9 codes for SSI following ambulatory surgery was 55.31% (95% CI, 12.69%–91.33%) and specificity was 99.94% (99.89%–99.97%).CONCLUSIONSSSI following pediatric ambulatory surgery occurs at an appreciable rate and conveys morbidity on children.Infect Control Hosp Epidemiol 2016;37:931–938
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Putnam LR, Levy SM, Blakely ML, Lally KP, Wyrick DL, Dassinger MS, Russell RT, Huang EY, Vogel AM, Streck CJ, Kawaguchi AL, Calkins CM, St Peter SD, Abbas PI, Lopez ME, Tsao K. A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough? J Pediatr Surg 2016; 51:639-44. [PMID: 26590473 DOI: 10.1016/j.jpedsurg.2015.10.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 08/21/2015] [Accepted: 10/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. METHODS A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square. RESULTS Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. CONCLUSIONS Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.
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Affiliation(s)
- Luke R Putnam
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Shauna M Levy
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Martin L Blakely
- Vanderbilt Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin P Lally
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA
| | - Deidre L Wyrick
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Melvin S Dassinger
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Robert T Russell
- Children's of Alabama, University of Alabama Birmingham School of Medicine, Birmingham, AL, USA
| | - Eunice Y Huang
- Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Adam M Vogel
- St. Louis Children's Hospital, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Christian J Streck
- MUSC Children's Hospital, Medical University of South Carolina, Charleston, SC, USA
| | - Akemi L Kawaguchi
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA; Children's Hospital Los Angeles, Keck Medical Center of USC, Los Angeles, CA, USA
| | - Casey M Calkins
- Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Shawn D St Peter
- Children's Mercy Hospital, University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA
| | - Paulette I Abbas
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Monica E Lopez
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - KuoJen Tsao
- Children's Memorial Hermann Hospital, University of Texas Medical School at Houston, Houston, TX, USA.
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Cheng K, Li J, Kong Q, Wang C, Ye N, Xia G. Risk factors for surgical site infection in a teaching hospital: a prospective study of 1,138 patients. Patient Prefer Adherence 2015; 9:1171-7. [PMID: 26316722 PMCID: PMC4542557 DOI: 10.2147/ppa.s86153] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify risk factors for surgical site infection (SSI) in a teaching hospital. METHODS A prospective study was initiated to investigate risk factors for SSI at a university-affiliated tertiary care center from July 2013 to December 2014. The chi-square test for categorical variables was used to determine the significance of association, whereas the multivariate logistic regression model was used to examine independent risk factors for SSI. RESULTS A total of 1,138 patients met the inclusion criteria, in whom 36 cases of infection occurred during the hospitalization period and two cases occurred after discharge. Univariate analysis showed that SSI was associated with the type of operation, wound classification, volume of blood loss, blood transfusion, American Society of Anesthesiology score before surgery, risk index, duration of surgery, diabetes, cancer, gastrointestinal catheter, urinary catheter, postoperative drainage, and preprocedural white blood cell count. Multivariate analysis identified six independent parameters correlating with the occurrence of SSI: diabetes (odds ratio [OR] 6.400; 95% confidence interval [CI] 2.582-15.866; P=0.000); cancer (OR 2.427; 95% CI 1.028-5.732; P=0.043); preprocedural white blood cell count more than 10×10(9)/L (OR 6.988; CI 3.165-15.425; P=0.000); wound classification (clean contaminated [OR: 7.893; CI: 2.244-27.762; P=0.001]; contaminated [OR: 7.031; CI: 1.652-29.922; P=0.008]; dirty [OR: 48.778; CI: 5.418-439.164; P=0.001]); operative duration more than 120 minutes (OR 4.289; CI 1.773-10.378; P=0.001); and postoperative drainage (OR 3.957; CI 1.422-11.008; P=0.008). CONCLUSION Our data suggest that all these risk factors could be regarded as potential indicators of SSI and that relevant preventive measures should be taken to reduce SSI and improve patient outcomes.
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Affiliation(s)
- Keping Cheng
- Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
- Correspondence: Keping Cheng, Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Gulou district of Nanjing 210009, People’s Republic of China, Tel +86 25 8327 2069, Email
| | - Jiawei Li
- Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Qingfang Kong
- Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Changxian Wang
- Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Nanyuan Ye
- Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
| | - Guohua Xia
- Department of Infection Control, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu Province, People’s Republic of China
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Abstract
BACKGROUND The objective of the study is to study surgical site infection (SSI) rates and risk factors in a pediatric population. METHODS We conducted a prospective cohort study to estimate the SSI rate at a national pediatric referral center, covering all patients managed at the Orthopedic Surgery Department of the Niño Jesús Children's University Teaching Hospital from January 2010 through December 2012. Risk factors and antibiotic prophylaxis were monitored. A comparison between Spanish and US data was performed, with a breakdown by National Nosocomial Infection Surveillance risk indices. We also conducted a comparative study of SSI rates from 2010 to 2012 to assess the impact of the epidemiologic surveillance system. RESULTS The study population of 1079 patients had a SSI rate of 2.8%. SSI rates were calculated for spinal fusion and other musculoskeletal procedures according to the National Nosocomial Infection Surveillance risk index. In the case of other musculoskeletal procedures, our SSI rates were 0.8 times lower than the overall Spanish rate, but higher than US rates for all risk categories. For spinal fusion procedures, our SSI rates were 1.2 times higher than the Spanish rates and 3.5 times higher than National Nosocomial Infection Surveillance rates. This latter finding should be interpreted with caution because it was based on a small sample. The multivariate analysis indicated that the only predictive factors of SSI were American Society of Anesthesiologists score and age. CONCLUSIONS The surveillance program showed that for clean procedures, SSI incidence decreased from 4% in 2010 to 3.2% in 2011 and to 2.4% in 2012.
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Vu LT, Vittinghoff E, Nobuhara KK, Farmer DL, Lee H. Surgical site infections in neonates and infants: is antibiotic prophylaxis needed for longer than 24 h? Pediatr Surg Int 2014; 30:587-92. [PMID: 24805114 DOI: 10.1007/s00383-014-3506-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose is to determine whether use of perioperative antibiotics for more than 24 h decreases the incidence of SSI in neonates and infants. METHODS We studied neonates and infants who had clean-contaminated or contaminated gastrointestinal operations from 1996 to 2006. Patient- and operation-related variables, duration of perioperative antibiotics, and SSI within 30 days were ascertained by retrospective chart review. In assessing the effects of antibiotic duration, we controlled for confounding by indication using standard covariate adjustment and propensity score matching. RESULTS Among 732 operations, the incidence of SSI was 13%. Using propensity score matching, the odds of SSI were similar (OR 1.1, 95% CI 0.6-1.9) in patients who received ≤24 h of postoperative antibiotics compared to >24 h. No difference was also found in standard covariate adjustment. This multivariate model identified three independent predictors of SSI: preoperative infection (OR 3.9, 95% CI 1.4-10.9) and re-operation through the same incision, both within 30 days (OR 3.5, 95% CI 1.7-7.4) and later (OR 2.3, 95% CI 1.4-3.8). CONCLUSION In clean-contaminated and contaminated gastrointestinal operations, giving >24 h of postoperative antibiotics offered no protection against SSI. An adequately powered randomized clinical trial is needed to conclusively evaluate longer duration antibiotic prophylaxis.
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Affiliation(s)
- Lan T Vu
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0570, USA,
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King A, Stellar JJ, Blevins A, Shah KN. Dressings and Products in Pediatric Wound Care. Adv Wound Care (New Rochelle) 2014; 3:324-334. [PMID: 24761363 DOI: 10.1089/wound.2013.0477] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 09/20/2013] [Indexed: 01/28/2023] Open
Abstract
Significance: The increasing complexity of medical and surgical care provided to pediatric patients has resulted in a population at significant risk for complications such as pressure ulcers, nonhealing surgical wounds, and moisture-associated skin damage. Wound care practices for neonatal and pediatric patients, including the choice of specific dressings or other wound care products, are currently based on a combination of provider experience and preference and a small number of published clinical guidelines based on expert opinion; rigorous evidence-based clinical guidelines for wound management in these populations is lacking. Recent Advances: Advances in the understanding of the pathophysiology of wound healing have contributed to an ever-increasing number of specialized wound care products, most of which are predominantly marketed to adult patients and that have not been evaluated for safety and efficacy in the neonatal and pediatric populations. This review aims to discuss the available data on the use of both more traditional wound care products and newer wound care technologies in these populations, including medical-grade honey, nanocrystalline silver, and soft silicone-based adhesive technology. Critical Issues: Evidence-based wound care practices and demonstration of the safety, efficacy, and appropriate utilization of available wound care dressings and products in the neonatal and pediatric populations should be established to address specific concerns regarding wound management in these populations. Future Directions: The creation and implementation of evidence-based guidelines for the treatment of common wounds in the neonatal and pediatric populations is essential. In addition to an evaluation of currently marketed wound care dressings and products used in the adult population, newer wound care technologies should also be evaluated for use in neonates and children. In addition, further investigation of the specific pathophysiology of wound healing in neonates and children is indicated to promote the development of wound care dressings and products with specific applications in these populations.
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Affiliation(s)
- Alice King
- Pediatric Advanced Wound and Skin Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Divisions of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Judith J. Stellar
- Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anne Blevins
- Pediatric Advanced Wound and Skin Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kara Noelle Shah
- Pediatric Advanced Wound and Skin Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Divisions of Dermatology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Departments of Pediatrics and Dermatology, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Segal I, Kang C, Albersheim SG, Skarsgard ED, Lavoie PM. Surgical site infections in infants admitted to the neonatal intensive care unit. J Pediatr Surg 2014; 49:381-4. [PMID: 24650461 PMCID: PMC5756080 DOI: 10.1016/j.jpedsurg.2013.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/31/2013] [Accepted: 08/02/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND Surgical interventions are common in infants admitted to the neonatal intensive care unit (NICU). Despite our awareness of the broad impact of surgical site infection (SSI), there are little data in neonates. Our objective was to determine the rate and clinical impact of SSI in infants admitted to the NICU. METHODS Provincial population-based study of infants admitted to a tertiary care NICU. SSI, explicitly defined, was included if it occurred within 30 days of a skin/mucosal-breaking surgical intervention. RESULTS Among 724 infants who underwent 1039 surgical interventions very low birth weight (VLBW) infants were over-represented. The overall SSI rate was 4.3 per 100 interventions [CI 95% 3.2 to 5.7], up to 19 per 100 dirty interventions (wound class 4) [CI 95% 4.0 to 46]. Rates were higher in infants following gastroschisis closure (13 per 100 infants [CI 95% 5.8 to 24]), whereas they were generally low following a ligation of a ductus arteriosus. Infants with SSI required longer hospitalization after adjusting for co-morbidities (p<0.001). CONCLUSIONS Data from this relatively large contemporary study suggest that SSI rates in the NICU setting are more comparable to the pediatric age group. However, VLBW infants and those undergoing gastroschisis closure represent high risk groups.
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Affiliation(s)
- Ilan Segal
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA
| | - Christine Kang
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1
| | - Susan G. Albersheim
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Child & Family Research Institute, 950 west 28th Avenue, Vancouver BC V5Z4H4
| | - Erik D. Skarsgard
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Department of Surgery, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA
| | - Pascal M. Lavoie
- Children’s & Women’s Health Centre of British Columbia, Vancouver BC, Canada V6H 3N1,Department of Pediatrics, University of British Columbia, 2329 West Mall Vancouver BC, V6T 1ZA,Child & Family Research Institute, 950 west 28th Avenue, Vancouver BC V5Z4H4
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Chirurgische Infektionen. KINDERCHIRURGIE 2013. [PMCID: PMC7124103 DOI: 10.1007/978-3-642-29779-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Der menschliche Organismus ist von einer unzähligen Menge von Mikroorganismen umgeben. Dringen diese Krankheitserreger in uns ein, dann laufen Wechselbeziehungen zwischen dem Eindringling und dem Wirtsorganismus ab. Krankheit resultiert, wenn die Mikroorganismen aufgrund ihrer verschiedenen Determinanten der Pathogenität und Virulenz den Wettlauf mit der Infektabwehr des Makroorganismus gewonnen haben. Mit diesem Problem hatten sich Chirurgen zu allen Zeiten auseinanderzusetzen und es hat bis heute nicht an Aktualität verloren.
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Mortellaro VE, Gasior AC, Knott EM, Shah SR, Ostlie DJ, Holcomb GW, St Peter SD. Is there an increased risk of complications with laparoscopy looking for a contralateral patent processus vaginalis? J Laparoendosc Adv Surg Tech A 2012; 22:710-2. [PMID: 22870947 DOI: 10.1089/lap.2012.0044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In young children with a unilateral congenital inguinal hernia, the relatively high incidence of an occult contralateral patent processus vaginalis (CPPV) has led to the practice of laparoscopic contralateral exploration. The effect on postoperative complications such as surgical site infection from performing the laparoscopy has not been previously reported. PATIENTS AND METHODS A retrospective review was conducted on all patients who underwent a unilateral inguinal hernia repair from January 1, 2000 to March 1, 2010. We compared those children who underwent laparoscopic evaluation of the contralateral inguinal ring with those who did not. Patient demographics and operative data outcomes were evaluated. Student's t test was used to compare continuous variables, and the chi-squared test with Yates's correction was used for discrete variables. RESULTS There were 1164 patients who underwent a unilateral inguinal hernia repair during the 10-year study period, and laparoscopy was used in 1010 patients. There were no intraoperative complications from the laparoscopy. In the group who underwent laparoscopy, the mean age was 4.0±3.6 years old, and 88% were male. At laparoscopic exploration, 315 (31%) patients were found to have a CPPV. There were 10 patients (1.0%) who developed a surgical site infection. Infection developed in the side used for laparoscopic exploration in 9 patients and in the contralateral side in 1 patient. All patients with surgical site infections were treated initially with oral antibiotics. Abscesses developed in 2 patients, requiring incision and drainage. No patient required hospital admission or reoperation. In the 154 patients who did not undergo laparoscopy, mean age was 4.3±4.4 years (P=.35), and 85.8% were male (P=.54). There was one wound infection identified in this control group (0.6%) (P=1.00). There was no difference in rate of recurrence (control group, 0%; exploration group, 0.6%; P=.72). CONCLUSIONS There is minimal risk of infection or recurrence following unilateral inguinal hernia repair, and this risk is not increased with the use of contralateral exploration using laparoscopy.
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Affiliation(s)
- Vincent E Mortellaro
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, MO, USA
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Pediatric surgical site infection in the developing world: a Kenyan experience. Pediatr Surg Int 2012; 28:523-7. [PMID: 22297835 DOI: 10.1007/s00383-012-3058-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2012] [Indexed: 10/14/2022]
Abstract
BACKGROUND The purpose of the current study was to determine the incidence of pediatric surgical site infections(SSIs) at an academic children’s hospital in rural sub-Saharan Africa and to identify potentially modifiable risk factors. METHODS Prospectively collected data from 1,008 surgical admissions to Bethany Kids Kijabe Hospital (Kijabe, Kenya) were analyzed retrospectively. Follow-up data were available in 940 subjects. RESULTS SSIs occurred in 6.8% of included subjects(N = 64). Superficial (69%) and deep (29%) infections of the back (38%) and head (25%) were most common. When comparing children who developed SSI to those who did not, we found that wound contamination classification and duration of operation were the only variables with significant differences between groups. CONCLUSIONS Our rate of SSI among pediatric patients insub-Saharan Africa is the lowest reported in the literature to date. More work is needed to identify modifiable risk factors for pediatric SSI in low- and middle-income countries.
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Abstract
The skin is a vital organ with key protective functions. Infants in the NICU are at risk for skin injury because of developmental immaturity and intensive care treatments. When skin injury occurs, the neonatal nurse is challenged to provide wound care to optimize functional and cosmetic healing. Optimal wound care requires basic knowledge of the mechanisms of injury, physiology of wound healing, host factors affecting wound healing, and wound assessment. This knowledge provides the basis for determining appropriate wound treatment, including dressing selection. Attention to pain issues associated with wound care is difficult because of the infant's developmental stage, but is essential because of the potentially negative life-long impact of pain. The premature infant's propensity for skin stripping limits the selection of appropriate dressing, as does the paucity of research examining wound care products in this population.
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Vogels HDE, Bruijnen CJP, Beasley SW. Establishing benchmarks for the outcome of herniotomy in children. Br J Surg 2010; 97:1135-9. [PMID: 20632283 DOI: 10.1002/bjs.7041] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although complication rates following herniotomy in children are low, reported rates vary. The aim of this study was to propose desirable outcome measures that can be used by surgeons to assess the quality of their service. METHODS A review of prospectively collected data on all hernias operated on by the Christchurch-based paediatric surgical service was undertaken. Complication rates were determined and compared with those reported in the literature. Rates for children aged 1 year or above were compared with those in children aged less than 1 year. RESULTS There were 3128 herniotomies performed, with an overall recurrence rate of 0.6 per cent. Wound infections occurred in 0.9 per cent, but were confined to infants aged less than 12 months. The rate of acquired cryptorchidism was 0.4 per cent and testicular atrophy 0.8 per cent in boys. Injury to the vas deferens was recognized in 0.1 per cent. Children under 1 year of age were more likely to develop recurrence than older children (0.9 versus 0.2 per cent respectively; odds ratio 4.56, P = 0.013). CONCLUSION Complication rates were relatively low compared with those reported previously, but were considered achievable in most paediatric surgical units. Specific attention should be paid to the youngest infants, as this group has the highest complication rate. Minimum standards can be proposed based on these and other published outcomes.
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Affiliation(s)
- H D E Vogels
- Department of Paediatric Surgery, Christchurch Hospital, Christchurch, New Zealand
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Abstract
BACKGROUND/PURPOSE This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations. METHODS This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as "clean," "clean-contaminated," "contaminated," or "dirty or infected," and specified duration of perioperative antibiotics as "none," "single preoperative," "24 hours," or ">24 hours." Unweighted kappa score was calculated to estimate interrater reliability. RESULTS Overall interrater reliability for wound classification was poor (kappa = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis. CONCLUSIONS There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis.
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Ameh EA, Mshelbwala PM, Nasir AA, Lukong CS, Jabo BA, Anumah MA, Nmadu PT. Surgical Site Infection in Children: Prospective Analysis of the Burden and Risk Factors in a Sub-Saharan African Setting. Surg Infect (Larchmt) 2009; 10:105-9. [DOI: 10.1089/sur.2007.082] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Emmanuel A. Ameh
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Philip M. Mshelbwala
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Abdulrasheed A. Nasir
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Christopher S. Lukong
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Basheer A. Jabo
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Mark A. Anumah
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Paul T. Nmadu
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
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Chirurgische Infektionen. KINDERCHIRURGIE 2009. [PMCID: PMC7122246 DOI: 10.1007/978-3-540-89032-4_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Der menschliche Organismus ist von einer unzähligen Menge von Mikroorganismen umgeben. Dringen diese Krankheitserreger in uns ein, dann laufen Wechselbeziehungen zwischen dem Eindringling und dem Wirtsorganismus ab. Krankheit resultiert, wenn die Mikroorganismen aufgrund ihrer verschiedenen Determinanten der Pathogenität und Virulenz den Wettlauf mit der Infektabwehr des Makroorganismus gewonnen haben. Mit diesem Problem hatten sich Chirurgen zu allen Zeiten auseinanderzusetzen—und es hat bis heute nicht an Aktualität verloren.
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Southwood LL. Principles of antimicrobial therapy: what should we be using? Vet Clin North Am Equine Pract 2007; 22:279-96, vii. [PMID: 16882476 DOI: 10.1016/j.cveq.2006.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Although the use of antimicrobials has had an insurmountable impact on preventing patient morbidity and mortality, problems with antimicrobial resistance and antimicrobial-induced diarrhea are becoming more apparent in human and veterinary medicine. The mortality associated with nosocomial infection with antimicrobial-resistant bacteria in human patients is alarming. Similarly, in veterinary medicine, the morbidity and high cost of treatment of patients with postoperative infection, for example, are concerns. Specifically in equine medicine, the high morbidity and mortality associated with antimicrobial-induced diarrhea have been devastating in many equine practices. Misuse of antimicrobials is extremely common in human and veterinary medicine. All clinicians have the responsibility to consider the appropriateness of their antimicrobial use carefully and, whenever possible, to minimize antimicrobial administration to patients.
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Affiliation(s)
- Louise L Southwood
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348, USA.
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Ichikawa S, Ishihara M, Okazaki T, Warabi K, Kato Y, Hori S, Lane GJ, Hiramatsu K, Inada E, Kobayashi H, Yamataka A. Prospective study of antibiotic protocols for managing surgical site infections in children. J Pediatr Surg 2007; 42:1002-7; discussion 1007. [PMID: 17560210 DOI: 10.1016/j.jpedsurg.2007.01.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE We adopted antibiotic (Ab) protocols for managing surgical site infections in children and assessed their effectiveness. METHODS We used our protocols on 1313 children between 2004 and 2005. All wounds were monitored for 30 days and classified as clean, clean-contaminated, contaminated, or dirty-infected. Infections were defined as superficial, deep, or organ/space. A retrospective study involving 721 children who had surgery in 2003 was also performed. Chi2 statistical analysis was performed. RESULTS Postprotocol, all Abs were administered accurately by anesthesiologists and infections developed in only 22 cases (1.7%): 0.2% (clean), 2.6% (clean-contaminated), 5.8% (contaminated), and 20.8% (dirty-infected), respectively; 21 were superficial or deep and 1 was organ/space. Age at surgery and sex did not influence incidence, neither did length of surgery for clean-contaminated, contaminated, and dirty-infected wounds; clean wounds were excluded because all surgery was minor. Overall, incidence of infections was 1.2% for elective surgery and 4.5% for emergency surgery (P < .01). Preprotocol, only 67% had Ab and infections developed in 27 cases (3.7%), which is significantly higher than in postprotocol (P < .01). CONCLUSIONS Accurate administration of Ab and careful supervision by an infection control team appear to be effective for preventing wound infections in children.
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Affiliation(s)
- Satoko Ichikawa
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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