Incidence and risk factors for surgical site infection post-hysterectomy in a tertiary care center

A meta-analysis of the risk factors of surgical site infection after hysterectomy for endometrial cancer

Surgical Site Infection (SSI) is one of the common postoperative complications after hysterectomy for endometrial cancer (EC). Previous studies have investigated the risk factors for SSI in patients with EC. However, big differences in research results exist, and the correlation coefficients of different research results are quite different. A meta-analysis was conducted to examine the risk factors related to SSI in patients with EC. We searched English databases to collect case-control studies or cohort studies published before July 20, 2023, including PubMed, Web of Science, Embase and ScienceDirect. The risk of bias in the included studies was assessed via Newcastle-Ottawa Scale. The analysis was performed using RevMan 5.4.1 tool. A total of 6 articles (n = 3647) were selected in this meta-analysis. The following risk factors were presented to be significantly correlated with SSI in EC: laparotomy (OR = 2.66, 95% CI [1.57, 4.54]), postoperative blood sugar ≥10 mmol/L (OR = 4.38, 95% CI [2.83, 6.78]), Federation International of Gynaecology and Obstetrics (FIGO) stage-III or IV (OR = 2.27, 95% CI [1.49, 3.46]). The occurrence of SSI is influenced by a variety of factors. Thus, we should pay close attention to high-risk subjects and take crucial targeted interventions to lower the SSI risk after hysterectomy. Owing to the limited quality and quantity of the included studies, more rigorous studies with adequate sample sizes are needed to verify the conclusion.

Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy

BACKGROUND

The use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis.

METHODS

We reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others.

RESULTS

In the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate.

CONCLUSIONS

The effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.

Trends in Same-Day Discharge Rate After Minimally Invasive Sacrocolpopexy and Propensity Score-Matched Analysis of Postoperative Complication Rates Using the National Surgical Quality Improvement Program Database

OBJECTIVE

The primary aim of this study was to review trends in the same-day discharge (SDD) rate after minimally invasive sacrocolpopexy (MISCP). The secondary aim was to compare the composite 30-day postoperative complication rates between propensity score-matched SDD and admitted cohorts.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2019. Patients who underwent MISCP were identified by Current Procedural Terminology codes. Concurrent hysterectomy, anterior or posterior repairs, rectopexy, and midurethral sling were also identified. Multivariable logistic regression and propensity score matching were performed.

RESULTS

A total of 12,762 MISCP patients were captured: 3,968 underwent MISCP only, 4,065 underwent MISCP with total laparoscopic hysterectomy, 734 underwent MISCP with laparoscopically assisted vaginal hysterectomy, and 3,995 underwent MISCP with laparoscopic supracervical hysterectomy. Overall, the SDD rate was 16.3%, with an increase from 12.3% in 2015 to 23.1% in 2019. Multivariable logistic regression showed that admitted patients were more likely to be older, to be of Black race, have an American Society of Anesthesiologists classification of 3 or 4, have hypertension requiring medication, have longer operative time, and have undergone concurrent anterior or posterior repair, rectopexy, or sling. After propensity score matching, the composite postoperative complication rates were similar between the 2 cohorts (5.7% vs 6.4%, P = 0.818). However, superficial surgical site infection was more likely in the SDD cohort (adjusted odds ratio, 2.3; P < 0.001) and blood transfusion in the admitted cohort (adjusted odds ratio, 11.9; P = 0.0.34).

CONCLUSIONS

The rate of SDD after MISCP seems to be increasing. Composite postoperative complication rates are similar between SDD and admitted cohorts.

Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database

BACKGROUND

Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database.

METHODS

IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period.

RESULTS

Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy.

CONCLUSIONS

Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.

Effect of Nursing Intervention in the Operating Room Based on Simple Virtual Reality Augmented Technology on Preventing Gastrointestinal Surgical Incision Infection

Gastrointestinal surgery is currently a common gastrointestinal surgery in clinical practice. In recent years, the incidence of gastrointestinal diseases has gradually increased and increased as the lifestyle of modern people has developed and changed. Both physical health and quality of life have a serious impact. In the actual process, it was found that multiple links in operating room care may increase the risk of postoperative infections for patients. Therefore, this article proposes nursing in operating room based on simple virtual reality augmented technology. This article mainly studies the effect of nursing intervention on preventing gastrointestinal surgical incision infection, and hopes to provide help for preventing gastrointestinal surgical incision infection. In this trial, 80 patients with gastrointestinal surgery were randomly divided into two groups, each with 40 people. The experimental group was treated with an operating room nursing intervention combined with traditional treatment methods. Controls were treated with traditional nursing combined with traditional treatment, and both groups were analyzed for acceptance of nursing intervention in the operating room, poor mood, various indicator levels, postoperative complications, and postoperative incisional infections. The experiment proved that the postoperative rehabilitation indexes of the experimental group were better than those of the control group, the excellent rate of wound healing reached 92.5%, and the incidence of wound infection was only 5%, which was lower than that of the control group. This demonstrates that nursing intervention in the operating room can help to reduce the infection rate at the patient's incision site, increase the level of surgical indicators, promote healing of the incision site as quickly as possible, and significantly improve the safety of clinical treatment.

Risk factors of vaginal cuff infection in women undergoing laparoscopic hysterectomy for benign gynecological diseases

AIM

This study aimed to identify the risk factors for vaginal cuff infection after laparoscopic hysterectomy for benign gynecological diseases.

METHODS

We conducted a retrospective cohort study among 1559 Japanese women who underwent total laparoscopic hysterectomy (TLH) for benign indications between 2014 and 2018 at Teine Keijinkai Hospital in Sapporo, Japan. All patients received preoperative antibiotics based on appropriate timing, choice, and weight-based dosing. We assessed the risk factors of vaginal cuff infection after TLH, including demographic and clinical variables, and patient- and surgery-related factors, using univariable and multivariable logistic regression analyses.

RESULTS

Among all the patients who underwent TLH, 71 cases of vaginal cuff infections (4.6%) were recorded. Univariate analyses showed that current smoking, pathological result of adenomyosis, use of Seprafilm as an antiadhesive material, white blood cell counts on postoperative day (POD) 2, C-reactive protein (CRP) level on POD2 and postoperative vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. In multivariate analysis, current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection.

CONCLUSION

Current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were identified as significant risk factors of vaginal cuff infection in the 30 days after surgery in Japanese women who underwent TLH for benign indications.

Infectious complications of laparoscopic and robotic hysterectomy: a systematic literature review and meta-analysis

OBJECTIVE

We performed a systematic review of the literature and meta-analysis of the infectious complications of hysterectomy, comparing robotic-assisted hysterectomy to conventional laparoscopic-assisted hysterectomy.

METHODS

We searched PubMed, CINAHL, CDSR, and EMBASE through July 2018 for studies evaluating robotic-assisted hysterectomy, laparoscopic-assisted hysterectomy, and infectious complications. We employed random-effect models to obtain pooled OR estimates. Heterogeneity was evaluated with I² estimation and the Cochran Q statistic. Pooled ORs were calculated separately based on the reason for hysterectomy (eg, benign uterine diseases, endometrial cancer, and cervical cancer).

RESULTS

Fifty studies were included in the final review for the meta-analysis with 176 016 patients undergoing hysterectomy. There was no statistically significant difference in the number of infectious complication events between robotic-assisted hysterectomy and laparoscopic-assisted hysterectomy (pooled OR 0.97; 95 % CI 0.74 to 1.28). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing robotic-assisted hysterectomy to laparoscopic-assisted hysterectomy among patients with benign uterine disease (pooled OR 1.10; 95 % CI 0.70 to 1.73), endometrial cancer (pooled OR 0.97; 95 % CI 0.55 to 1.73), or cervical cancer (pooled OR 1.09; 95 % CI 0.60 to 1.97).

CONCLUSION

In our meta-analysis the rate of infectious complications associated with robotic-assisted hysterectomy was no different than that associated with conventional laparoscopic-assisted hysterectomy.

Prevention of Surgical Site Infections in Gynecologic Surgery: A Review of Risk Factors and Recommendations

Background: Surgical site infections (SSIs) are a type of health care-associated infection that can cause significant patient harm. Many are preventable. Postoperative courses complicated by an SSI can equate to longer hospital stays, lost time from work, and the need for reoperation. Methods: This review addresses types of SSIs, risk factors, and best practices for preventing SSIs associated with gynecologic surgery. Results: Best practices to reduce SSIs are divided into preoperative, intraoperative, and postoperative activities. Preoperative considerations include patient showering, hair removal, glycemic control, and hand and forearm scrub. Intraoperative concerns are antibiotic prophylaxis, skin preparation prior to the start of surgery, and the operating room environment. Postoperative concerns are surgical dressing, vacuum-assisted wound closure, and patient instructions. Conclusion: Best practices should be established and followed to reduce the risk of SSI associated with gynecologic surgery.

Postoperative infections in women undergoing hysterectomy for benign indications: a cohort study

BACKGROUND

There is limited data on the incidence of postoperative infections following hysterectomy by route of surgery. We hypothesize that vaginal hysterectomy has lower rates of postoperative infection than laparoscopic and abdominal hysterectomies.

METHODS

A retrospective cohort study and independent hand review of charts of participants undergoing hysterectomy at five hospitals from September 2011 through May 2015 was performed. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and were reviewed by the investigators. The primary outcome was the development of Clostridium difficile infection, urinary tract infection, surgical site infection, or yeast vaginitis within 60 days following surgery.

RESULTS

In total, 2742 women underwent hysterectomy: abdominal 17.5% (AH), laparoscopic 65.8% (LH), and vaginal 16.7% (VH). The composite postoperative infection rate for the four specified variables was 8.5% (232). In comparing surgical route, AH was most commonly associated with CDI (0.6%, p <0.001), SSI (6.0%, P=0.001), and yeast vaginitis (1.9%, p <0.001), while VH was most commonly associated with UTI (8.1%, P=0.002). After controlling for demographic and operative factors, multivariable analysis showed that hysterectomy route was not associated with infection. Independent predictors for postoperative infection were increasing age, American Society of Anesthesiologists physical status classification, operative time, and hospital type.

CONCLUSIONS

Infectious complications after hysterectomy are uncommon, accounting for 8.5% of cases. Multivariable analysis showed that demographic and operative variables were more likely to serve as independent predictors of development of infection than hysterectomy route.

Trends of and factors associated with cesarean section related surgical site infections in Guinea

Since the adoption of free obstetric care policy in Guinea in 2011, no study has examined the surgical site infections in maternity facilities. The objective of this study was to assess the trends of and factors associated with surgical site infection following cesarean section in Guinean maternity facilities from 2013 to 2015. This was a retrospective cohort study using routine medical data from ten facilities. Overall, the incidence of surgical site infections following cesarean section showed a declining trend across the three periods (10% in 2013, 7% in 2014 and 5% in 2015, P<0.001). Women who underwent cesarean section in 2014 (AOR: 0.70; 95%CI: 0.57-0.84) and 2015 (AOR: 0.43; 95%CI: 0.34-0.55) were less likely to develop surgical site infections during hospital stay than women operated in 2013. In the contrary, women with comorbidities were more likely to experience surgical site infection (AOR: 1.54; 95% CI: 1.25-1.90) than those who did not have comorbidities. The reductions achieved in 2014 and 2015 (during the Ebola outbreak) should be sustained in the post-Ebola context.

Evaluation of hospital readmissions for surgical site infections in Italy

Background

The objectives of this investigation are to assess the prevalence of hospital readmissions for surgical site infections (SSIs) in patients aged ≥18 in Italy and to describe the clinical characteristics of these patients and evaluate the possible association with readmission for SSIs.

Methods

A retrospective epidemiological study was conducted between January and May 2015 considering a sample of patients aged ≥18 years admitted to the surgical wards of two hospitals in Naples and undergoing surgery in the year 2014.

Results

3.8% of patients had been readmitted and 28.8% of them were readmitted to hospital due to SSIs. The multiple logistic regression model showed that readmissions for SSIs were significantly more common in smokers (odds ratio [OR] = 3.14; 95% confidence interval [CI] = 1.13-8.69), in patients with immunosuppression status (OR = 8.28; 95% CI = 1.76-38.87), in patients with low serum albumin (OR = 3.07; 95% CI = 1.05-9.01) and in patients who had undergone a surgical procedure classified as contaminated (OR = 10:44; 95% CI = 3.11-35.01) compared with those that had undergone a surgical procedure classified as clean.

Conclusions

The results point to the need that hospital infection prevention strategies are implemented in order to reduce morbidity and mortality for patients. Moreover, the measures taken to prevent infections would lead to a reduction in health spending since almost one third of readmissions to the hospital in our study were due to SSIs.

Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy

STUDY OBJECTIVE

To quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

PATIENTS

Women who underwent hysterectomy from 2006-2015 and recorded in NSQIP database.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

SSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43- 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05-1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20-1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34-2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI.

CONCLUSION

In addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.

Prevention of surgical site infection via antibiotic administration according to guidelines after gynecological surgery

AIM

We modified the antimicrobial prophylaxis of surgical site infection (SSI) according to the guidelines of the Japanese Society of Chemotherapy and Japan Society of Infectious Diseases (hereinafter referred to as optimization) and measured outcomes.

METHODS

From April 2016 to March 2017, we performed cesarean section and open hysterectomy with optimization, and compared the outcome to that of surgery performed without optimization between April 2014 and March 2016. We measured the rates of antibiotic discontinuation, appropriate antibiotic selection, SSI incidence, resumption of antibiotic therapy and fever incidence, as well as the length of postoperative hospital stay and medical expenses for antibiotics to evaluate the appropriateness and outcomes of antibiotic prophylaxis.

RESULTS

Optimization resulted in a change in the method of selecting antibiotics for cesarean section, but there was no change in SSI incidence rate (0.74% vs 0.0%, P = 0.36). Optimization reduced the use of antibiotics and medical expenses of hysterectomy (median reduction of 50% and 78% for hysterectomy without or with lymphadenectomy, respectively). However, there was no change in outcome regarding SSI incidence (5.7% vs 0.0%, P = 0.11 and 7.8% vs 9.5%, P = 0.77, respectively).

CONCLUSION

Appropriate use of antibiotics according to guidelines reduced antibiotic dose and medical expenses, but there was no change in outcome regarding SSI incidence rate. These findings suggested that implementation of dosing regimens according to the guidelines would be useful to reduce antibiotic medicine costs and prevent resistant bacteria and complications associated with antibiotics.

Surgical site infections following caesarean operations at a Jordanian teaching hospital: Frequency and implicated factors

Surgical site infections (SSIs) following caesarean surgeries are common. The present study aimed to evaluate the frequency of SSIs following caesareans at Jordan University Hospital during the 30 postoperative days and to identify factors associated with increased SSIs risk. Data regarding the occurrence of SSIs were collected both prospectively via follow-up phone calls and retrospectively via reviewing wound culture results and clinical notes. SSI cases were subsequently determined utilizing predefined criteria. Data relating to possible risk factors of SSIs were collected from patient interviews and hospital records. Risk factors for SSIs were identified via logistic regression. A high rate of SSIs (14.4%) was detected; implicated factors included body mass index ≥36 kg/m² prior to pregnancy odds ratio (OR) 3.8, 95% confidence interval (95% CI) 1.6-9.4, hospital stay longer than 3.5 days OR 2.3, 95% CI 1.4-3.6, having the operation at a gestational age greater than 40 weeks OR 2.2, 95% CI 1.3-3.9. Receiving a higher weight-adjusted dose of the prophylactic antibiotic cefazolin was associated with lower SSIs risk OR 0.967, 95% CI 0.94-0.99.In conclusion, a high rate of SSIs following caesareans was detected, and modifiable risk factors of SSIs should be incorporated into targeted policies aiming to reduce the rate of SSIs.

Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery

OBJECTIVE

Surgical site infections (SSIs) can lead to substantial morbidity, prolonged hospitalization, increased costs, and death in patients undergoing colorectal procedures. We sought to investigate the effect of using an SSI reduction bundle on the rate of SSIs in gynecologic cancer patients undergoing colon surgery.

METHODS

We identified all gynecologic cancer patients who underwent colon resection at our institution from 2014 to 2016, during which time a service-wide SSI reduction bundle was introduced. The intervention included preoperative oral antibiotics with optional mechanical bowel preparation, skin preparation with antibacterial solution, and the use of a separate surgical closing tray. SSI rates were assessed within 30days post-surgery.

RESULTS

Of 233 identified patients, 115 had undergone colon surgery prior to (PRE) and 118 after (POST) the implementation of the intervention. A low anterior resection was the most common colon surgery in both cohorts. The incidence of SSI within 30days of surgery was 43/115 (37%) in the PRE and 14/118 (12%) in the POST cohorts (p≤0.001). Wound dehiscence was noted in 30/115 (26%) and 2/118 (2%) patients, respectively (p≤0.001). In patients whose operation took longer than 360min, 30-day SSI rates were 37% (28/76) and 12% (8/67), respectively (p≤0.001). In patients with an estimated blood loss >500cm³, SSI rates were 44% (27/62) and 15% (10/67), respectively (p≤0.001).

CONCLUSIONS

The implementation of an SSI reduction bundle was associated with a significant reduction in 30-day SSIs in these patients. The intervention remained effective in patients undergoing longer operations and in those with increased blood loss.