Surgical site infection: incidence and impact on hospital utilization and treatment costs

Modern Trends in Surgical Site Infection Rates for Colorectal Surgery: A National Surgical Quality Improvement Project Study 2013-2020

BACKGROUND

Few studies have investigated trends in global surgical site infection rates in colorectal surgery in the past decade.

OBJECTIVE

This study seeks to describe changes in rates of different surgical site infections from 2013 to 2020, identify risk factors for surgical site infection occurrence, and evaluate the association of minimally invasive surgery and infection rates in colorectal resections.

DESIGN

A retrospective analysis of the National Surgical Quality Improvement Program database 2013-2020 identifying patients undergoing open or laparoscopic colorectal resections by procedure codes was performed. Patient demographic information, comorbidities, procedures, and complications data were obtained. Univariable and multivariable logistic regression analyses were performed.

SETTING

This was a retrospective study.

PATIENTS

A total of 279,730 patients received colorectal resections from 2013 to 2020.

MAIN OUTCOME MEASURES

The primary outcome measure was the rate of surgical site infection, divided into superficial, deep incisional, and organ space infections.

RESULTS

There was a significant decrease in rates of superficial infections ( p < 0.01) and deep incisional infections ( p < 0.01) from 5.9% in 2013 to 3.3% in 2020 and from 1.4% in 2013 to 0.6% in 2020, respectively, but a rise in organ space infections ( p < 0.01) from 5.2% in 2013 to 7.1% in 2020. Minimally invasive techniques were associated with decreased odds of all surgical site infections compared to open techniques ( p < 0.01) in multivariate analysis, and adoption of minimally invasive techniques increased from 59% in 2013 to 66% in 2020.

LIMITATIONS

The study is limited by its retrospective nature and variables available for analysis.

CONCLUSIONS

Superficial and deep incisional infection rates have significantly decreased, likely secondary to improved adoption of minimally invasive techniques and infection prevention bundles. Organ space infection rates continue to increase. Additional research is warranted to clarify current recommendations for mechanical bowel preparation and oral antibiotic use as well as to study novel interventions to decrease postoperative infection occurrence. See Video Abstract .

TENDENCIAS MODERNAS EN LAS TASAS DE INFECCIN DEL SITIO QUIRRGICO PARA CIRUGA COLORRECTAL UN ESTUDIO DEL PROYECTO NACIONAL DE MEJORA DE LA CALIDAD QUIRRGICA

ANTECEDENTES:Hay pocos estudios que investiguen las tendencias en las tasas globales de infección del sitio quirúrgico en cirugía colorrectal en la última década.OBJETIVO:Este estudio busca describir cambios en las tasas de diferentes infecciones del sitio quirúrgico entre 2013 y 2020, identificar factores de riesgo para la aparición de ISQ y evaluar la asociación de la cirugía mínimamente invasiva y las tasas de infección en resecciones colorrectales.DISEÑO:Se realizó un análisis retrospectivo de la base de datos del Programa Nacional de Mejora de la Calidad Quirúrgica 2013-2020 que identifica a los pacientes sometidos a resecciones colorrectales abiertas o laparoscópicas mediante códigos de procedimiento. Se obtuvo información demográfica de los pacientes, comorbilidades, procedimientos y datos de complicaciones. Se realizó regresión logística univariable y multivariable.AJUSTE:Este fue un estudio retrospectivo.PACIENTES:Un total de 279,730 pacientes recibieron resección colorrectal entre 2013 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:La medida de resultado primaria fue la tasa de infección del sitio quirúrgico, dividida en infecciones superficiales, incisionales profundas y del espacio de órganos.RESULTADOS:Hubo una disminución significativa en las tasas de infecciones superficiales (p < 0,01) e infecciones incisionales profundas ( p < 0,01) del 5,9% en 2013 al 3,3% en 2020 y del 1,4% en 2013 al 0,6% en 2020, respectivamente. pero un aumento en las infecciones del espacio de los órganos ( p < 0,01) del 5,2 % en 2013 al 7,1 % en 2020. El uso de técnicas mínimamente invasivas se asoció con una disminución de las probabilidades de todas las infecciones del sitio quirúrgico en comparación con las técnicas abiertas ( p < 0,01) en el análisis multivariado y la adopción de técnicas mínimamente invasivas aumentó del 59% en 2013 al 66% en 2020.LIMITACIONES:El estudio está limitado por la naturaleza retrospectiva y las variables disponibles para el análisis.CONCLUSIONES:Las tasas de infección superficial y profunda han disminuido significativamente, probablemente debido a una mejor adopción de técnicas mínimamente invasivas y esquemas de prevención de infecciones. Las tasas de infección del espacio de los órganos continúan aumentando. Se justifica realizar investigaciones adicionales para aclarar las recomendaciones actuales para la preparación intestinal mecánica y el uso de antibióticos orales, así como para estudiar intervenciones novedosas para disminuir la aparición de infecciones posoperatorias. (Traducción-Dr. Yolanda Colorado ).

Effects of povidone-iodine wound irrigation on surgical site infection in gastroenterological surgery: A randomized controlled trial

BACKGROUND

The irrigation efficacy of a povidone-iodine solution to prevent surgical site infection is still controversial. We assessed the irrigation effect with a povidone-iodine solution on the incidence of surgical site infection after gastroenterological surgery.

METHODS

This study is a single-center, prospective, randomized, blinded-end point superiority trial for surgical wound irrigation. Patients undergoing gastroenterological surgery were randomly assigned in a 1:1 replacement ratio using computer-generated randomization. Patients were grouped according to their surgical wound treatment into the control group using the normal sterile saline and the povidone-iodine group using 10% povidone-iodine solution after the NS solution. The main finding was 30-day surgical site infections assessed in the full analysis set.

RESULTS

From November 2020 to December 2022, 697 of 894 patients were eligible for the study, among which 347 were in the povidone-iodine group and 350 in the control group. Thirty-day surgical site infections occurred in 100 (14%) patients-54 (16%) in the povidone-iodine group and 46 (13%) in the control group (odds ratio, 1.229; 95% CI, 0.800-1.889; P = .406). Superficial incisional surgical site infections occurred in 30 (9%) and 15 (4%) patients, respectively (odds ratio, 2.154; 95% CI, 1.134-4.090; P = .026). Only 3 patients (1%) in the control group developed adverse skin reactions.

CONCLUSION

This study examined the irrigation efficacy of povidone-iodine for surgical site infection prevention compared to control in gastroenterological surgery. Povidone-iodine wound irrigation has shown no additional beneficial effect on the occurrence of surgical site infections.

Surgical-site infection in multifetal cesarean delivery

PURPOSE

The relationship between multifetal cesarean delivery and surgical-site infection (SSI) is unclear. If SSI is more common in multifetal cesareans, adjustment of practices such as antibiotic dosing could be warranted. The purpose of this study was to determine whether patients undergoing multifetal cesarean delivery are more likely to experience SSI than those undergoing singleton cesarean delivery.

METHODS

This was a retrospective cohort study including all cesarean deliveries at a tertiary hospital from 10/1/2009 to 12/28/2018. The primary outcome was rate of SSI in women after multifetal cesarean delivery as compared to those who underwent singleton cesarean delivery. Univariable analysis and multivariable logistic regression were used to assess independent clinical factors associated with SSI in multifetal cesarean deliveries.

RESULTS

34,340 women underwent cesarean delivery during this period. 33,211 were singletons (96.7%), and 1,129 were multifetal (3.3%). There was no difference in the rate of SSI in multifetal gestations (15/1,129, 1.3%) as compared to singletons (493/33,211, 1.5%) (p = 0.670, OR 0.89 [95% CI 0.53, 1.50], aOR 1.06 [95% CI 0.61, 1.84]). Limiting analysis to multifetal deliveries, prolonged rupture of membranes (p < 0.004, OR 5.43 [95% CI 1.49, 19.88]), labor augmentation (p < 0.001, OR 15.84 [1.74, 144.53]), and chorioamnionitis (p < 0.001, OR 15.43 [95% CI 3.11, 76.62]) were more common in women with SSI.

DISCUSSION

SSI is not increased in multifetal cesarean delivery as compared to singleton cesarean delivery. In multifetal cesareans, chorioamnionitis, prolonged rupture of membranes, and labor augmentation were associated with increased odds of SSI.

Incisional Negative Pressure Wound Therapy for Wounds in Patients with Lower Intestinal Perforations

Objectives

Laparotomy for lower intestinal perforation is associated with a high incidence of surgical site infections. This study aimed to assess whether incisional negative pressure wound therapy (iNPWT) could reduce the incidence of these infections and wound dehiscence in patients with lower intestinal perforation.

Methods

This single-center prospective study was conducted between September 2019 and July 2022. In the therapy group, wounds were closed with subcuticular sutures, and iNPWT was applied at -120 mmHg for 5 days. A total of 10 days of iNPWT was employed. These patients were compared with a historical control group. The iNPWT group (Group A) comprised 22 patients.The historical control group (Group B) had 65 patients. Table outlines patient characteristics and compares the two study groups.

Results

Patient characteristics were demographically similar. The incidence of surgical site infections was lower in the therapy group than in the control group (9.1% vs. 52.3%, p < 0.001). Wound dehiscence was not observed in the therapy group but was noted in three patients (4.6%) in the control group. In univariate and multivariate analysis, an application of the therapy device was associated with reduced incidence of surgical site infections (p < 0.001 and p = 0.002, respectively).

Conclusions

The application of iNPWT in patients with lower intestinal perforation was associated with reduced surgical site infections.

What Is the Risk of Irrigation and Debridement Following Foot and Ankle Surgery? Development of a Risk Severity Scoring System

BACKGROUND

Surgical site infection (SSI) after foot and ankle surgery has serious negative effects on patient health and quality of life. While previous studies have looked at predisposing factors for SSI, to our knowledge, no study has proposed a risk severity score.

QUESTIONS/PURPOSES

Can a risk severity score, based on patient demographic characteristics and surgical variables, be developed for preoperative use in patients undergoing foot and ankle surgery that will calculate the risk of an irrigation and debridement (I&D) procedure within 90 days of surgery utilizing data from previous surgeries?

METHODS

A retrospective chart study was performed on patients undergoing foot and ankle surgery. Data on demographic characteristics including age, sex, and BMI were recorded. Data on patient factors including diabetes and smoking history were also recorded. Surgical details including length of surgery, procedure type, surgeon, antibiotic delivery time, antibiotic type, and antibiotic dose were analyzed. Of 2979 procedures, 1% (36) of I&Ds were performed within 90 days. The mean age at surgery was 49 ± 17 years, and 57% (1702) of patients were female. The mean BMI was 28 ± 6 kg/m2. The primary outcome was I&D within 90 days postoperatively. Descriptive statistics of differences in patient characteristics between those who underwent I&D and those who did not were examined using chi-square tests and t-tests (p < 0.05 was taken as significant). Significant variables from a simple regression analysis were included in a multiple logistic regression model with a forward stepwise procedure for variable selection. We required all data in the model to be categorical; thus, continuous variables such as time were dichotomized. We factored odds ratios determined by multiple regression for significant variables into the final risk severity score, and an easy-to-use tool based on this risk severity score was created in Excel (Microsoft).

RESULTS

Current tobacco use, diabetes, and longer operative times were the only factors associated with I&D within 90 days postoperatively. A risk severity score was developed using current tobacco use, diabetes, and length of surgery greater than 60 minutes as factors. A patient with a severity score of 0 (no risk factors) had a 0.6% chance of I&D within 90 days, while a severity score of 1 indicated a 1.1% chance, a score of 2 indicated a 2.1% chance, a score of 3 indicated a 4.0% chance, and a score of 4 (all risk factors) indicated a 7.5% chance of I&D within 90 days. A spreadsheet that can be used at the point of care was created based on these findings.

CONCLUSION

Our risk severity score may help inform preoperative patient guidance and operative planning. Calculating the score in the office setting during preoperative visits can also improve communication between physician and patient. Future research should focus on validation of this risk severity score at multiple institutions.

LEVEL OF EVIDENCE

Level III, prognostic study.

The efficacy of an alcohol-based nasal antiseptic versus mupirocin or iodophor for preventing surgical site infections: A meta-analysis

BACKGROUND

Nasal decolonization of Staphylococcus aureus is a proven strategy to reduce surgical site infections (SSI). Recently updated guidelines expanded nasal decolonization beyond traditionally high-risk populations to include the option for alcohol-based antiseptics (ABAs). We assessed the efficacy of a novel ABA for reducing SSI compared to mupirocin and iodophor.

METHODS

A literature search in Google Scholar, PubMed, MEDLINE, and Cochrane databases was completed of studies reporting SSI outcomes in hospitals using an ABA. Primary meta-analyses were conducted to analyze ABA clinical efficacy versus no intervention (7 studies); subanalyses compared the ABA to mupirocin (3 studies) or iodophor (2 studies).

RESULTS

One hundred forty-seven nasal decolonization titles for SSI prevention were identified, of which 7 were accepted. In the studies selected, 16,212 patients were included: 7,983 (49.24%) control group, and 8,129 (50.14%) intervention group. Significant effect sizes (measured as odds ratios [ORs]) and z-scores were found in all 3 meta-analyses: (OR = 3.178, z = 4.743, P < .001) in ABA clinical efficacy, (OR = 4.110, z = 3.167, P < .01) in ABA versus mupirocin, and (OR = 3.043, z = 3.155, P < .01) in ABA versus iodophor. Funnel plots for each demonstrated a lack of bias.

CONCLUSIONS

Statistically significant positive effects were identified in all 3 meta-analyses. An ABA appears to be a viable alternative to mupirocin or iodophors to reduce SSIs.

The effect of damage control laparotomy on surgical-site infection risks after emergent intestinal surgery

INTRODUCTION

Damage-control laparotomy has been widely used in general surgery. However, associated surgical-site infection risks have rarely been investigated. Damage-control laparotomy allows for additional opportunities for decontamination. We hypothesized that damage-control laparotomy would be associated with lower surgical-site infection risks compared with laparotomy with only primary fascial closure or with primary fascial and skin closure.

METHODS

Patients admitted for emergent intestinal surgery from 2006 to 2021 were included. Multivariate analyses were performed to identify surgical-site infection-associated risk factors. Although variables like laparotomy type (damage-control laparotomy, primary fascial closure, and primary fascial and skin closure) were provided by National Surgical Quality Improvement Program, other variables such as number of operations were retrospectively collected. P < .05 was considered significant.

RESULTS

Overall, 906 patients were included; 213 underwent damage-control laparotomy, 175 primary fascial closure, and 518 primary fascial and skin closure. Superficial, deep, and organ-space surgical-site infection developed in 66, 6, and 97 patients, respectively. Compared with primary fascial and skin closure, both damage-control laparotomy (odds ratio, 0.30 [95% CI, 0.13-0.73], P = .008) and primary fascial closure (odds ratio, 0.09 [95% CI, 0.02-0.37], P = .001) were associated with lower superficial incisional surgical-site infection but not organ-space surgical-site infection risk (odds ratio, 0.80 [95% CI, 0.29-2.19] P = .667 and odds ratio, 0.674 [95% CI, 0.21-2.14], P = .502, respectively). Body mass index was associated with increased risk of superficial incisional surgical-site infection (odds ratio, 1.06 [95% CI, 1.03-1.09], P < .001) whereas frailty was associated with organ space surgical-site infection (odds ratio, 3.28 [95% CI, 1.29-8.36], P = .013). For patients who underwent damage-control laparotomy, the number of operations did not affect risk of either superficial incisional surgical-site infection or organ space SSI.

CONCLUSION

Herein, compared with primary fascial and skin closure, both damage-control laparotomy and primary fascial closure were associated with lower superficial but not organ space surgical-site infection risks. For patients who underwent damage-control laparotomy, number of operations did not affect surgical-site infection risks.

Local Prophylactic Teicoplanin Effect on Spinal Fusion Surgery: A Comparative Retrospective Study

BACKGROUND

 Surgical site infection (SSI) is one of the most severe complications of spinal fusion surgery that lead to increased morbidity and mortality rates. Prophylactic antibiotic usage is one of the methods that reduce the possibility of SSI in this procedure. The aim of this study was to determine the effect of local subfascial teicoplanin usage on radiologic and functional outcomes and compare it to the effect of vancomycin on surgical outcomes in patients who underwent decompression with posterior instrumentation (DPI) for lumbar spinal stenosis (LSS).

METHODS

 Medical charts of patients with LSS who received DPI and met the study criteria were divided into three groups: the teicoplanin group included patients who underwent DPI with local teicoplanin before closure, the vancomycin group included patients who underwent DPI with local vancomycin, and the control group included patients who underwent DPI without any local prophylactic antibiotics.

RESULTS

 A total of 101 patients were included in the study. No significant differences were found among groups regarding demographics, follow-up, and clinical and functional outcomes. No significant differences were observed among groups regarding postoperative improvements in SF-36-MCS, SF-36-PCS, Oswestry Disability Index, and Visual Analog Scale (VAS; p > 0.05). In the teicoplanin and vancomycin groups, the SSI rate was lower than that in the control group (2/35, 1/34, and 5/32, respectively, p = 0.136) without statistical significance; however, the postoperative fusion volume was significantly higher in the teicoplanin group when compared to the other groups (3.35 ± 1.08, 2.68 ± 1.17, and 2.65 ± 1.28 cm3, respectively, p = 0.007).

CONCLUSIONS

 Although its cost is relatively higher, teicoplanin was a good alternative to vancomycin in preventing SSIs with a higher fusion rate, but no superiority was observed regarding other outcomes.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study

BACKGROUND

This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery.

METHODS

A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates.

RESULTS

In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment.

CONCLUSION

When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Evaluating the Differences of Wound Related Complications in Robotically Assisted Radical Cystectomy vs Open Radical Cystectomy

OBJECTIVE

To determine whether robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) compared to open radical cystectomy (ORC) or RARC with extracorporeal urinary diversion (ECUD) would result in a decreased rate of surgical site complications. RARC has been shown to be non-inferior to ORC. Both RARC and ORC are complicated by a high rate of perioperative morbidity, including wound-related complications, which may be decreased by a robotic approach with intracorporeal diversion.

METHODS

A retrospective review of our bladder cancer database for patients undergoing radical cystectomy from 2013-2021. Patients were stratified by surgical technique as RARC with ICUD vs ORC vs RARC with ECUD. Surgical site complications were measured at both 30- and 90-day intervals.

RESULTS

Of the 269 patients, 127 (47.2%) had RARC with ICUD, 118 (43.7%) had ORC, and 24 (8.9%) had RARC with ECUD (mean ages 71.0, 69.5, and 67.5, respectively). A comparison of the 3 groups demonstrated statistical significance at both the 30-day (P <.001) and 90-day (P <.001) timeframes for total surgical site complications, with RARC with ICUD having the fewest amount of patients experiencing a surgical site complication (0.8%) followed by ORC (25.4%) and RARC with ECUD (29.2%).

CONCLUSION

Overall, we observed lower surgical site complication rates among patients undergoing RARC with ICUD compared to patients who underwent ORC or RARC with ECUD. This study suggests that decreased surgical site complications may be one benefit of the minimally invasive approach, particularly in patients at high risk for surgical site complications after radical cystectomy.

Automated traffic monitoring of neurosurgical operating room

BACKGROUND

Operating room (OR) traffic disrupts airflow and increases particle count, which predisposes patients to surgical site infections, particularly in longer surgeries with hardware placement. The aim of this study is to evaluate the rate of traffic during neurosurgical procedures, as well as reasons for and perceptions of OR traffic.

METHODS

This is a single-center, multimethod study monitoring neurosurgical OR traffic through direct observation, automated monitoring, and interviews. Traffic was observed between the skin incision and closure. Personal interviews with OR teams including surgeons, anesthesia, and nurses were conducted to evaluate their perceptions of the frequency of OR traffic and reasons for OR traffic.

RESULTS

Direct observation reported OR door opening an average of 18 times, with 20 people entering or exiting per hour. The exact reason for traffic was not verified in all traffic cases and was able to be confirmed in only a third of the cases. Automated monitoring resulted in an average of 31 people entering or exiting the OR per hour. The procedure length was significantly associated with the number of people entering or exiting the OR per hour (P < .0001). Interviews highlighted that OR teams reported traffic to be significantly lower than observed and automated monitoring results, with approximately <6 people entering or exiting per hour.

CONCLUSIONS

OR traffic is higher than staff expected, and updated processes are required to reduce the number of times the OR door opens. Implementing automated observation of OR traffic could reduce the OR traffic and the risk for surgical site infection.

Precision in Prevention: Tailoring Single-Use Negative Pressure Wound Therapy Utilization Through Artificial Intelligence-Based Surgical Site Complications Risk and Cost Modeling

Background: Surgical site complications (SSCs) are common, yet preventable hospital-acquired conditions. Single-use negative pressure wound therapy (sNPWT) has been shown to be effective in reducing rates of these complications. In the era of value-based care, strategic allocation of sNPWT is needed to optimize both clinical and financial outcomes. Materials and Methods: We conducted a retrospective analysis using data from the Premier Healthcare Database (2017-2021) for 10 representative open procedures in orthopedic, abdominal, cardiovascular, cesarean delivery, and breast surgery. After separating data into training and validation sets, various machine learning algorithms were used to develop pre-operative SSC risk prediction models. Model performance was assessed using standard metrics and predictors of SSCs were identified through feature importance evaluation. Highest-performing models were used to simulate the cost-effectiveness of sNPWT at both the patient and population level. Results: The prediction models demonstrated good performance, with an average area under the curve of 76%. Prominent predictors across subspecialities included age, obesity, and the level of procedure urgency. Prediction models enabled a simulation analysis to assess the population-level cost-effectiveness of sNPWT, incorporating patient and surgery-specific factors, along with the established efficacy of sNPWT for each surgical procedure. The simulation models uncovered significant variability in sNPWT's cost-effectiveness across different procedural categories. Conclusions: This study demonstrates that machine learning models can effectively predict a patient's risk of SSC and guide strategic utilization of sNPWT. This data-driven approach allows for optimization of clinical and financial outcomes by strategically allocating sNPWT based on personalized risk assessments.

Costs and resource utilization patterns in surgical site infections: a pre-COVID-19 perspective from France, Germany, Spain, and the UK

BACKGROUND

Surgical site infections (SSIs), mainly caused by Staphylococcus aureus, pose a significant economic burden in Europe, leading to increased hospitalization duration, mortality, and treatment costs, particularly with drug-resistant strains such as meticillin-resistant S. aureus.

AIM

To conduct a case-control study on the economic impact of S. aureus SSI in adult surgical patients across high-volume centres in France, Germany, Spain, and the UK, aiming to assess the overall and procedure-specific burden across Europe.

METHODS

The SALT study is a multinational, retrospective cohort study with a nested case-control analysis focused on S. aureus SSI in Europe. The study included participants from France, Germany, Italy, Spain, and the UK who underwent invasive surgery in 2016 and employed a micro-costing approach to evaluate health economic factors, matching S. aureus SSI cases with controls.

FINDINGS

In 2016, among 178,904 surgical patients in five European countries, 764 developed S. aureus SSI. Matching 744 cases to controls, the study revealed that S. aureus SSI cases incurred higher immediate hospitalization costs (€8,810), compared to controls (€6,032). Additionally, S. aureus SSI cases exhibited increased costs for readmissions within the first year post surgery (€7,961.6 versus €5,298.6), with significant differences observed. Factors associated with increased surgery-related costs included the cost of hospitalization immediately after surgery, first intensive care unit (ICU) admission within 12 months, and hospital readmission within 12 months, as identified through multivariable analysis.

CONCLUSION

The higher rates of hospitalization, ICU admissions, and readmissions among S. aureus SSI cases highlight the severity of these infections and their impact on healthcare costs, emphasizing the potential benefits of evidence-based infection control measures and improved patient care to mitigate the economic burden.

Effective Surgical Site Infection Prevention Strategies for Diabetic Patients Undergoing Surgery: A Systematic Review

Surgical site infections (SSIs) pose a significant clinical challenge, with heightened risks and severe consequences for diabetic patients undergoing surgical procedures. This systematic review aims to synthesize the current evidence on effective prevention strategies for mitigating SSI risk in this vulnerable population. From inception to March 2024, we comprehensively searched multiple electronic databases (PubMed, Medline, Embase, Cochrane Library, CINAHL) to identify relevant studies evaluating SSI prevention strategies in diabetic surgical patients. Our search strategy followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, utilizing a combination of keywords and Medical Subject Headings (MeSH) terms related to diabetes, surgical site infections, prevention strategies, and surgical procedures. Inclusion criteria focused on peer-reviewed clinical trials, randomized controlled trials, and meta-analyses published in English. The search yielded three studies meeting the eligibility criteria, subject to data extraction and qualitative synthesis. Key findings highlighted the efficacy of interventions such as optimized perioperative glycemic control, timely prophylactic antibiotic administration, and meticulous preoperative skin antisepsis in reducing SSI rates among diabetic surgical patients. The potential for personalized prevention approaches based on individual patient factors, such as diabetes type and surgical complexity, was explored. This systematic review underscores the importance of a multifaceted, evidence-based approach to SSI prevention in diabetic surgical patients, integrating strategies like glycemic control, antibiotic prophylaxis, and preoperative skin antisepsis. Furthermore, our findings suggest the potential benefits of personalized care pathways tailored to individual patient characteristics. Implementing these interventions requires interdisciplinary collaboration, adaptation to diverse healthcare settings, and patient engagement through culturally sensitive education initiatives. This comprehensive analysis informs clinical practice, fosters patient safety, and contributes to the global efforts to enhance surgical outcomes for this high-risk population.

The Utility of Prevena Negative Pressure Wound Therapy on Groin Incisions for Critical Limb-Threatening Ischemia: A Single Institution Experience

BACKGROUND

Incisional negative pressure wound therapy (iNPWT) is an adjunctive treatment that uses constant negative pressure suction to facilitate healing. The utility of this treatment modality on vascular operations for critical limb-threatening ischemia (CLTI) has yet to be elucidated. This study compares the incidence of postoperative wound complications between the Prevena Incision Management System, a type of iNPWT, and standard wound dressings for vascular patients who also underwent plastic surgery closure of groin incisions for CLTI.

METHOD

We performed a retrospective cohort study of 40 patients with CLTI who underwent 53 open vascular surgeries with subsequent sartorius muscle flap closure. Patient demographics, intraoperative details, and wound complications were measured from 2015 to 2018 at the University of California San Francisco. Two cohorts were generated based on the modality of postoperative wound management and compared on wound healing outcomes.

RESULTS

Of the 53 groin incisions, 29 were managed with standard dressings, and 24 received iNPWT. Patient demographics, comorbidities, and operative characteristics were similar between the 2 groups. Patients who received iNPWT had a significantly lower rate of infection (8.33% vs 31.0%, P = 0.04) and dehiscence (0% vs 41.3%, P < 0.01). Furthermore, the iNPWT group had a significantly lower rate of reoperation (0% vs 17.2%, P = 0.03) for wound complications within 30 days compared with the control group and a moderately reduced rate of readmission (4.17% vs 20.7%, P = 0.08).

CONCLUSIONS

Rates of infection, reoperation, and dehiscence were significantly reduced in patients whose groin incisions were managed with iNPWT compared with standard wound care. Readmission rates were also decreased, but this difference was not statistically significant. Our results suggest that implementing iNPWT for the management of groin incisions, particularly in patients undergoing vascular operations for CLTI, may significantly improve clinical outcomes.

Preoperative MRSA screening using a simple questionnaire prior elective total joint replacement

INTRODUCTION

The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures.

METHODS

Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients.

RESULTS

Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening.

CONCLUSION

Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach.

Antimicrobial stewardship program for gastrointestinal surgeries at a Vietnamese tertiary hospital

Background

Antimicrobial Stewardship Programs (ASP) have been applied widely in high-resource countries to prevent surgical site infections (SSI). Evidence favoring ASP interventions (ASPi) in gastrointestinal surgeries from low and middle-income countries has been limited, especially in antimicrobial prophylaxis. We aimed to investigate this gap at a Vietnamese tertiary hospital.

Methods

We conducted a retrospective cohort study on patients undergoing clean-contaminated surgeries in 2015 who received standard of care (SoC) or SoC + ASPi. Primary outcome was 30-day SSI incidence. Secondary outcomes included length of stay (LoS) after surgery (days), cost of antibiotics, and cost of treatment (USD). Results were controlled for multiplicity and reported with treatment effect and 95% confidence interval (95%CI). A predictive model was built and cross-validated to detect patients at high risk of SSI.

Results

We included 395 patients for analysis (48.1% being female, mean age 49.4 years). Compared to patients receiving SoC, those with SoC + ASPi had a lower incidence of 30-day SSI (-8.8, 95%CI: -16.0 to -1.6, p = 0.042), shorter LoS after surgery (-1.1 days, 95%CI: -1.8 to -0.4, p = 0.004), and lower cost of antibiotics (-37.3 USD, 95%CI: -59.8 to -14.8, p = 0.012) and treatment (-191.1 USD, 95%CI: -348.4 to -33.8, p = 0.042). We estimated that by detecting patients at high risk of SSI with the predictive model and providing prophylactic measures, we could save 398120.7 USD per 1,000 cases of SSI.

Conclusion

We found that ASPi were associated with a reduction in risks of SSI, hospital stays, and cost of antibiotics/treatment in a Vietnamese tertiary hospital.

Preventing Surgical Site Infections in Geriatric Ankle Fracture Surgery with Closed-Incision Vacuum Therapy: A Pilot Study

BACKGROUND

Ankle fractures are among the most common fractures in older adult patients that need surgical treatment. The risk of surgical site infections (SSIs) after ankle fracture surgery ranges between 0.5% and 30%; SSI incidence is higher among older adults. Further, SSIs have significant consequences for subjective functional outcomes and create a need for prolonged intravenous antibiotic therapy and wound care. Accordingly, it is critical to determine risk factors for and establish optimal postoperative wound care to prevent SSIs.

OBJECTIVE

The aim of the pilot study was to examine the feasibility of closed-incision vacuum therapy (CIVT) to reduce rates of SSI in older adults.

METHODS

The authors performed a pilot study of a CIVT system in a population of 10 older adult patients after ankle fracture surgery.

RESULTS

Nine patients experienced uncomplicated wound healing of the lateral incision. One patient (10%) developed an SSI after premature removal of the vacuum system because of technical failure. Six weeks postoperation, overall satisfaction with the CIVT was high; none of the participants complained of incapacitating discomfort or disruptive limitations in postsurgical recovery.

CONCLUSIONS

The authors conclude that CIVT is a feasible, safe, and generally well-tolerated therapy to prevent SSIs in postoperative wound healing after open reduction and internal fixation in older adult patients after ankle fracture.

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study)

Background

Negative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life.

Method

This is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life.

Conclusion

Patients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Risk factors for surgical site infection in patients undergoing obstetrics and gynecology surgeries: A meta-analysis of observational studies

OBJECTIVE

The aim of this study was to identify the risk factors for surgical site infection (SSI) in patients undergoing obstetrics and gynecology surgeries through meta-analysis.

METHODS

Relevant original studies published from January 1945 to May 2023 were searched the CBM, PubMed, Embase, WOS, CNKI, Wanfang, vip, and Cochrane Library databases. Studies eligible were evaluated by two investigators following Newcastle-Ottawa Scale(NOS) criteria. Review Manager 5.3 software was used to analyse the combined effect sizes and test for heterogeneity, and Stata 14.0 software's Begg's Test and Egger's Test were used to test for bias.

RESULTS

13 case-control articles, including 860 cases in the case group and 13574 cases in the control group, met the inclusion criteria. Eventually, Our meta-analysis showed that SSI in patients undergoing obstetrics and gynecology surgeries was correlated with body mass index (BMI)≥24 (OR = 2.66; P < 0.0001), malignant lesions (OR = 4.65; P < 0.0001), operating time≥60min (OR = 2.58; P < 0.0001), intraoperative bleeding≥300ml (OR = 2.54; P < 0.0001), retained urinary catheter (OR = 4.45; P < 0.0001), and vaginal digital examination≥3times (OR = 2.52; P < 0.0001).

CONCLUSION

In this study, BMI≥24, intraoperative bleeding≥300ml, malignant lesions, operating time≥60min, retained urinary catheter, and vaginal digital examination≥3times were considered as independent risk factors for SSI in obstetrics and gynecology surgery. It is recommended that scholars be rigorous in designing the experimental process when conducting case-control or experimental studies in order to improve the quality of the study. Controlling patients' weight before obstetrical and gynecological surgery, shortening the operation time intraoperatively, and strictly controlling the indications of vaginal digital examination and retained urinary catheter can effectively reduce the incidence of SSI.

Posterior cranial vault distraction in children with syndromic craniosynostosis: the era of biodegradable materials-a comprehensive review of the literature and proposed novel global application

Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis.

Fracture related infection (FRI) of the upper extremity correlates with poor bone and soft tissue healing

PURPOSE

The purpose of this study was to evaluate the specific course and complication profile following the development of FRI in the upper extremity.

METHODS

An IRB-approved retrospective review was conducted on a consecutive series of operatively managed patients within an academic medical center between 1/2010 and 6/2022. Included patients met the following criteria: (1) upper extremity fracture definitively treated with internal fixation (2) development of criteria for suggestive or confirmatory FRI (as per the FRI Consensus Group) and (3) age ≥ 18 years. Baseline demographics, medical history, injury information, infection characteristics, hospital quality measures, and outcomes were recorded. A 3:1 propensity-matched control cohort of patients without FRI was obtained using the same dataset. Univariable analysis was performed to compare the outcomes (rate of nonunion, time to bone healing, need for soft tissue coverage, patient reported joint stiffness at final follow-up) of the FRI vs Non-FRI cohorts.

RESULTS

Of 2827 patients treated operatively for an upper extremity fracture, 43 (1.53%) met criteria for suggestive of confirmatory FRI. The successful propensity match (43 FRI, 129 Non-FRI) revealed no differences in demographics, baseline health status, or fracture location. FRI patients underwent more reoperations (p < 0.001), experienced an increased rate of removal of hardware (p < 0.001), and were admitted more frequently following index operation (p < 0.001). The FRI cohort had higher rates of fracture nonunion (p = 0.003), and a prolonged mean time to bone healing in months (8.37 ± 7.29 FRI vs. 4.14 ± 5.75 Non-FRI, p < 0.001). Additionally, the FRI cohort had a greater need for soft tissue coverage throughout their post-operative fracture treatment (p = 0.014). While there was no difference in eventual bone healing (p = 0.250), FRI patients experienced a higher incidence of affected joint stiffness at final follow-up (p < 0.001).

CONCLUSION

Patients who develop an FRI of the upper extremity undergo more procedures and experience increased complications throughout their treatment, specifically increased joint stiffness. Despite this, ultimate outcome profiles are similar between patients who experience FRI and those who do not following operative repair of an upper extremity fracture.

LEVEL OF EVIDENCE

III.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study

BACKGROUND

Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure.

METHODS

We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition.

RESULTS

We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 ​% vs. 11.9 ​%; p ​= ​0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 ​% vs. 4.4 ​%; p ​= ​0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group.

CONCLUSION

The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.

Surgical site infections after glioblastoma surgery: boon or bane?

BACKGROUND

Surgical site infections (SSIs) are among the most common postoperative complications. Glioblastoma multiforme is the most frequent malignant brain tumor with a dismal prognosis despite combined treatment. The effect of SSIs on the course of glioblastoma patients has not been fully clarified since available data are limited and partially contradictory. The aim of this study is to investigate the impact of SSIs on the course of patients with glioblastoma.

METHODS

The medical records of all patients undergoing surgery for glioblastoma between 2010 and 2020 in our institution were scanned and those with surgical site infections after glioblastoma resection were identified and compared to an age-matched control group. Overall survival and progression-free survival were the primary endpoints followed by the number of hospitalizations and the length of stay in hospital.

RESULTS

Out of 305 patients undergoing surgery for glioblastoma, 38 patients with postoperative surgical site infection after resection were identified and 15 (5 men and 10 women aged between 9 and 72) were included in this study. 23 patients were excluded. The control group consisted of 30 age-matched patients without SSI (18 men and 12 women). There were no significant differences in median overall survival. Progression-free survival was higher in the SSI group. The number of hospitalizations and the length of stay were significantly higher in the SSI group.

CONCLUSION

Our data suggest that SSIs might reduce early recurrences without affecting overall survival. Furthermore, they might decrease health-related quality of life by doubling the total length of hospital stay.

Tailored Pre-Operative Antibiotic Prophylaxis to Prevent Post-Operative Surgical Site Infections in General Surgery

The average American today undergoes three inpatient and two outpatient surgical procedures during one's life, each of which carries with it a risk of post-operative infection. It has long been known that post-operative infections cause significant morbidity in the immediate peri-operative period, but recent evidence suggests that they can have long-term consequences as well, increasing a patient's risk of infectious complications in unrelated surgeries performed months or even years later. While there are several theories on the origin of this association, including bacterial colonization of a post-operative infectious wound site, antimicrobial resistance from curative courses of antibiotics, subclinical immunosuppression, or the creation of an inflammatory "pathobiome" following an infectious insult, it is ultimately still unclear why patients who experience a single post-operative infection seem to be at a significantly higher risk of experiencing subsequent ones. Regardless, this association has significant implications for the routine use of pre-operative antibiotic prophylaxis. Indeed, while the prescription of antibiotics pre-operatively has dramatically reduced the rate of post-operative infections, the chosen prophylaxis regimens are typically standardized according to national guidelines, are facing increasing antimicrobial resistance patterns, and have been unable to reduce the risk of post-operative infection to acceptably low levels for certain surgeries. As a result, some clinicians have speculated that tailoring pre-operative antibiotic prophylaxis according to a patient's prior infectious and operative history could improve efficacy and further reduce the rate of post-operative infections. The purpose of this review is to describe the evidence for the link between multiple post-operative infections and explore the efficacy of individualized pre-operative prophylaxis.

pH-Responsive Wound Dressing Based on Biodegradable CuP Nanozymes for Treating Infected and Diabetic Wounds

Nanozymes, emerging nanomaterials for wound healing, exhibit enzyme-like activity to modulate the levels of reactive oxygen species (ROS) at wound sites. Yet, the solo regulation of endogenous ROS by nanozymes often falls short, particularly in chronic refractory wounds with complex and variable pathological microenvironments. In this study, we report the development of a multifunctional wound dressing integrating a conventional alginate (Alg) hydrogel with a newly developed biodegradable copper hydrogen phosphate (CuP) nanozyme, which possesses good near-infrared (NIR) photothermal conversion capabilities, sustained Cu ion release ability, and pH-responsive peroxidase/catalase-mimetic catalytic activity. When examining acute infected wounds characterized by a low pH environment, the engineered Alg/CuP composite hydrogels demonstrated high bacterial eradication efficacy against both planktonic bacteria and biofilms, attributed to the combined action of catalytically generated hydroxyl radicals and the sustained release of Cu ions. In contrast, when applied to chronic diabetic wounds, which typically have a high pH environment, these composite hydrogels exhibit significant angiogenic performance. This is driven by the provision of catalytically generated dissolved oxygen and a beneficial supplement of Cu ions released from the degradable CuP nanozyme. Further, a mild thermal effect induced by NIR irradiation amplifies the catalytic activities and bioactivity of Cu ions, thereby enhancing the healing process of both infected and diabetic wounds. Our study validates that the synergistic integration of photothermal effects, catalytic activity, and released Cu ions can concurrently yield high antibacterial efficiency and tissue regenerative activity, rendering it highly promising for various clinical applications in wound healing.

Optimal antiseptic skin preparation agents for minimizing surgical site infection following surgery: cost and cost-effectiveness analysis

BACKGROUND

The application of antiseptic skin agents prior to incision minimizes the rate of surgical site infection. Despite their ubiquity, the optimal skin preparation agent remains uncertain. A retrospective economic analysis was conducted to complement the results from the NEWSkin Prep trial which prospectively compared three preparation agents.

METHODS

A cost and cost-effectiveness analysis was performed from a healthcare service perspective to compare chlorhexidine with 70% ethanol, and aqueous povidone-iodine, against povidone-iodine with 70% ethanol. Resource use estimates accounted for hospital admissions, readmissions associated with surgical site infection, outpatient and general practitioner attendances, visits from community nurses and therapeutic consumables. The measure of effectiveness comprised the net difference in number of patients with surgical site infections per 1000 patients. Costs were compared using a two-sample Welch's t-test. Deterministic and probabilistic sensitivity analyses were performed to evaluate the incremental cost-effectiveness ratio.

RESULTS

The null hypothesis that the mean costs for the trial arms were significantly different was not rejected (Welch's t-test P value: 0.771 for chlorhexidine with 70% ethanol against povidone-iodine with 70% ethanol; and 0.955 for aqueous povidone-iodine against povidone-iodine with 70% ethanol). Based on bootstrap averages, the chlorhexidine with 70% ethanol intervention generated 8.0 fewer surgical site infections per 1000 patients and net cost savings of €151,698 (Euros) per 1000 patients compared with povidone-iodine with 70% ethanol, and aqueous povidone-iodine produced a net cost saving of €37,494 per 1000 patients but generated an additional 11.6 surgical site infections per 1000 patients compared with povidone-iodine with 70% ethanol. The comparison of chlorhexidine with 70% ethanol to povidone-iodine with 70% ethanol was sensitive to the inclusion of cost outliers, while the comparison of aqueous povidone-iodine to povidone-iodine with 70% ethanol was sensitive to the estimated cost per surgical site infection.

CONCLUSION

Based on the outcomes from the NEWSkin Prep study, this economic analysis found no definitive evidence in favour of any one of the study comparators. Future model-based economic analyses of alternative skin preparations should critically address the quality of evidence and integrate the results from the NEWSkin Prep study.

Effect of Negative Pressure Wound Therapy on Surgical Site Infections following Stoma Reversal in Colorectal Surgery: A Meta-Analysis

BACKGROUND

Surgical site infections (SSI) are common complications after surgery, which cause other complications and increase medical costs. However, the effect of negative-pressure wound therapy (NPWT) for the prevention of SSI at stoma reversal remains inconclusive, with controversial results. This meta-analysis aimed to evaluate the safety and efficacy of NPWT following stoma reversal in colorectal surgery to prevent SSI and other wound complications.

METHODS

We conducted a systematic search of the PubMed, EMBASE, and Cochrane Library databases for articles published up to July 2022 and identified relevant studies reporting the NPWT administration following stoma reversal in colorectal surgery compared with non-pressure dressing. The primary outcome was the incidence of SSI, and the secondary outcomes were hematoma, seroma, and length of hospital stay (LOS).

RESULTS

Nine studies were included in the meta-analysis, with 825 patients with (n = 310) or without (n = 515) NPWT. Pooled SSI rate was lower in the NPWT group than in the non-pressure dressing group (OR = 0.50; 95% CI: 0.29, 0.84; P = 0.01). There was no significant effect on hematoma (OR = 0.21; 95% CI: 0.03, 1.27; P = 0.09), seroma (OR = 0.26; 95% CI: 0.05, 1.28; P = 0.1) and LOS (MD = -0.16, 95% CI: -0.83, 0.51; P = 0.64).

CONCLUSION

The use of NPWT following stoma reversal in colorectal surgery reduced the incidence of SSI. However, this conclusion needs to be interpreted with caution, and further studies should be conducted to confirm in higher-quality RCTs.

Reducing urinary tract infection in female pelvic surgery: A retrospective cohort study

OBJECTIVE

To compare prebundle versus postbundle implementation urinary tract infection (UTI) rates among inpatients within 6 weeks of clean-contaminated pelvic reconstructive surgery.

METHODS

The authors conducted a retrospective cohort study from September 2019 to December 2021 at a tertiary hospital. The bundle strategy included the following: universal preoperative UTI check with treatment if positive, replacing prolonged postoperative voiding trials on the ward with earlier discharge and indwelling catheter removal by a nurse continence advisor the next day, and daily cranberry extract for 6 weeks postoperatively. UTI was defined as positive urine culture (≥100 000 colony-forming unit per mL) in a symptomatic patient. Data analysis involved hypothesis testing and logistic regression.

RESULTS

The authors reviewed 132 postbundle inpatient charts and retained 93 for analyses. The results were compared with 204 prebundle inpatient charts. The rate of postoperative UTI decreased from 17.6% in the prebundle group to 6.5% after bundle implementation (P = 0.01). The adjusted odds ratio for postbundle versus prebundle likelihood of UTI was 0.35 (95% confidence interval, 0.13-0.98; P = 0.045). Significantly more postbundle patients compared with prebundle patients were discharged home on the first day postoperatively (76.3% vs. 37.7%, P < 0.001).

CONCLUSIONS

A clinical bundle can significantly decrease both UTI rates and hospital stay after pelvic reconstructive surgery.

Incidence and risk factors of surgical site infection in patients with head and neck cancer: A meta-analysis

We systematically review the incidence and risk factors of surgical site infection (SSI) in patients with head and neck cancer. PubMed, Embase, Cochrane Library, and Web of Science databases were searched to obtain studies on the risk factors for SSI in patients with HNC. The retrieval time was from the establishment of the database to February 2023. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias in included studies. Meta-analysis was performed by using Stata 15.1 software. A total of 32 articles including 128 919 patients with head and neck cancer and 2949 cases of SSI were included in this meta-analysis. The incidence rate of SSI in head and neck cancer ranges from 19% to 29%, and the overall infection rate was 24%. Meta-analysis indicated that BMI < 20 kg/m2 (OR, 2.64; 95% CI, 1.74-4.00; I2 , 0%), diabetes (OR, 3.00; 95% CI, 2.12-4.16; I2 , 60.6%), ASA score (OR, 1.51; 95% CI, 1.29-1.77; I2 , 0%), radiotherapy (OR, 2.27; 95% CI, 1.87-2.77; I2 , 44.8%), chemotherapy (OR, 2.36; 95% CI, 1.64-3.40; I2 , 0%), clindamycin antibiotic (OR, 2.99; 95% CI, 1.82-2.93; I2 , 36.5%), deficit repair (OR, 3.76; 95% CI, 1.22-11.59; I2 , 91.4%), neck dissection (OR, 2.13; 95% CI, 1.63-2.79; I2 , 16.4%), blood transfusion (OR, 2.29; 95% CI, 1.52-3.45; I2 , 66.2%), mandibular (OR, 3.17; 95% CI, 1.85-5.42; I2 , 73%), tracheostomy (OR, 2.51; 95% CI, 1.74-3.62; I2 , 86.4%), operation time (OR, 1.42; 95% CI, 1.16-1.74; I2 , 86.4%), ALB (OR, 2.48; 95% CI, 1.95-3.15; I2 , 5.3%) were risk factors of surgical site infection in patients with head and neck cancer (p < 0.05). The results of the sensitivity analysis showed good agreement in all risk factors and the results had stability. The present meta-analysis suggests that BMI < 20 kg/m2 , diabetes, ASA score, radiotherapy, chemotherapy, clindamycin antibiotic, deficit repair, neck dissection, blood transfusion, mandibular, tracheostomy, operation time, and ALB were significant risk factors for SSI.

Negative Pressure Wound Therapy in Closed Colorectal Surgical Incisions: A Systematic Review and Meta-Analysis

The utilization of negative pressure wound therapy (NPWT) in lowering the incidence of infections in closed colorectal surgical incisions has not been thoroughly established, and recent trials have had conflicting results. This meta-analysis was conducted to synthesize the findings of available trial data and carefully evaluate the effectiveness of this intervention in colorectal surgery. The databases PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were combed for randomized controlled trials (RCTs) that compared negative pressure wound therapy to standard dressing in closed wounds of patients undergoing colorectal surgery. The incidence of surgical site infections (SSIs) was the primary outcome. Secondary outcomes included the occurrence of seroma and hematoma. The trial results were represented as odds ratios (OR) with a 95% confidence interval (CI), and a fixed-effects model was used. Nine studies found eligible were included, and the pooled results revealed that negative pressure wound therapy significantly reduced the incidence of surgical site infections (OR: 0.70; 95% CI: 0.53, 0.93; P= 0.02). Furthermore, there was a significant reduction in seroma (OR: 0.27; 95% CI: 0.08, 0.95; P = 0.04) and hematoma (OR: 0.20; 95% CI: 0.04, 0.96; P = 0.04). The use of negative pressure wound therapy for primarily closed incisions has been increasing, and our results indicate that it is superior to standard surgical dressings in preventing surgical site infections and other wound complications in colorectal surgeries.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials

INTRODUCTION

The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers.

METHODS AND ANALYSIS

Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour).

ETHICS AND DISSEMINATION

Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42018090261.

Preoperative Epidural Steroid Injections and Postoperative Infections After Lumbar or Cervical Spine Surgery: A Systematic Review and Meta-Analysis

Objective

To determine the risk difference and 95% prediction intervals (PIs) for postoperative infections (POIs) associated with preoperative epidural steroid injections (ESIs) in adults undergoing lumbar or cervical spine surgery.

Methods

Comprehensive database searches were conducted from inception dates through December 2023. Inclusion criteria included all study designs involving adults receiving a preoperative ESI before lumbar or cervical decompression or fusion spine surgery. Risk of bias was assessed using a modified tool developed for uncontrolled studies. The summary estimates of risk difference and the corresponding PIs were reported.

Results

A total of 12 studies were included in the systematic review, of which 9 were included in the meta-analysis. Preoperative ESIs within 1 month of lumbar spine decompression or fusion surgery were associated with a 0.6% and 2.31% greater risk of a POI, respectively. In adults ≥65 years of age, ESIs within 1 or 1-3 months of lumbar spine decompression or fusion surgery were associated with a 1.3% and 0.6% greater risk of a POI, respectively. Preoperative ESIs within 3 months of cervical spine fusion were not associated with an increased risk of a POI. The bounds of all corresponding 95% PIs were nonsignificant.

Conclusion

The observations of this study provide summary estimates of risk difference and 95% PIs, which could be used to support shared decision-making about the use of ESIs before cervical or lumbar spine surgery.

Effect of Pre-Operative Low Serum Pre-Albumin on Surgical Site Infection in Post-Surgery Subjects: A Systematic Review and Meta-Analysis

Background: The correlation between pre-operative serum pre-albumin and surgical site infection (SSI) has been the focus of many studies. However, existing literature presents conflicting evidence on this association. Therefore, this meta-analysis was conducted to determine the significance of low serum pre-albumin as a prognostic factor SSI, and to assess the potential utility of pre-albumin in predicting SSI. Methods: A comprehensive literature search and analysis was conducted in PubMed, Web of Science, Cochrane of Library, Scopus, Embase, and Google Scholar databases through August 2022 to identify studies reporting low pre-operative serum pre-albumin levels in patients undergoing surgery and their association with SSIs. The pooled risk estimates were shown in odds ratio with 95% confidence interval. The random effect model was used according to the test of heterogeneity among studies. Subgroup analyses and sensitivity analyses were performed to identify the possible sources of heterogeneity. This meta-analysis was prospectively registered in the PROSPERO database (number: CRD42022376167). Results: Nine studies involving 5,306 patients were eligible. The results demonstrated an association between low pre-operative serum pre-albumin levels and a higher probability of developing SSI (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.28-3.26). Conclusions: Our findings suggest that low serum pre-albumin level may serve as an independent and valuable predictor of SSI. These results provide important insights for clinicians in identifying high-risk patients and implementing preventive measures.

Formative evaluation of the development and implementation of the automated surveillance of postoperative infections tool

BACKGROUND

The gold standard for detecting postoperative complications uses databases like the American College of Surgeons National Surgical Quality Improvement Program, a multi-centered database based on manual chart review. However, their limitations and costs have led many centers to discontinue participation. Novel techniques to detect postoperative complications must be developed and implemented with surgeon involvement, which is paramount to their adoption. We sought to assess surgeons' opinions of a newly developed postoperative complication detection tool, the Automated Surveillance of Postoperative Infections, within the contextual clinical environment.

METHODS

This was a multi-site qualitative formative evaluation of surgeon perceptions of the Automated Surveillance of Postoperative Infections. We conducted semi-structured interviews and focus groups with surgeons and presented the Automated Surveillance of Postoperative Infections concept. Important domains and constructs, as categorized by Consolidated Framework for Implementation Research, were identified to support the successful adoption and implementation of the Automated Surveillance of Postoperative Infections.

RESULTS

Twenty-four surgeons with 10 surgical subspecialties were interviewed. The following 4 main themes were found: (1) perception of the Automated Surveillance of Postoperative Infections tool-to provide important data that can improve and support clinical outcomes; (2) environment for implementation-description of factors to support or impede implementation; (3) adaptability of the Automated Surveillance of Postoperative Infections-to work with the complexity of surgical cases; and (4) the Automated Surveillance of Postoperative Infections report format and details.

CONCLUSIONS

We successfully captured the perspectives and suggestions of surgeons to improve the Automated Surveillance of Postoperative Infections and potential barriers during the initial development phase. Barriers included fear of punitive action from reports and complex surgical cases. Facilitators identified were the need to improve clinical outcomes and organizational support. The results of this formative evaluation will be used to further develop Automated Surveillance of Postoperative Infections, starting with a prototype, the Automated Surveillance of Postoperative Infections 1.0.

Staphylococcus aureus surgical site infection rates in 5 European countries

OBJECTIVE

To determine the overall and procedure-specific incidence of surgical site infections (SSI) caused by Staphylococcus aureus (S. aureus) as well as risk factors for such across all surgical disciplines in Europe.

METHODS

This is a retrospective cohort of patients with surgical procedures performed at 14 European centres in 2016, with a nested case-control analysis. S. aureus SSI were identified by a semi-automated crossmatching bacteriological and electronic health record data. Within each surgical procedure, cases and controls were matched using optimal propensity score matching.

RESULTS

A total of 764 of 178 902 patients had S. aureus SSI (0.4%), with 86.0% of these caused by methicillin susceptible and 14% by resistant pathogens. Mean S. aureus SSI incidence was similar for all surgical specialties, while varying by procedure.

CONCLUSIONS

This large procedure-independent study of S. aureus SSI proves a low overall infection rate of 0.4% in this cohort. It provides proof of principle for a semi-automated approach to utilize big data in epidemiological studies of healthcare-associated infections. Trials registration The study was registered at clinicaltrials.gov under NCT03353532 (11/2017).

Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is a health-threatening complication following caesarean section (CS); however, to the authors' knowledge, there is no worldwide estimate of the burden of post-CS SSIs. Therefore, this systematic review and meta-analysis aimed to estimate the global and regional incidence of post-CS SSIs and associated factors.

METHODS

International scientific databases were searched systematically for observational studies published from January 2000 to March 2023, without language or geographical restrictions. The pooled global incidence rate was estimated using a random-effects meta-analysis (REM), and then stratified by World-Health-Organization-defined regions as well as by sociodemographic and study characteristics. Causative pathogens and associated risk factors of SSIs were also analysed using REM. Heterogeneity was assessed with I2.

RESULTS

In total, 180 eligible studies (207 datasets) involving 2,188,242 participants from 58 countries were included in this review. The pooled global incidence of post-CS SSIs was 5.63% [95% confidence interval (CI) 5.18-6.11%]. The highest and lowest incidence rates for post-CS SSIs were estimated for the African (11.91%, 95% CI 9.67-14.34%) and North American (3.87%, 95% CI 3.02-4.83%) regions, respectively. The incidence was significantly higher in countries with lower income and human development index levels. The pooled incidence estimates have increased steadily over time, with the highest incidence rate during the coronavirus disease 2019 pandemic (2019-2023). Staphylococcus aureus and Escherichia coli were the most prevalent pathogens. Several risk factors were identified.

CONCLUSION

An increasing and substantial burden from post-CS SSIs was identified, especially in low-income countries. Further research, greater awareness and the development of effective prevention and management strategies are warranted to reduce post-CS SSIs.

The effect of preoperative oral nutritional supplementation on surgical site infections among adult patients undergoing elective surgery: A systematic review and meta-analysis

INTRODUCTION

Mixed findings are reported on the effect of oral nutritional supplements in reducing Surgical Site Infections (SSIs).

MATERIAL AND METHODS

PubMED, EMBASE and Cochrane were searched. Studies from inception to July 2022 were included if they involved adults undergoing elective surgery and compared preoperative macronutrient oral nutritional supplements to placebo/standard diet.

RESULTS

Of 372 unique citations, 19 were included (N ​= ​2480): 13 RCTs (N ​= ​1506) and 6 observational studies (N ​= ​974). Moderate-certainty evidence suggested that nutritional supplements SSI risk (OR 0.54, 95% C.I. 0.40-0.72, N ​= ​2718 participants). In elective colorectal surgery, this risk-reduction was 0.43 (95% C.I. 0.26-0.61, N ​= ​835 participants) and among patients who received Impact 0.48 (95% C.I. 0.32-0.70, N ​= ​1338).

CONCLUSION

Oral nutritional supplements prior to adult elective surgery may significantly reduce SSIs, with an overall 50% protective effect. This protective effect persisted in subgroup analysis of colorectal surgery patients and the use of Impact.

Enhanced recovery protocols for ambulatory surgery

INTRODUCTION

In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.

Incidence and impact of surgical site complications on length of stay and cost of care for patients undergoing open procedures

Background

Surgical site complications (SSCs) can have serious and life-threatening consequences for patients; however, their frequency and impact on healthcare utilization across surgical procedures, particularly for non-infectious SSCs, are unknown. This study examined incidence of overall SSCs and non-infectious SSCs in patients undergoing open surgical procedures in the United States and their effect on length of stay (LOS) and costs.

Methods

This retrospective study utilizing 2019-2020 data from Medicare and Premier Health Database identified patients with SSCs during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSCs. Mean LOS and costs attributable to SSCs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSC on LOS and costs across healthcare settings.

Results

Overall and non-infectious SSC rates were 7.3 % and 5.3 % respectively for 2,696,986 Medicare and 6.7 % and 5.0 % for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSC were 7.8 days and $15,339 for Medicare patients and 6.2 days and $17,196 for Premier patients. Incremental LOS and cost attributable to non-infectious SSCs were 6.5 days and $12,703 and 5.2 days and $14,477 for Medicare and Premier patients respectively.

Conclusions

This study utilizing two large national databases provides strong evidence that SSCs, particularly non-infectious SSCs, are not uncommon in open surgeries and result in increased healthcare utilization and costs. These findings demonstrate the need for increased adoption of evidence-based interventions that can reduce SSC rates.

Assessment of risk factors associated with surgical site infection following abdominal surgery: a systematic review

Objective

Surgical site infections (SSIs) are among the most common healthcare-associated infections occurring following 1%-3% of all surgical procedures. Their rates are the highest following abdominal surgery. They are still associated with increased morbidity and healthcare costs despite the advancement in the medical field. Many risk factors for SSIs following abdominal surgery have been identified. The aim of this study is to comprehensively assess these risk factors as published in peer-reviewed journals.

Design

A systematic review was conducted with accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Setting

The databases for search were PubMed and Cochrane Library, in addition to reference lists. Studies were retrieved and assessed for their quality. Data were extracted in a designed form, and a stratified synthesis of data was conducted to report the significant risk factors.

Participants

Patients undergoing general abdominal surgery.

Intervention

The intervention of general abdominal surgery.

Main outcome measures

To identify and assess the risk factors for SSI following abdominal surgery.

Results

Literature search yielded 813 articles, and the final screening process identified 11 eligible studies. The total number of patients is 11 996. The rates of SSI ranged from 4.09% to 26.7%. Nine studies were assessed to be of high quality, the remaining two studies have moderate quality. Stratified synthesis of data was performed for risk factors using summary measures (OR/risk ratio, 95% CI, and p value). Male sex and increased body mass index (BMI) were identified as significant demographic risk factors, and long operative time was among the major significant procedure-related risk factors.

Conclusions

Male sex, increased BMI, diabetes, smoking, American Society of Anesthesiologists classification of >2, low albumin level, low haemoglobin level, preoperative hospital stay, long operative time, emergency procedure, open surgical approach, increased wound class, intraoperative blood loss, perioperative infection, perioperative blood transfusion, and use of drains are potential independent risk factors for SSI following abdominal surgery.

Ciprofloxacin-Loaded Polyvinylpyrrolidone Foils for the Topical Treatment of Wound Infections with Methicillin-Resistant Staphylococcus aureus (MRSA)

Bacterial infections are a constant challenge in the management of acute and chronic wounds. Chronic wounds, such as diabetic foot ulcers, have increased significantly in the last few years due to the rise of an aging population. A better understanding of the infectious pathophysiological mechanisms is urgently needed along with new options for the treatment of wound infections and wound-healing disorders. New advances in the preparation of biocompatible dressing materials that can be loaded with antimicrobial drugs may improve the topical treatment of infected wounds. In this study, we investigated the antimicrobial activity of polyvinylpyrrolidone (PVP) foils loaded with ciprofloxacin (Cipro-foils) in the presence of acetic acid as a co-solvent. We used ex vivo human wounds that were infected with two bacterial strains: methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa (PAO1). The effectiveness of the treatment was demonstrated by the quantification of the living bacteria extracted from the wound and the detection of released immunological mediators in skin extracts and in the skin culture media. We found that Cipro-foils effectively treated the infection with both PAO1 and MRSA. Other than PAO1, MRSA had no lytic activity toward skin proteins. MRSA infections increased cytokines' expression and release. Interestingly, treatment with Cipro-foils could partially counteract these effects.

No Link Between Inadvertent Surgical Glove Contamination and Surgical Site Infection in Patients Undergoing Elective Neurosurgical Operations

INTRODUCTION

Controllable factors associated with surgical site infections (SSIs) have focused on reducing contamination of the surgical field with potential pathogens. The aim of this prospective study is to determine the incidence of glove contamination in a series of elective neurosurgical operations and determine the relationship of such glove contamination to subsequent SSI. We hypothesize that contamination of surgical gloves is associated with subsequent SSI.

METHODS

In this prospective quality improvement study, gloves of the surgical team were swabbed for standard culture just prior to wound closure of elective neurosurgical operations. Patient characteristics, surgical details, and occurrence of subsequent SSIs were collected retrospectively from the electronic medical records. Data were analyzed with χ2 with Fisher's exact test and Student's t test.

RESULTS

Surgical glove contamination occurred in 10 of 96 elective neurosurgical cases (10.4%). SSIs occurred in 6 cases (6.2%), but no SSI occurred in a case in which surgical glove contamination occurred (P = 1). SSI was associated with younger patient age (P = 0.0448), and surgical glove contamination was associated with less resident experience (P = 0.0354).

CONCLUSIONS

Surgical glove contamination identified at the time of wound closure does not correlate with the development of subsequent SSI in elective neurosurgical operations.

Incidence of surgical site infections after cervical spine surgery: results of a single-center cohort study adhering to multimodal preventive wound control protocol

PURPOSE

The incidence of surgical site infections is considered a relevant indicator of perioperative and postoperative care quality. The aim of this study is to analyze and evaluate SSIs after elective cervical spine surgery under the guidance of our preventive multimodal wound protocol.

METHODS

A monocentric observational cohort study analyzed 797 patients who underwent cervical spine surgery from 2005 to 2010 (mean age 51.58 ± 11.74 year, male 56.09%, mean BMI 26.87 ± 4.41, ASA score 1-2 in 81.68% of patients), fulfilling the entry criteria: (1) cervical spine surgery performed by neurosurgeons (degenerative disease 85.19%, trauma 11.04%, tumor 3.76%), (2) elective surgery, (3) postoperative care in our neurointensive care unit. Our preventive wound control protocol management focused mainly on antibiotic prophylaxis, wound hygiene regime, and drainage equipment. All wound complications and surgical site infections were monitored up for 1 year after surgery.

RESULTS

We had only 2 (0.25%) patients with SSI after cervical spine surgery-one organ/space infection (osteomyelitis, primary due to liquorrhea) after anterior surgical approach, and one deep surgical site infection (due to dehiscence) after posterior approach. We had 17 (2.13%) patients with some wound complications (secretion 7, dehiscence 4, hematoma 1, edema 3, and liquorrhea 2) that were not classified as SSI according to the CDC guidelines.

CONCLUSION

Concerning our study population of patients undergoing elective cervical surgery, with ASA scores 1-2 in 81.68% of our patients, the incidence of SSI was 0.14% after anterior surgical approach, 1.4% after posterior surgical approach, and 0.25% altogether in the referred cohort.

Antibiotic Prophylaxis in Clean Hand Surgery: A Prospective Cohort Analysis of Major and Minor Complications

Purpose

The indications for prophylactic antibiotics in hand surgery remain undefined. Current literature has focused solely on readmission and reoperation for surgical site infection, while neglecting minor infectious complications treated at outpatient follow-up in addition to complications from antibiotic therapy observed after surgery. This study sought to analyze major and minor infection rates, as well as adverse effects of preoperative antibiotics after clean hand surgery.

Methods

A prospective cohort study was conducted over a 6-month period. The cohorts included patients who received preoperative antibiotic prophylaxis and those that did not. Patient details and operative data were obtained during the first postoperative visit following the index surgery. Primary outcomes assessed were as follows: (1) major infection, defined as admission or reoperation for infection; (2) minor infection, defined as use of postoperative oral antibiotics; and (3) complications of antibiotic therapy.

Results

A total of 377 consecutive patients underwent operations of the upper extremity. Complications from preoperative antibiotic therapy were seen in 6.9% of patients. Overall, there were no major postoperative infections and the minor postoperative infection rate was 5.6%. The minor infection rate was 6.9% (9/131) among patients who did not receive preoperative antibiotics and 4.9% (12/246) among patients who received preoperative antibiotics (P = .57).

Conclusions

A 5.6% minor infection rate was identified following clean hand surgery, with no cases of major infection. Preoperative antibiotics did not demonstrate benefit in terms of reduction of minor infections, but they did yield a 6.9% adverse reaction rate, including one case of Clostridium difficile infection warranting hospitalization. Caution is recommended while prescribing prophylactic antibiotics for clean hand surgeries, given the lack of clear benefits and the potential for adverse effects.

Type of Study/level of evidence

Prognostic II.

Predictive Value of Routine WBC Count Obtained Before Discharge for Organ Space Infection in Children with Complicated Appendicitis: Results from the Eastern Pediatric Surgery Network

BACKGROUND

The objective of this study was to evaluate the clinical utility of a routine predischarge WBC count (RPD-WBC) for predicting postdischarge organ space infection (OSI) in children with complicated appendicitis.

STUDY DESIGN

This was a multicenter study using NSQIP-Pediatric data from 14 hospitals augmented with RPD-WBC data obtained through supplemental chart review. Children with fever or surgical site infection diagnosed during the index admission were excluded. The positive predictive value (PPV) for postdischarge OSI was calculated for RPD-WBC values of persistent leukocytosis (≥9.0 × 10 3 cells/μL), increasing leukocytosis (RPD-WBC > preoperative WBC), quartiles of absolute RPD-WBC, and quartiles of relative proportional change from preoperative WBC. Logistic regression was used to calculate predictive values adjusted for patient age, appendicitis severity, and use of postdischarge antibiotics.

RESULTS

A total of 1,264 children were included, of which 348 (27.5%) had a RPD-WBC obtained (hospital range: 0.8 to 100%, p < 0.01). The median RPD-WBC was similar between children who did and did not develop a postdischarge OSI (9.0 vs 8.9; p = 0.57), and leukocytosis was absent in 50% of children who developed a postdischarge OSI. The PPV of RPD-WBC was poor for both persistent and increasing leukocytosis (3.9% and 9.8%, respectively) and for thresholds based on the quartiles of highest RPD-WBC values (>11.1, PPV: 6.4%) and greatest proportional change (<32% decrease from preoperative WBC; PPV: 7.8%).

CONCLUSIONS

Routine predischarge WBC data have poor predictive value for identifying children at risk for postdischarge OSI after appendectomy for complicated appendicitis.

Machine Learning Model for Assessment of Risk Factors and Postoperative Day for Superficial vs Deep/Organ-Space Surgical Site Infections

Background. Deep and organ space surgical site infections (SSI) require more intensive treatment, may result in more severe clinical disease and may have different risk factors when compared to superficial SSIs. Machine learning (ML) algorithms provide the opportunity to analyze multiple factors to predict of the type and time of development of SSI. Therefore, we developed a ML model to predict type and postoperative week of SSI. Methodology. A case-control study was conducted among patients who developed a SSI after undergoing general surgery procedures at a tertiary care hospital between 2019 to 2020. Patients were followed for 30 days. Six ML algorithms were trained as predictors of type of infection (superficial vs deep/organ space) and time of infection, and tested using area under the receiver operating characteristic curve (AUC-ROC). Results. Data for 113 patients with SSIs was available. Of these 62 (54.8%) had superficial and 51 had (45.2%) deep/organ space infections. Compared with other ML algorithms, the XG boost univariate model had highest AUC-ROC (.84) for prediction of type of SSI and Stochastic gradient boosting univariate, logistic regression univariate, XG boost univariate, and random forest classification univariate model had the highest AUC-ROC (.74) for prediction of week of infection. Conclusions. ML models offer reasonable accuracy in prediction of superficial vs deep SSI and time of developing infection. Follow-up duration and allocation of treatment strategies can be informed by ML predictions.

Surgical site infection trends in community hospitals from 2013 to 2018

OBJECTIVE

Sparse recent data are available on the epidemiology of surgical site infections (SSIs) in community hospitals. Our objective was to provide updated epidemiology data on complex SSIs in community hospitals and to characterize trends of SSI prevalence rates over time.

DESIGN

Retrospective cohort study.

METHODS

SSI data were collected from patients undergoing 26 commonly performed surgical procedures at 32 community hospitals in the southeastern United States from 2013 to 2018. SSI prevalence rates were calculated for each year and were stratified by procedure and causative pathogen.

RESULTS

Over the 6-year study period, 3,561 complex (deep incisional or organ-space) SSIs occurred following 669,467 total surgeries (prevalence rate, 0.53 infections per 100 procedures). The overall complex SSI prevalence rate did not change significantly during the study period: 0.58 of 100 procedures in 2013 versus 0.53 of 100 procedures in 2018 (prevalence rate ratio [PRR], 0.84; 95% CI, 0.66-1.08; P = .16). Methicillin-sensitive Staphylococcus aureus (MSSA) complex SSIs (n = 480, 13.5%) were more common than complex SSIs caused by methicillin-resistant S. aureus (MRSA; n = 363, 10.2%).

CONCLUSIONS

The complex SSI rate did not decrease in our cohort of community hospitals from 2013 to 2018, which is a change from prior comparisons. The reason for this stagnation is unclear. Additional research is needed to determine the proportion of or remaining SSIs that are preventable and what measures would be effective to further reduce SSI rates.

Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study

BACKGROUND

Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established.

MATERIALS AND METHODS

Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay.

RESULTS

A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis.

CONCLUSIONS

In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.