Surgical wound infection rates in Spain: data summary, January 1997 through June 2012

Effect of the Implementation of a Surgical Care Bundle in the Incidence of Surgical Site Infection in Spine Surgery: A Quasi-Experimental Study

STUDY DESIGN

Quasi-experimental intervention study.

OBJECTIVE

To assess the effect of a clinical safety and quality improvement plan for patients undergoing spinal fusion surgery on the incidence of surgical site infection (SSI).

SUMMARY OF BACKGROUND DATA

In recent years, infection surveillance and control programs based on care bundles have been included in surgical protocols. These have proven to be essential tools for the prevention and control of SSI, providing indicators for improvement and allowing the characterization of related risk factors.

METHODS

A quasi-experimental study was carried out with analysis before and after the introduction of a preventive care bundle (clinical safety and quality improvement plan). Patients who underwent spinal fusion surgery were included. The incidence of SSI up to 90 days after surgery (maximum incubation period) was assessed. The effect of the intervention was evaluated with the adjusted odds ratio (oR) using a logistic regression model.

RESULTS

A total of 1554 patients were included, 690 in the period 2007 to 2011 (before) and 864 during 2012 to 2018 (after). SSI incidence decreased from 4.2% to 1.9% after the plan (OR: 0.43; 95% confidence interval: 0.23-0.80; P  = 0.006). There was also an improvement in the adequacy of antibiotic prophylaxis, preoperative preparation, and hair removal procedure after the introduction of the care bundle.

CONCLUSION

After implementation of the care bundle, the incidence of SSI in spine fusion surgery decreased significantly. Multivariate analysis showed that the care bundle was an independent protective factor. The implementation of these measures should be reinforced on the routine medical practice to reduce the SSI incidence.Level of Evidence: 3.

Surgical site infection in hip arthroplasty in a 10-year follow-up prospective study: Risk and factors associated

BACKGROUND

The increased demand for hip arthroplasty means a growing number of postsurgical complications. This study aims to assess the risk of surgical site infection (SSI) in a teaching hospital; develop regional, national and international external comparisons; and evaluate SSI-related risk factors, particularly according to the timing of surgery (urgent/unplanned or elective).

METHODS

Prospective cohort study from January 2008 to December 2018. Patients were followed up to 90 days after surgery. Primary endpoint was SSI incidence according to the Centers for Disease Control and Prevention criteria. Multivariate analysis was conducted to find independently associated SSI risk factors. The association between risk factors and SSI incidence was assessed by reference to odds ratio (OR). Analyses were also performed among urgent/unplanned and elective patients to identify whether SSI risk factors differed between groups.

RESULTS

The study population (n = 1,808) has an overall SSI rate of 3.0% (95% confidence interval [CI]: 2.4-3.9). Timing of surgery caused an effect modification, so surgery duration> 75th percentile (OR: 3.8; 95% CI: 1.5-9.8) and inadequate preparation (OR: 3.3; 95% CI: 1.1-10.0) were independent risk factors in the urgent/unplanned group; National Healthcare Safety Network risk index≥ 2 (OR: 6.3; 95% CI: 0.1-19.2) and transfusion (OR: 3.6; 95% CI: 1.1-11.9) in the elective group.

CONCLUSIONS

Hospital infection surveillance systems allow identifying risk factors susceptible to change. Characterization of factors that caused an effect modification is key to identify areas of quality improvement, including reducing operating times, preventing perioperative blood transfusion, or improving patient preparation before surgery.

Major ambulatory surgery in breast diseases

INTRODUCTION

The use of ambulatory surgery (AS) for breast pathology (BP) has increased. The objective of this study is to analyse a group of patients treated surgically for breast pathology in order to evaluate its quality and security in a MAS setting in 2017.

METHODS

A retrospective review of all patients undergoing breast surgery was conducted within an AS programme from January to December 2017 in Consorcio Hospital General Universitario of Valencia (CHGUV). The study analysed the number of patients, exclusion reasons, type of surgical procedures, evolution of substitution rate (SR), rate and causes of conversion to admission, postoperative complications, motives for not being included in the ambulatory programme and the satisfaction rate of the patients treated with ambulatory surgery. This has been compared with a 2013 group.

RESULTS

In 2017, 396 procedures for BP were performed: 170 for benign and 226 for malignant disease. The SR for the global mammary pathology was 72.8%. The SR for benign pathology was 93.4% and the SR for malignant pathology was 57.2%, which has increased in recent years from 45.4% in 2013. The unexpected hospitalization rate (HR) of malignant pathologies was 14.1%, while the HR in benign pathologies was 0.6%. Patients hospitalized for malignant pathologies presented higher complications (17%) than ambulatory patients (8.5%) and benign pathologies (6.5%).

CONCLUSIONS

At the CHGUV, the SR has steadily increased in malignant pathologies. The unexpected hospitalization rate is determined by perioperative sentinel lymph node biopsy results. AS for the treatment of mammary pathology is efficient and safe.

A New Surgical Site Infection Risk Score: Infection Risk Index in Cardiac Surgery

Various scoring systems attempt to predict the risk of surgical site infection (SSI) after cardiac surgery, but their discrimination is limited. Our aim was to analyze all SSI risk factors in both coronary artery bypass graft (CABG) and valve replacement patients in order to create a new SSI risk score for such individuals. A priori prospective collected data on patients that underwent cardiac surgery (n = 2020) were analyzed following recommendations from the Reporting of studies Conducted using Observational Routinely collected health Data (RECORD) group. Study participants were divided into two periods: the training sample for defining the new tool (2010–2014, n = 1298), and the test sample for its validation (2015–2017, n = 722). In logistic regression, two preoperative variables were significantly associated with SSI (odds ratio (OR) and 95% confidence interval (CI)): diabetes, 3.3/2–5.7; and obesity, 4.5/2.2–9.3. The new score was constructed using a summation system for punctuation using integer numbers, that is, by assigning one point to the presence of either diabetes or obesity. The tool performed better in terms of assessing SSI risk in the test sample (area under the Receiver-Operating Characteristic curve (aROC) and 95% CI, 0.67/055–0.76) compared to the National Nosocomial Infections Surveillance (NNIS) risk index (0.61/0.50–0.71) and the Australian Clinical Risk Index (ACRI) (0.61/0.50–0.72). A new two-variable score to preoperative SSI risk stratification of cardiac surgery patients, named Infection Risk Index in Cardiac surgery (IRIC), which outperforms other classical scores, is now available to surgeons. Personalization of treatment for cardiac surgery patients is needed.

Surgical site infection in elective clean and clean-contaminated surgeries in developing countries

BACKGROUND

Surgical site infection (SSI) is both the most frequently studied healthcare-associated infection and the most common healthcare-associated infection in the developing world. A systematic review and meta-analysis was conducted to evaluate the relative size of this burden and to estimate the prevalence of SSI in clean and clean-contaminated surgeries in a large sample of countries in the developing world.

METHODS

A systematic search of the MEDLINE/PubMed, Scopus, and LILACS databases was conducted to identify studies providing the prevalence of SSI in elective clean and clean-contaminated surgeries in 39 countries or regions around the world. Data of interest were limited to publications from January 2000 to December 2017. Studies with information on the number of cases of SSI and number of total elective clean and clean-contaminated surgeries during the same period were included in this evaluation. Studies lacking clear definition of the total number of exposed patients were excluded.

RESULTS

Based on the combined data from the 99 articles evaluated in this analysis, the overall prevalence of SSI in elective clean and clean-contaminated surgeries was estimated to be 6% (95% confidence interval (CI) 5-7%). This increased to 15% (95% CI 6-27%) when considering only those reports with post-discharge surveillance data. The overall prevalence of SSI in Africa/Middle East, Latin America, Asia, and China was 10% (95% CI 6-15%), 7% (95% CI 5-10%), 4% (95% CI 4-5%), and 4% (95% CI 2-6%), respectively. Significant variability in the data was confirmed by both the funnel plot and the Egger test (p=0.008).

CONCLUSIONS

Although the data are variable, it is clear that the incidence of SSI in the developing world is higher than that in the developed world.

Surgical site infection incidence and risk factors in knee arthroplasty: A 9-year prospective cohort study at a university teaching hospital in Spain

BACKGROUND

Surgical site infection (SSI) is one of the complications posed by knee replacement surgery. Hospital-based infection surveillance systems may provide indicators of improvement and allow the characterization of risk factors critical to reduce infection. The aims of this study were to compare the incidence of SSI in our center with rates in the Madrid Region, Spain, and the United States, and to evaluate any possible SSI-related risk factor in knee replacement surgery.

METHODS

All patients who underwent knee replacement surgery at a tertiary hospital in 2008-2016 were included. SSI was defined according to Centers for Disease Control and Prevention criteria. Infection rate was calculated. The association between risk factors and SSI incidence was assessed by reference to odds ratio (OR) with multivariate analysis.

RESULTS

The study population (n = 1969) had a global SSI risk of 1.0%. We found a declining trend in the follow-up period, from an SSI risk of 1.8% in 2009 to 0.4% in 2016. Independent risk factors included hair removal (OR: 3.09, 95% confidence interval [CI]: 1.27-7.50) and National Healthcare Safety Network risk index ≥ 2 (OR: 9.37, 95% CI: 2.90-30.26).

CONCLUSION

This study identified risk factors that showed the necessity to strictly comply with wound decontamination and patient preparation protocols, reduce surgery duration, and identify patients who require comprehensive monitoring.

Incidence of surgical wound infection in renal surgery. The effect of antibiotic prophylaxis appropriateness. A prospective cohort study

OBJECTIVE

To assess compliance with the antibiotic prophylaxis protocol for patients who underwent renal surgery and its effect on the incidence of surgical wound infection.

MATERIAL AND METHODS

We performed a prospective cohort study and assessed the overall compliance and each aspect of the antibiotic prophylaxis (start, administration route, antibiotic of choice, duration and dosage) and reported the compliance rates. The qualitative variables were compared with the chi-squared test, and the quantitative variables were compared with Student's t-test. We studied the effect of antibiotic prophylaxis compliance on the incidence of surgical wound infection in renal surgery, with the relative risk.

RESULTS

The study included 266 patients, with an overall compliance rate of 90.6%. The major cause of noncompliance (3.8%) was the start of the prophylaxis, and the incidence rate of surgical wound infections was 3.4%. We found no relationship between antibiotic prophylaxis noncompliance and surgical wound infections (RR=0.26; 95%CI: 0.1-1.2; P>.05). Laparoscopic surgery had a lower incidence of surgical wound infections than open surgery (RR=0.10; 95%CI: 0.01-0.79).

CONCLUSIONS

The antibiotic prophylaxis compliance was high. The incidence of surgical site infection was low, and there was no relationship between the incidence of surgical site infection and antibiotic prophylaxis compliance. The incidence of infection was lower in laparoscopic surgery.

Incidence of surgical site infection and risk factors in rectal surgery: A prospective cohort study

INTRODUCTION

Surgical site infection (SSI) is the main cause of nosocomial infection in Spain. The aim of this study was to analyze the incidence of SSI and to evaluate its risk factors in patients undergoing rectal surgery.

METHODS

Prospective cohort study, conducted from January 2013 to December 2016. Patient, surgical intervention and infection variables were collected. Infection rate was calculated after a maximum period of 30 days of incubation. The effect of different risk factors on infection was assessed using the odds ratio adjusted by a logistic regression model.

RESULTS

The study included 154 patients, with a mean age of 69.5±12 years. The most common comorbidities were diabetes mellitus (24.5%), chronic obstructive pulmonary disease (17%) and obesity (12.6%). The overall incidence of SSI during the follow-up period was 11.9% (CI95%: 7.8-17.9) and the most frequent microorganism was Escherichia coli (57.9%). Risk factors associated with surgical wound infection in the univariate analysis were blood transfusion, drain tubes and vasoactive drug administration (P<.05).

CONCLUSIONS

The incidence of SSI in rectal surgery was low. It is crucial to assess SSI incidence rates and to identify possible risk factors for infection. We recommend implementing surveillance and hospital control programs.

[Rates of surgical wound infection in hip arthroplasty (2007-2015)]

OBJECTIVE

To estimate the incidence of surgical site infection in the hip replacement procedure during nine years of follow-up in a local public hospital.

MATERIAL AND METHODS

A prospective study conducted between 2007 and 2015, using the Clinical Indicators of Continuous Quality Improvement (INCLIMECC) tool. All primary hip prostheses and revisions were studied. The definitions, criteria and categories for surgical site infection were those estimated for the risk index of the National Nosocomial Infections Surveillance of Centres for Disease Control and Prevention. Crude and adjusted rates were calculated by risk index.

RESULTS

A total of 999 interventions were included. The overall infection rate was 1.5% (95%CI: 0.75-2.25). Surgical prophylaxis was prescribed in 98.3% of the cases, and was adequate in 70.7%, with the main cause of inadequacy being its prolonged duration in 71.3%. The infection rate was 53%, being better than the rates published for Spanish hospitals INCLIMECC in the period 1997-2012. But they were 19% higher than those published for the USA according to the National Healthcare Safety Network, and 50% higher than expected according to data published for Europe by the European Centre for Disease Prevention and Control.

DISCUSSION

The infection rate in the present study is better than those described in the Spanish literature, but it is higher than those published for Europe and North America. Strategies for surveillance and control of infections associated with health care allow the evaluation of trends and the impact of prevention measures.

Antibiotic prophylaxis adequacy in knee arthroplasty and surgical wound infection: Prospective cohort study

OBJECTIVE

Antibiotic prophylaxis is the most suitable tool for preventing surgical wound infection. This study evaluated adequacy of antibiotic prophylaxis in surgery for knee arthroplasty and its effect on surgical site infection.

MATERIAL AND METHOD

Prospective cohort study. We assessed the degree of adequacy of antibiotic prophylaxis, the causes of non-adequacy, and the effect of non-adequacy on surgical site infection. Incidence of surgical site infection was studied after a maximum incubation period of a year. To assess the effect of prophylaxis non-adequacy on surgical site infection we used the relative risk adjusted with the aid of a logistic regression model.

RESULTS

The study covered a total of 1749 patients. Antibiotic prophylaxis was indicated in all patients and administered in 99.8% of cases, with an overall protocol adequacy of 77.6%. The principal cause of non-compliance was the duration of prescription of the antibiotics (46.5%). Cumulative incidence of surgical site infection was 1.43%. No relationship was found between prophylaxis adequacy and surgical infection (RR=1.15; 95% CI: .31-2.99) (P>.05).

DISCUSSION

Surveillance and infection control programs enable risk factors of infection and improvement measures to be assessed. Monitoring infection rates enables us to reduce their incidence.

CONCLUSIONS

Adequacy of antibiotic prophylaxis was high but could be improved. We did not find a relationship between prophylaxis adequacy and surgical site infection rate.

[Effect of compliance with an antibiotic prophylaxis protocol in surgical site infections in appendectomies. Prospective cohort study]

BACKGROUND

Antibiotic prophylaxis is the most suitable tool for preventing surgical site infection. This study assessed compliance with antibiotic prophylaxis in surgery for acute appendicitis, and the effect of this compliance on surgical site infection.

MATERIAL AND METHODS

Prospective cohort study to evaluate compliance with antibiotic prophylaxis protocol in appendectomies. An assessment was made of the level of compliance with prophylaxis, as well as the causes of non-compliance. The incidence of surgical site infection was studied after a maximum incubation period of 30 days. The relative risk adjusted with a logistic regression model was used to assess the effect of non-compliance of prophylaxis on surgical site infection.

RESULTS

The study included a total of 930 patients. Antibiotic prophylaxis was indicated in all patients, and administered in 71.3% of cases, with an overall protocol compliance of 86.1%. The principal cause of non-compliance was time of initiation. Cumulative incidence of surgical site infection was 4.6%. No relationship was found between inadequate prophylaxis compliance and infection (relative risk=0.5; 95% CI: 0.1-1.9) (P>.05).

CONCLUSIONS

Compliance of antibiotic prophylaxis was high, but could be improved. No relationship was found between prophylaxis compliance and surgical site infection rate.

Prediction of surgical site infection after colorectal surgery

BACKGROUND

Surgical site infection (SSI) after colorectal surgery is a frequent complication associated with substantial morbidity. Our objective was to identify surgical predictors of SSI in patients undergoing colorectal surgery using a retrospective case-control design.

MATERIAL AND METHODS

Randomly selected patients from all those undergoing colorectal surgery (2007-2013). Cases were patients who developed SSI within 30 days. Controls were patients who did not develop SSI within 30 days. Patients undergoing multiple procedures during a single surgical intervention were excluded. SSI was diagnosed according to Centers for Disease Control and Prevention definitions. The main outcome measures were SSI, surgical variables, and cumulative survival (Kaplan-Meier method). Variables considered predictors were compared using log-rank test.

RESULTS

Of 911 patients undergoing colorectal surgery, 221 developed SSI (24.3%; 95% confidence interval, 24.0-24.6). On univariate analysis, significant risk factors for SSI were: female sex (P = .02), >72 hours preoperative stay (P = .04), open surgery (P = .08), incision class: contaminated and dirty (P = .001), and emergency procedures (P = .006). On multivariate analysis, significant independent predictors of SSI and survival were dirty surgery (hazard ratio [HR], 2.12; P = .015), contaminated surgery (HR, 1.74; P = .009), female sex (HR, 1.58; P = .003), open surgery, (HR, 1.51; P = .015) and >72 hours preoperative stay (HR, 1.48; P = .024).

CONCLUSIONS

Dirty or contaminated surgery, female sex, open surgery, and >72 hours preoperative stay were significant predictors of SSI.

The Development of Statistical Models for Predicting Surgical Site Infections in Japan: Toward a Statistical Model–Based Standardized Infection Ratio

OBJECTIVE

To develop and internally validate a surgical site infection (SSI) prediction model for Japan.

DESIGN

Retrospective observational cohort study.

METHODS

We analyzed surveillance data submitted to the Japan Nosocomial Infections Surveillance system for patients who had undergone target surgical procedures from January 1, 2010, through December 31, 2012. Logistic regression analyses were used to develop statistical models for predicting SSIs. An SSI prediction model was constructed for each of the procedure categories by statistically selecting the appropriate risk factors from among the collected surveillance data and determining their optimal categorization. Standard bootstrapping techniques were applied to assess potential overfitting. The C-index was used to compare the predictive performances of the new statistical models with those of models based on conventional risk index variables.

RESULTS

The study sample comprised 349,987 cases from 428 participant hospitals throughout Japan, and the overall SSI incidence was 7.0%. The C-indices of the new statistical models were significantly higher than those of the conventional risk index models in 21 (67.7%) of the 31 procedure categories (P<.05). No significant overfitting was detected.

CONCLUSIONS

Japan-specific SSI prediction models were shown to generally have higher accuracy than conventional risk index models. These new models may have applications in assessing hospital performance and identifying high-risk patients in specific procedure categories.

Infect. Control Hosp. Epidemiol. 2016;37(3):260–271

Diminishing Surgical Site Infections in Australia: Time Trends in Infection Rates, Pathogens and Antimicrobial Resistance Using a Comprehensive Victorian Surveillance Program, 2002–2013

OBJECTIVE

To evaluate time trends in surgical site infection (SSI) rates and SSI pathogens in Australia.

DESIGN

Prospective multicenter observational cohort study.

SETTING

A group of 81 Australian healthcare facilities participating in the Victorian Healthcare Associated Infection Surveillance System (VICNISS).

PATIENTS

All patients underwent surgeries performed between October 1, 2002, and June 30, 2013. National Healthcare Safety Network SSI surveillance methods were employed by the infection prevention staff at the participating hospitals.

INTERVENTION

Procedure-specific risk-adjusted SSI rates were calculated. Pathogen-specific and antimicrobial-resistant (AMR) infections were modeled using multilevel mixed-effects Poisson regression.

RESULTS

A total of 183,625 procedures were monitored, and 5,123 SSIs were reported. Each year of observation was associated with 11% risk reduction for superficial SSI (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.88–0.90), 9% risk reduction for deep SSI (RR, 0.91; 95% CI, 0.90–0.93), and 5% risk reduction for organ/space SSI (RR, 0.95; 95% CI, 0.93–0.97). Overall, 3,318 microbiologically confirmed SSIs were reported. Of these SSIs, 1,174 (35.4%) were associated with orthopedic surgery, 827 (24.9%) with coronary artery bypass surgery, 490 (14.8%) with Caesarean sections, and 414 (12.5%) with colorectal procedures. Staphylococcus aureus was the most frequently identified pathogen, and a statistically significant increase in infections due to ceftriaxone-resistant Escherichia coli was observed (RR, 1.37; 95% CI, 1.10–1.70).

CONCLUSIONS

Standardized SSI surveillance methods have been implemented in Victoria, Australia. Over an 11-year period, diminishing rates of SSIs have been observed, although AMR infections increased significantly. Our findings facilitate the refinement of recommended surgical antibiotic prophylaxis regimens and highlight the need for a more expansive national surveillance strategy to identify changes in epidemiology.

Infect Control Hosp Epidemiol 2015;00(0): 1–8