Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and strategies for implementation

Evaluation of Timing of Antimicrobial Surgical Prophylaxis on Rates of Surgical Site Infections

Background: Surgical site infections (SSIs) are common healthcare-associated infections, and national guidelines recommend that antimicrobial prophylaxis (AP) be administered 60 min prior to incision. However, there are limited data regarding the "most optimal" time for administration within the 60-min window. Patients and Methods: This was a multicenter, retrospective study of adult (≥18-year-old) patients that underwent an abdominal hysterectomy, colorectal surgery, or craniotomy and received AP within 60 min of incision. Incidence of SSI was compared between patients who received AP 0-30 versus 31-60 min of incision. In addition, a predefined subgroup analysis evaluated incidence of SSI for 15-min intervals within the 60-min timeframe. Results: Of the 277 patients included in the primary analysis, 233 (84.1%) and 44 (15.9%) received AP 0-30 min and 31-60 min prior to incision, respectively. SSIs were documented in 6.0% (14/233) versus 4.5% (2/44) of patients in the primary analysis (p = 0.703). In the secondary analysis, 137 (49.5%), 95 (34.3%), 34 (12.3%), and 11 (4.0%) patients received AP 0-15, 16-30, 31-45, and 46-60 min prior to incision, respectively. There was no difference in incidence of SSIs among the 15-min intervals (4.4% vs. 8.4% vs. 2.9% vs. 9.1%, p = 0.487). Of the 16 patients in this study that incurred a SSI, 5 patients had positive cultures, of which 3 contained bacteria that proved to be resistant to the antibiotic used for AP. Conclusions: The results of our analysis support current national guidelines. Future investigation of different intervals (e.g., AP 15-45 min prior to incision) may be beneficial on the basis of pharmacokinetics of routinely prescribed AP.

Coronavirus Disease 2019 Pandemic and Reduced Surgical Site Infection After Cardiac Surgery: A Potential Blessing in Disguise

Background: The coronavirus disease 2019 (COVID-19) pandemic has brought about drastic hygienic measures, one upside of which might be the mitigated occurrence of surgical site infection (SSI). This study investigated the association of the pandemic with SSI occurrence after cardiac surgeries. Patients and Methods: From 2014 to 2022, patients undergoing cardiac surgery were included and categorized into pre-pandemic and during-pandemic groups. Surgical site infections were classified into harvest-site, superficial sternal, and complex sternal infection. Multiple logistic regression and inverse probability weighting assessed the association of the pandemic with SSI. Results: Among a total of 26,143 patients, 793 SSIs occurred. The during-pandemic patients were younger (61.87 ± 10.58 vs. 65.64 ± 11.82) with a higher male proportion (70.1% vs. 67.4%) and a higher prevalence of all studied comorbidities/risk factors (expect cigarette smoking). Total SSI rate decreased substantially from 3.3% before COVID-19 to 1.8% afterward (p < 0.001). Inverse probability weights analyses evinced an independent association of the pandemic with a reduced risk of total (adjusted odds ratio [OR]; 0.59; 95% confidence interval [CI], 0.45-0.78), harvest-site (adjusted OR, 0.36; 95% CI, 0.19-0.70), and superficial sternal infection (adjusted OR, 0.60; 95% CI, 0.43-0.81). No significant association was observed with complex sternal site infection (adjusted OR, 1.05; 95% CI, 0.55-2.01). Multivariable regression recapitulated these findings. Conclusions: The COVID-19 pandemic independently pertained to more than a 40% reduction in SSI occurrence, particularly affecting harvest-site and superficial sternal infections. However, there remains the possibility of the implications of other known and unknown confounders on the observed association. To some extent, the decrease in SSIs after the pandemic can be justified by reinforced hygienic precautions, emphasizing the necessity of extending the adherence to these measurements into the post-COVID-19 era to maintain the status quo.

Multicenter parallel randomized trial evaluating incisional negative pressure wound therapy for the prevention of surgical site infection after lower extremity bypass

OBJECTIVE

Incisional negative pressure wound therapy (iNPWT) applied over all incisions after lower extremity bypass in the prevention of surgical site infections (SSIs) is unclear. The primary and secondary aims of this study were to investigate if prophylactic iNPWT after the elective lower extremity bypass prevents SSI and other surgical wound complications.

METHODS

This was a multicenter, parallel, randomized controlled trial. Patients undergoing elective lower extremity bypass in 3 hospitals were randomized to either iNPWT or standard dressings. SSIs or other wound complications were assessed within the first 90 days by wound care professionals blinded to the randomized result. The validated Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay (ASEPSIS) score was used to objectively assess the wounds. ASEPSIS score ≥21 is defined as an SSI. Unilateral and bilateral groups were analyzed with the Fisher exact test and the McNemar test, respectively.

RESULTS

In the unilateral group (n = 100), the incidence of SSI in the iNPWT group was 34.9% (15/43), compared with 40.3% (23/57) in the control group, according to the ASEPSIS score (P = .678). In the bilateral group (n = 7), the SSI rate was 14.3% (1/7) in the iNPWT group compared with 14.3% (1/7) in the control group (P = 1.00). In the unilateral group, there was a higher wound dehiscence rate in the control group (43.9%) compared with the iNPWT group (23.3%) (P = .0366). No serious iNPWT-related adverse events were recorded.

CONCLUSIONS

There was no reduction of SSI rates in leg incisions with iNPWT compared with standard dressings in patients undergoing elective lower extremity bypass, whereas iNPWT reduced the incidence of wound dehiscence.

Recent Advances of Chitosan-Based Hydrogels for Skin-Wound Dressings

The management of wound healing represents a significant clinical challenge due to the complicated processes involved. Chitosan has remarkable properties that effectively prevent certain microorganisms from entering the body and positively influence both red blood cell aggregation and platelet adhesion and aggregation in the bloodstream, resulting in a favorable hemostatic outcome. In recent years, chitosan-based hydrogels have been widely used as wound dressings due to their biodegradability, biocompatibility, safety, non-toxicity, bioadhesiveness, and soft texture resembling the extracellular matrix. This article first summarizes an overview of the main chemical modifications of chitosan for wound dressings and then reviews the desired properties of chitosan-based hydrogel dressings. The applications of chitosan-based hydrogels in wound healing, including burn wounds, surgical wounds, infected wounds, and diabetic wounds are then discussed. Finally, future prospects for chitosan-based hydrogels as wound dressings are discussed. It is anticipated that this review will form a basis for the development of a range of chitosan-based hydrogel dressings for clinical treatment.

Prevention of surgical site infection and sepsis in pregnant obese women

Obesity is a major determinant of health outcomes and is on the increase in women worldwide. It predisposes to surgical site infection (SSI). Risk factors for the SSI include extremes of age, smoking, comorbidities such as hypertension and diabetes, inappropriate vertical abdominal and or uterine wall incisions, increased operating time, subcutaneous layer of 3 cm or more, and unnecessary use of subcutaneous drain. Most bacteria that cause SSIs are human commensals. Common organisms responsible for SSI include Staphylococcus aureus and coliforms such as Proteus mirabilis, and Escherichia coli. A surgeon's gloves post caesarean section in the obese has a preponderance of Firmicutes and Bacteroidetes, which increases SSI risk. The interaction of skin commensals and vaginal microbiome at the surgical incision site increases the risk of SSI in the obese compared to non-obese. Minimizing the risk of SSI involves modification of risk factors, timely treatment of SSI to prevent sepsis and compliance with the recommended care bundles.

Association between periodontitis and postoperative complications in hospital medical surgical procedures: a systematic review

Background

Periodontitis is potentially harmful in the perioperative period due to biofilm generating a environment for bacteria to spread and colonize other anatomical areas, which can generate a potential risk of infection, delayed healing, increased morbidity, and even induce avulsion in intubated patients, and subsequent aspiration or ingestion of teeth with increased mobility.

Objective

Associate the presence of periodontitis and postoperative complications in patients who underwent an in-hospital medical surgical procedure.

Methods

A systematic review based on studies extracted from PubMed and Scopus was carried out on June 10, 2020, based on the Population, Intervention, Comparison and Result search strategy. As inclusion criteria, the studies had to include all the disaggregated terms of the research question, have a publication date of less than 15 years, and the target population had to have undergone elective hospital medical-surgical interventions. The exclusion criteria corresponded to not presenting an analytical or experimental observational study design, not having made a periodontal clinical diagnosis of the study subjects, and not expressing in the results the presence of postoperative medical-hospital complications. Articles were assessed for quality by supplementing the STROBE guideline and Newcastle Ottawa, for risk of bias by supplementing the STROBE guideline and the Cochrane Collaboration handbook tool.

Results

A total of 131 articles were obtained, which were subjected to a selection process, resulting in 5 final analytical observational studies. A meta-analysis was performed and determined that periodontitis was a risk factor to postoperative complications after surgical procedures with an OR = 4,76; 95%CI [1,11-20,41].

Conclusions

Optimize the guidelines for assessing quality and risk of bias can make their comparison with other studies complex, however it was determined in a statistically significant way that patients with periodontitis have a higher risk of generating postoperative complications after a medical hospital surgery.

Impact of surgical site infection on unplanned hospital readmissions, initiation of adjuvant treatment following surgery, and disease-free survival on patients with upper aerodigestive tract squamous cell carcinoma

INTRODUCTION

Unplanned hospital readmission (UHR) is an important indicator of the quality of the healthcare system in place. It has various implications for the patients and the healthcare system at large. In this article, we have attempted to understand the various factors influencing UHR and the start of adjuvant treatment following cancer surgery.

PATIENTS & METHODS

In this study adult patients above 18 years of age with upper aerodigestive tract squamous cell carcinoma who underwent surgery at our center between July 2019 to December 2019 were included in the study. Various factors influencing UHR and delay in receiving adjuvant treatment were analyzed.

RESULTS

A total of 245 patients satisfied the inclusion criteria. Surgical site infection (SSI) was the factor that had the maximum influence on the UHR (p < 0.002, OR: 5.6, 95% CI: [1.911-16.4]) and delaying the start of adjuvant treatment (p = 0.008, OR: 3.786, 95% CI: [1.421-10.086]) on multivariate analysis. Surgery lasting for >4 h and patients who had received prior treatment tended to develop SSI postoperatively. The presence of SSI also seemed to have had a negative influence on disease-free survival (DFS) as well.

CONCLUSIONS

SSI is an important postoperative complication having major implications in terms of increased UHR and delays in starting adjuvant treatment which in turn is reflected as a poorer DFS among patients who develop SSI postoperatively.

Surgical site infections after elective craniotomy for brain tumor: a study on potential risk factors and related treatments

BACKGROUND

Surgical site infection (SSI) is a common complication following craniotomy that increases morbidity, mortality, and medical expenses. The objectives of this study were to determine the relevant risk factors associated with SSI after elective craniotomy for brain tumor and analyse the treatments for SSI.

METHODS

A retrospective nested case‒control study was conducted using data from patients who underwent craniotomy for brain tumor resection at the Neurosurgical Oncology Department No. 6 of Beijing Tiantan Hospital, Capital Medical University, between January 2019 and December 2021. Risk factors for SSI were determined using multivariate logistic regression analysis. We analyzed microbiological and related treatment data for different SSI types.

RESULTS

Among 2061 patients who underwent craniotomy for brain tumor, 31 had SSI (1.50%). In the multivariate logistic regression analysis, body mass index (BMI) and operative duration were identified as independent risk factors for SSI. The most common microorganism isolated from SSIs was Staphylococcus epidermidis (22.9%), and drug sensitivity results showed that gram-positive bacteria were sensitive to linezolid, vancomycin and tigecycline, whereas gram-negative bacteria were sensitive to meropenem, cefepime and ceftazidime. Six of the seven patients who underwent bone flap removal due to osteomyelitis were infected with gram-negative bacteria.

CONCLUSIONS

BMI and operative duration were identified as independent risk factors for SSI. Diabetes mellitus, previous ratio therapy, type of incision, recurrence tumor and other risk factors were not found to be associated with the occurrence of SSI in this study.

The Impact of Postoperative Antibiotic and Duration After Implant-Based Breast Reconstruction on Resistance Among Cultured Species

BACKGROUND

There is a growing presence of literature within plastic surgery that establishes best practice for postoperative antibiotics after implant-based breast reconstruction (IBBR), although it has not been widely adopted or translated into clinical practice. This study aims to determine how antibiotic and duration affects patient outcomes. We hypothesize that IBBR patients who receive a longer duration of postoperative antibiotics will demonstrate higher rates of antibiotic resistance as compared with the institutional antibiogram.

METHODS

A retrospective chart review included patients who underwent IBBR between 2015 and 2020 at a single institution. Variables of interest included patient demographics, comorbidities, surgical techniques, infectious complications, and antibiograms. Groups were classified by antibiotic (cephalexin, clindamycin, or trimethoprim/sulfamethoxazole) and duration (≤7 days, 8-14 days, and >14 days).

RESULTS

There were a total of 70 patients who experienced infections included in this study. Onset of infection did not differ based on antibiotic during either device implantation (postexpander P = 0.391; postimplant P = 0.234). Antibiotic and duration did not have an established relationship with explantation rate either (P = 0.154). In patients who had Staphylococcus aureus isolated, there was significantly increased resistance to clindamycin when compared with the institutional antibiogram (sensitivities of 43% and 68%, respectively).

CONCLUSIONS

Neither antibiotic nor duration displayed a difference in overall patient outcomes, including explantation rates. In this cohort, S. aureus strains isolated in association with IBBR infections demonstrated a higher level of resistance to clindamycin compared with strains isolated and tested within the broader institution.

IPOM plus versus IPOM standard in incisional hernia repair: results of a prospective multicenter trial

PURPOSE

Laparoscopic ventral hernia repair is a well-established technique with satisfying outcomes even at long term for the treatment of incisional and ventral hernia. However, the literature debate is still ongoing regarding the preferred surgical technique. Nowadays, two approaches are commonly adopted: the intraperitoneal onlay mesh repair (sIPOM) and the intraperitoneal onlay mesh reinforcement with defect closure before mesh placement (pIPOM). The aim of this prospective analysis is to compare the postoperative outcomes of patients treated for incisional hernia (IH) with sIPOM and pIPOM after 36 months follow-up in terms of recurrence, quality of life and wound events.

METHODS

Patients receiving pIPOM and sIPOM for IH were actively followed up for 36 months. At the outpatient clinic, hernia recurrence (HR), mesh bulging (MB), quality of life with the Gastrointestinal Quality of Life Index (GIQLI) and wound events were assessed.

RESULTS

Between January 2015 and January 2019, 98 patients underwent a pIPOM and 89 underwent an sIPOM. At 36 months, nine patients (4 in pIPOM and 5 in sIPOM) experienced an HR, while MB was recorded in four patients in pIPOM and nine in sIPOM. No statistically significant difference could be identified also in terms of final GIQLI score and wound events.

CONCLUSIONS

LVHR with or without fascial closure, also in our study, provides satisfactory results in terms of safety and efficacy. The discordant results in the literature are probably related to independent variables such as the type of mesh, the type of suture and closure technique. Therefore, was the funeral of sIPOM done too early? STUDY DATASET IS AVAILABLE ON CLINICALTRIALS.

GOV ID

NCT05712213.

The role of main pancreatic duct stent in the enucleation of benign/borderline pancreatic head tumors: a cohort study

PURPOSE

This study aimed to reveal the role of preoperative main pancreatic duct (MPD) stent placement in reducing the intraoperative main pancreatic duct injury rate and the incidence of postoperative pancreatic leakage following pancreatic tumor enucleation.

METHODS

A retrospective cohort analysis was performed for all patients with benign/borderline pancreatic head tumors who were treated with enucleation. The patients were divided into two groups (standard vs. stent) depending on whether they underwent main pancreatic duct stent placement prior to surgery.

RESULTS

Thirty-three patients were finally included in the analytical cohort. Compared with the standard group, patients in the stent group had a shorter distance between tumors and main pancreatic duct (p=0.01) and presented with larger tumors (p<0.01). The rates of POPF (grade B&C) were 39.1% (9/23) and 20% (2/10) in the standard and stent groups, respectively (p<0.01). Major postoperative complications occurred more frequently in the standard group than in the stent group (14 versus 2; p<0.01). No significant differences in mortality, in-hospital stay or medical cost were observed between the two groups (p>0.05).

CONCLUSIONS

MPD stent placement prior to surgery may facilitate pancreatic tumor enucleation, minimize MPD injury and decrease the occurrence of postoperative fistula.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Healthcare professionals' knowledge and attitudes of surgical site infection and surveillance: A narrative systematic review

AIM

This systematic review reports on healthcare professionals' knowledge and attitudes of surgical site infection and surgical site infection surveillance as well as interventions aimed at enhancing healthcare professionals' knowledge and attitudes.

BACKGROUND

Surgical site infection is a serious adverse outcome following surgery. Despite the presence of international guidelines, the prevention of surgical site infections remains a challenge for patients and hospitals. It is critical that healthcare professionals have sufficient knowledge on surgical site infection and on their role in implementing evidence-based prevention strategies.

DESIGN

This review is reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines.

METHODS

A search was undertaken in the following databases: Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycARTICLES, PsycINFO and Web of Science for studies published between January 2010 and March 2022. Studies that examined healthcare professionals' knowledge and attitudes in relation to surgical site infection, surgical site infection surveillance and risk factors for their development were included. We also included studies that examined interventions that aimed to enhance healthcare professionals' knowledge and attitude in relation to surgical site infection, surveillance, and risk factors. We also described the impact of such interventions on the incidence of surgical site infections.

RESULTS

A total of 26 studies were included. Results were synthesised narratively according to the review objectives. Findings from this review show that knowledge of what surgical site infection is and its prevention was poor amongst healthcare professionals, while attitudes were positive particularly in relation to healthcare professionals' role in prevention. Only three studies examined the effects of interventions on healthcare professionals' knowledge of surgical site infection and surgical site infection prevention. Of those, two used multimodal educational interventions and found statistically significant improvement in knowledge.

CONCLUSIONS

Overall knowledge of surgical site infection and its prevention is poor amongst healthcare professionals, while attitudes were positive particularly in relation to healthcare professionals' role in prevention. There is a need for more experimental research to evaluate interventions which aim to address healthcare professionals' knowledge and attitudes towards surgical site infection prevention and surveillance. Such studies should include all healthcare professionals involved in the care of a surgical patient.

TWEETABLE ABSTRACT

Knowledge and attitudes of surgical site infection prevention amongst healthcare professionals.

The Effect of a Checklist for Perioperative Hyperglycemia Management on Surgical Site Infections: A Randomized Controlled Trial

PURPOSE

This study was conducted to evaluate the effect of managing perioperative normoglycemia using a structured and standardized normoglycemia checklist on surgical site infection (SSI).

DESIGN

The study is a prospective randomized controlled experimental case-control study.

METHODS

A normoglycemia checklist was applied to the patients selected for the experimental group preoperatively, intraoperatively, and postoperatively (continuous insulin infusion applied to keep the blood glucose level within the range of 80 to 150 mg/dl until 48 hours postoperative) according to their blood glucose levels. The routine practice available in the clinic was applied to the control group.

FINDINGS

The rate of SSI development in the control group (27.5%) was significantly higher than in the experimental group (2.5%) (P < .05). The culture was examined only in patients with deep incisional SSI, and E. Coli and Gram (-) Bacillus were the most prolific microorganisms. The risk of re-hospitalization of the control group patients was 2 times higher than the experimental group (P < .05).

CONCLUSIONS

This study reports the prevalence, diagnosis, and pathophysiology of perioperative hyperglycemia in patients undergoing cholecystectomy and provides a practical method for the management of blood glucose levels in surgery patients diagnosed with diabetes mellitus and developing stress hyperglycemia.

Surgical Site Infection Prevention: A Review

IMPORTANCE

Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer.

OBSERVATIONS

Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis.

CONCLUSIONS AND RELEVANCE

Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.

The Diagnostic Value of Blood Next-Generation Sequencing in Early Surgical Site Infection After Spine Surgery

Objective

To determine the diagnostic value of blood next-generation sequencing (NGS) in early surgical site infection after spine surgery. Because the blood is sterile in healthy individuals, it is expected that blood NGS is both sensitive and specific for the detection of infection.

Methods

A total of 28 patients with definitive spinal surgical site infections and controls (n=30) were retrospectively included. The postoperative results of NGS and culture on different samples, such as blood and drainage fluid, were obtained and compared to evaluate the diagnostic value of blood NGS. The diagnostic value parameters (sensitivity, specificity, etc.) were calculated.

Results

Among the four bacteriological exam methods, blood NGS was both sensitive and specific for the determination of infection after spine surgery. The sensitivities of blood and drainage fluid NGS were similar (0.82 vs 0.89, P=0.617). However, the specificities of the two assessments differed, which were 0.97 for blood NGS and 0.40 for drainage fluid NGS (P<0.001). The sensitivities of bacterial culture were lower than those of NGS (blood: 0.82 vs 0.25, P<0.001; drainage fluid: 0.89 vs 0.61, P<0.001), regardless of the sample type. However, the specificities of bacterial culture were equal to or higher than those of NGS (blood: 0.97 vs 0.97, P=1.000; drainage fluid: 0.40 vs 0.80, P=0.002).

Conclusion

This article emphasizes the superiority of blood NGS in infection detection and bacterial determination in patients undergoing spine surgery. Compared with traditional drainage fluid bacterial culture and NGS, blood NGS was more sensitive and specific, and its extensive application could be expected.

Potassium penicillin and gentamicin pharmacokinetics in healthy conscious and anesthetized horses

OBJECTIVE

To determine the effects of general anesthesia on the safety and efficacy of co-administered potassium penicillin G (PEN) and gentamicin (GENT) in horses.

STUDY DESIGN

Nonrandomized crossover.

ANIMALS

Six adult, Thoroughbred horses.

METHODS

Horses were administered PEN (22 000 IU/kg IV) and GENT (6.6 mg/kg IV). Plasma samples were collected over a 6 h period and synovial fluid was collected at 30 min and 6 h respectively. Drug administration and sample collection protocols were repeated after at least a 48 hour washout period and induction of anesthesia using xylazine/ketamine and maintenance with isoflurane gas. Drug concentrations were determined using ultrapressure liquid chromatography with mass spectrometry. A 2-compartment model was used to determine pharmacokinetics and differences were determined between conscious and anesthetized horses using paired t-tests (significance P < .05).

RESULTS

Potassium penicillin g and GENT had higher minimum plasma concentrations (PEN 0.44 vs. 0.11 μg/mL, P = .002; GENT 3.0 vs. 1.9 μg/mL, P = .009), longer half lives (PEN 71 vs. 59 min, P = .018; GENT 149 vs. 109 min, P = .038), and slower clearances (PEN 3.41 vs. 5.1 mL/kg/min, P = .005; GENT 1.18 vs. 1.48 mL/kg/min, P = .028) in anesthetized horses vs. conscious horses. The PEN concentrations remained above the breakpoint minimum inhibitory concentration (MIC, 0.5 μg/mL) for 332 min in anesthetized vs. 199 min in conscious horses. The GENT concentrations reached 10 times higher than the breakpoint MIC (2 μg/mL) in all horses and were maintained for 58 vs. 59 min in anesthetized and conscious states, respectively. Synovial fluid concentrations were higher in conscious horses vs. anesthetized horses at 30 min for PEN (7.0 vs. 0.93 μg/mL, P < .001) and 30 (5.3 μg/mL vs. 0.79 μg/mL, P < .001) and 360 min (3.4 vs. 1.82 μg/mL, P < .003) for GENT.

CONCLUSION

General anesthesia resulted in lower intrasynovial concentrations and delayed clearance of PEN/GENT in horses.

CLINICAL SIGNIFICANCE

Redosing healthy anesthetized horses with PEN prior to 4-5 h is not necessary. When administered to anesthetized horses, intravenous PEN/GENT may not reach adequate intrasynovial concentrations to treat or prevent common pathogens. The doses or dosing intervals of antimicrobials administered to horses undergoing anesthesia may need to be adjusted to ensure maintenance of safe and effective plasma concentrations.

Independent risk factor for surgical site infection after orthopedic surgery

No significant progress has been made in the study of orthopedic surgical site infection (SSI) after different orthopedic surgery, and the analysis and prevention of risk factors for orthopedic SSI urgently need to be solved. A total of 154 patients underwent orthopedic surgery from April 2018 to December 2020. General information such as gender, age, marriage, diagnosis, surgical site, and anesthesia method was recorded. Statistical methods included Pearson chi-square test, univariate and multivariate logistic regression analyses, and receiver operating characteristic (ROC) curves. Based on Pearson's chi-square test, sex (P = .005), age (P = .027), marriage (P = .000), diagnosis (P = .034), and surgical site (P = .000) were significantly associated with SSI after orthopedic surgery. However, in the multiple linear regression analysis, only the surgical site (P = .035) was significantly associated with SSI after orthopedic surgery. In terms of multivariate logistic regression level, surgical site (odds ratio [OR] = 1.568, P = .039) was significantly associated with SSI. ROC curves were constructed to determine the effect of the surgical site on SSI after different orthopedic surgery (area under the curve [AUC] = 0.577, 95% CI = 0.487-0.0.666). In summary, the surgical site is an independent risk factor for SSI after orthopedic surgery, and "trauma" is more likely to develop SSI than spine, arthrosis, and others.

Pillars for prevention and control of healthcare-associated infections: an Italian expert opinion statement

Healthcare-associated infections (HAIs) represent a relevant problem for all healthcare facilities, because they involve both the care aspect and the economic management of the hospital. Most HAIs are preventable through effective Infection Prevention and Control (IPC) measures. Implementation and improvement of IPC programs are critical to reducing the impact of these infections and the spread of multi-resistant microorganisms. The purpose of this Expert Opinion statement was to provide a practical guide for healthcare organizations, physicians, and nursing staff on the optimal implementation of the core components of Infection Prevention and Control, as recommended by a board of specialists after in-depth discussion of the available evidence in this field. According to their independent suggestions and clinical experiences, as well as evidence-based practices and literature review, this document provides a practical bundle of organizational, structural, and professional requirements necessary to promote, through multimodal strategies, the improvement of the quality and safety of care with respect to infectious risk in order to protect the patient, facilities, and healthcare providers.

Temporal Trends in Deep Surgical Site Infections After Six Orthopaedic Procedures Over a 12-year Period Within a US-based Healthcare System

INTRODUCTION

Centers of excellence and bundled payment models have driven perioperative optimization and surgical site infection (SSI) prevention with decolonization protocols and antibiotic prophylaxis strategies. We sought to evaluate time trends in the incidence of deep SSI and its causative organisms after six orthopaedic procedures in a US-based integrated healthcare system.

METHODS

We conducted a population-level time-trend study using data from Kaiser Permanente's orthopaedic registries. All patients who underwent primary anterior cruciate ligament reconstruction (ACLR), total knee arthroplasty (TKA), elective total hip arthroplasty (THA), hip fracture repair, shoulder arthroplasty, and spine surgery were identified (2009 to 2020). The annual incidence of 90-day deep SSI was identified according to the National Healthcare Safety Network/Centers for Disease Control and Prevention guidelines with manual chart validation for identified infections. Poisson regression was used to evaluate annual trends in SSI incidence with surgical year as the exposure of interest. Annual trends in overall incidence and organism-specific incidence were considered.

RESULTS

The final study sample was composed of 465,797 primary orthopaedic procedures. Over the 12-year study period, a decreasing trend in deep SSI was observed for ACLR and hip fracture repair. Although there was variation in incidence rates for specific operative years for TKA, elective THA, shoulder arthroplasty, and spine surgery, no consistent decreasing trends over time were found. Decreasing rates of Staphylococcus aureus infections over time after hip fracture repair, shoulder arthroplasty, and spine surgery and decreasing trends in antibiotic resistance after elective THA and spine surgery were also observed. Increasing trends of polymicrobial infections were observed after TKA and Cutibacterium acnes after elective THA.

CONCLUSIONS

The overall incidence of deep SSI after six orthopaedic procedures was rare. Decreasing SSI rates were observed for ACLR and hip fracture repair within our US-based healthcare system. Polymicrobial infections after TKA and Cutibacterium acnes after elective THA warrant closer surveillance.

LEVEL OF EVIDENCE

IV.

Development and Validation of a Model for Predicting Surgical Site Infection After Pelvic Organ Prolapse Surgery

IMPORTANCE

Surgical site infection (SSI) is a common and costly complication. Targeted interventions in high-risk patients may lead to a reduction in SSI; at present, there is no method to consistently identify patients at increased risk of SSI.

OBJECTIVE

The aim of this study was to develop and validate a model for predicting risk of SSI after pelvic organ prolapse surgery.

STUDY DESIGN

Women undergoing surgery between 2011 and 2017 were identified using Current Procedural Terminology codes from the Centers for Medicare and Medicaid Services 5% Limited Data Set. Surgical site infection ≤90 days of surgery was the primary outcome, with 41 candidate predictors identified, including demographics, comorbidities, and perioperative variables. Generalized linear regression was used to fit a full specified model, including all predictors and a reduced penalized model approximating the full model. Model performance was measured using the c-statistic, Brier score, and calibration curves. Accuracy measures were internally validated using bootstrapping to correct for bias and overfitting. Decision curves were used to determine the net benefit of using the model.

RESULTS

Of 12,334 women, 4.7% experienced SSI. The approximated model included 10 predictors. Model accuracy was acceptable (bias-corrected c-statistic [95% confidence interval], 0.603 [0.578-0.624]; Brier score, 0.045). The model was moderately calibrated when predicting up to 5-6 times the average risk of SSI between 0 and 25-30%. There was a net benefit for clinical use when risk thresholds for intervention were between 3% and 12%.

CONCLUSIONS

This model provides estimates of probability of SSI within 90 days after pelvic organ prolapse surgery and demonstrates net benefit when considering prevention strategies to reduce SSI.

A Network Meta-Analysis and GRADE Assessment of the Effect of Preoperative Oral Antibiotics with and Without Mechanical Bowel Preparation on Surgical Site Infection Rate in Colorectal Surgery

Objective

To compare the effect of different methods of bowel preparation on the incidence of surgical site infections (SSI), anastomotic leakage (AL), and mortality in patients undergoing elective colorectal surgery.

Background

Recent guidelines advise mechanical bowel preparation with oral antibiotics (MBP-OA) for the prevention of SSI in colorectal surgery. Recent trials suggest oral antibiotics (OA) alone may be sufficient.

Methods

PubMed, MEDLINE, and Embase were searched from inception until 10-08-2021. We included randomized controlled trials (RCTs) comparing multiple methods of bowel preparation (mechanical bowel preparation [MBP], OA, MBP-OA, or no preparation) with regards to clinical outcomes such as incidence of SSI, AL, and mortality rates. A frequentist random-effects network meta-analysis was conducted to estimate the network effects of the different treatment options.

Results

We included 48 studies with 13,611 patients. Compared to no preparation, combined direct and indirect network estimates showed a relative risk (RR) for SSI of 0.57 (95% confidence interval [CI], 0.45-0.72) for MBP-OA, 0.68 (95% CI, 0.49-0.95) for OA, and 1.05 (95% CI, 0.87-1.26) for MBP. The RR for MBP-OA compared to OA was 0.84 (95% CI, 0.60-1.19); in sensitivity analysis of mainly laparoscopic procedures this effect of MBP-OA was more profound (RR, 0.56; 95% CI, 0.31-0.99).

Conclusions

This network meta-analysis of RCTs finds that both mechanical bowel preparation with oral antibiotics and oral antibiotics alone are comparably effective in the prevention of SSI. The evidence is uncertain about the relative benefit of MBP-OA compared to OA alone. Therefore, it seems justified to use either of the 2 for the prevention of SSI in colorectal surgery.

Identifying the Risk Factors Associated with Surgical Site Infection Following Cesarean Section in Adolescent Mothers

STUDY OBJECTIVE

This study aimed to determine the modifiable risk factors associated with surgical site infection (SSI) after cesarean section in adolescent pregnant patients.

DESIGN

Retrospective case-control study SETTING: Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey PARTICIPANTS: Pregnant adolescents (≤ 19 years) who underwent cesarean section at our institution between January 2014 and March 2021 INTERVENTIONS AND MAIN OUTCOME MEASURES: To determine the modifiable and nonmodifiable risk factors associated with SSI following cesarean section in adolescents. The diagnosis of SSI was made according to the criteria defined by the Centers for Disease Control and Prevention (CDC).

RESULTS

SSI was diagnosed in 62 (2.9%) of 2105 adolescent mothers who underwent cesarean section. Univariate and multivariate analyses confirmed that body mass index (BMI) (OR = 2.35; 95% CI, 1.3-4.78), induction of labor (OR = 1.9; 95% CI, 1.2-3.71), and preoperative hemoglobin values less than 10 g/dl (OR = 2.1; 95% CI, 1.2-4.46) were risk factors for SSI in adolescent mothers. Patient- and operation-related risk factors did not reach the level of statistical significance.

CONCLUSIONS

BMI, labor induction, and antenatal anemia were independent risk factors for SSI in adolescents. Among these, BMI and anemia were modifiable patient-related risk factors. Addressing obesity in adolescents and treating prenatal anemia could be the first steps toward preventing SSI.

Evaluation of Incise Drape Lift Using 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol Preoperative Skin Preparations in a Human Volunteer Knee Model

Background

Before surgery, skin is prepped with antiseptics to reduce risk of surgical site infections. An incise drape can be used as an additional modality to immobilize any remaining bacteria. Good adhesion of this drape is critical for infection prevention.

Methods

This is a randomized controlled study using a human volunteer knee model (n = 30) to evaluate the adhesion performance of an incise drape comparing 2 skin preparations. A new investigational 2% chlorhexidine gluconate/70% isopropyl alcohol skin prep (prep A) was compared with an existing skin prep containing the same active agents (prep B). Two samples of an iodine-impregnated incise drape were placed on each knee after prepping. Knees were flexed in dry conditions, under a saline-soaked gauze, and after saline lavage. The frequency of drape lift was recorded after each challenge.

Results

After dry flex, 4 of 60 samples (6.7%) had lifted on prep A and 0 on prep B (P = .125). After wet flex, 20 of 60 samples (33%) had lifted on prep A, whereas 42 of 60 samples (70%) had lifted on prep B (P < .0001). After lavage, 23 of 60 samples (38%) had lifted on prep A, whereas 48 of 60 samples (80%) had lifted on prep B (P < .0001). Both preps were well tolerated with minimal erythema and no edema, rash, dryness, or denudation observed. No adverse events were reported.

Conclusions

Prep A resulted in reduced frequency of incise drape lift from skin under wet conditions in this model compared with prep B.

Surgical Masks Affect the Peripheral Oxygen Saturation and Respiratory Rate of Anesthesiologists

Background

Surgical masks (SMs) protect medical staff and reduce surgical site infections. Extended SM use may reduce oxygen concentrations in circulation, causing hypoxia, headache, and fatigue. However, no research has examined the effects of wearing SMs on oxygenation and physical discomfort of anesthesiologists.

Methods

An electronic questionnaire was established and administered through WeChat, and a cross-sectional survey was conducted to determine SM use duration and related discomfort of operating room medical staff. Then, operating room anesthesiologists were enrolled in a single-arm study. Peripheral blood oxygen saturation (SpO2), heart rate, and respiratory rate were determined at different times before and after SM use. Shortness of breath, dizziness, and headache were subjectively assessed based on the visual analog scale (VAS) scores.

Results

In total, 485 operating room medical staff completed the electronic questionnaire; 70.5% of them did not change SMs until after work, and 63.9% wore SMs continuously for more than 4 h. The proportion of anesthesiologists was the highest. After wearing masks for 4 h, the shortness of breath, fatigue, and dizziness/headache rates were 42.1, 34.6, and 30.9%, respectively. Compared with other medical staff, the proportion of subjective discomfort of anesthesiologists increased significantly with prolonged SM use from 1 to 4 h. Thirty-five anesthesiologists completed the study. There was no difference in anesthesiologist SpO2, heart rate, or respiratory rate within 2 h of wearing SMs. After more than 2 h, the variation appears to be statistically rather than clinically significant—SpO2 decreased (98.0 [1.0] vs. 97.0 [1.0], p &lt; 0.05), respiratory rate increased (16.0 [3.0] vs. 17.0 [2.0], p &lt; 0.01), and heart rate remained unchanged. As mask use duration increased, the VAS scores of shortness of breath, dizziness, and headache gradually increased.

Conclusion

In healthy anesthesiologists, wearing SMs for more than 2 h can significantly decrease SpO2 and increase respiratory rates without affecting heart rates.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Evaluation of Postoperative Development of Saphenous Vein Graft Incision Site Infections in Patients Undergoing Isolated Coronary Artery Bypass Graft Surgery: A Single Center Experience

Objective: This study aimed to evaluate surgical site infection patients developing saphenous vein graft incision site infection after isolated coronary artery bypass graft surgery performed in the cardiovascular surgery clinic of our hospital in the last 12 years to reveal the causative microorganisms, risk factors, and clinical characteristics. Material and Methods: A total of 34 surgical site infection patients (23 females, 11 males; mean age 68.0±9.0 years; range 51-86 years) who underwent isolated coronary artery bypass graft surgery in the cardiovascular surgery clinic of our hospital between March 2009 and November 2020 and who postoperatively developed saphenous vein graft incision site infection were included in the study. The patients' demographic data, underlying diseases, and preoperative, intraoperative, and postoperative risk factors were analyzed retrospectively. Results: In all isolated coronary artery bypass graft surgeries performed over a period of about 12 years, the rate of saphenous vein graft incision site surgical site infection was found to be 0.8%. Of these, 23 (67.6%) were evaluated as superficial incisional surgical site infection and 11 (32.4%) as deep incisional surgical site infection. In the patients who developed surgical site infection, the parameters of age, female sex, obesity, diabetes mellitus, smoking, emergency surgery, use of more than 1 saphenous vein graft, prolonged operation, cardiopulmonary bypass, and aortic clamp durations, intraoperative blood transfusion, length of stay in the intensive care unit, use of inotropes, and total length of hospital stay were all found to be significant. The microorganisms in purulent discharge cultures consisted of Gram-negative bacteria in 18 (53%), Gram-positive bacteria in 12 (35.3%), and fungi in 1 (2.9%). No pathogenic microorganism growth was observed in 5 (14.7%) patients. In the patients with surgical site infection, coagulase-negative staphylococci (17.6%) and Escherichia coli (17.6%) were the most frequently isolated agents. Conclusion: Particular attention should be paid to surgical site infection in patients undergoing a cardiovascular surgery intervention. It should be noted that post coronary artery bypass graft surgery surgical site infection can be reduced by determining its risk factors, modifying surgical techniques, and postoperative close monitoring of patients. Follow-up and personal care are crucial after discharge and an empirical treatment approach should be determined when an infection occurs, taking into account that coagulase-negative staphylococci and E. coli were the two leading infectious agents in our hospital.

Antimicrobial Prophylaxis Reduces the Rate of Surgical Site Infection in Upper Gastrointestinal Surgery: A Systematic Review

Surgical site infection occurs with high frequency in gastrointestinal surgery, contributing to the high incidence of morbidity and mortality. The accepted practice worldwide for the prevention of surgical site infection is providing single- or multiple-dose antimicrobial prophylaxis. However, most suitable antibiotic and optimal duration of prophylaxis are still debated. The aim of the systematic review is to assess the efficacy of antimicrobial prophylaxis in controlling surgical site infection rate following esophagogastric surgery. PubMed and Cochrane databases were systematically searched until 31 October 2021, for randomized controlled trials comparing different antimicrobial regimens in prevention surgical site infections. Risk of bias of studies was assessed with standard methods. Overall, eight studies concerning gastric surgery and one study about esophageal surgery met inclusion criteria. No significant differences were detected between single- and multiple-dose antibiotic prophylaxis. Most trials assessed the performance of cephalosporins or inhibitor of bacterial beta-lactamase. Antimicrobial prophylaxis (AMP) is effective in reducing the incidence of surgical site infection. Multiple-dose antimicrobial prophylaxis is not recommended for patients undergoing gastric surgery. Further randomized controlled trials are needed to determine the efficacy and safety of antimicrobial prophylaxis in esophageal cancer patients.

The role of postoperative antibiotic duration on surgical site infection after lumbar surgery

OBJECTIVE

Despite a general consensus regarding the administration of preoperative antibiotics, poorly defined comparison groups and underpowered studies prevent clear guidelines for postoperative antibiotics. Utilizing a data set tailored specifically to spine surgery outcomes, in this clinical study the authors aimed to determine whether there is a role for postoperative antibiotics in the prevention of surgical site infection (SSI).

METHODS

The Michigan Spine Surgery Improvement Collaborative registry was queried for all lumbar operations performed for degenerative spinal pathologies over a 5-year period from 2014 to 2019. Preoperative prophylactic antibiotics were administered for all surgical procedures. The study population was divided into three cohorts: no postoperative antibiotics, postoperative antibiotics ≤ 24 hours, and postoperative antibiotics > 24 hours. This categorization was intended to determine 1) whether postoperative antibiotics are helpful and 2) the appropriate duration of postoperative antibiotics. First, multivariable analysis with generalized estimating equations (GEEs) was used to determine the association between antibiotic duration and all-type SSI with adjusted odds ratios; second, a three-tiered outcome-no SSI, superficial SSI, and deep SSI-was calculated with multivariable multinomial logistical GEE analysis.

RESULTS

Among 37,161 patients, the postoperative antibiotics > 24 hours cohort had more men with older average age, greater body mass index, and greater comorbidity burden. The postoperative antibiotics > 24 hours cohort had a 3% rate of SSI, which was significantly higher than the 2% rate of SSI of the other two cohorts (p = 0.004). On multivariable GEE analysis, neither postoperative antibiotics > 24 hours nor postoperative antibiotics ≤ 24 hours, as compared with no postoperative antibiotics, was associated with a lower rate of all-type postoperative SSIs. On multivariable multinomial logistical GEE analysis, neither postoperative antibiotics ≤ 24 hours nor postoperative antibiotics > 24 hours was associated with rate of superficial SSI, as compared with no antibiotic use at all. The odds of deep SSI decreased by 45% with postoperative antibiotics ≤ 24 hours (p = 0.002) and by 40% with postoperative antibiotics > 24 hours (p = 0.008).

CONCLUSIONS

Although the incidence of all-type SSI was highest in the antibiotics > 24 hours cohort, which also had the highest proportions of risk factors, duration of antibiotics failed to predict all-type SSI. On multinomial subanalysis, administration of postoperative antibiotics for both ≤ 24 hours and > 24 hours was associated with decreased risk of only deep SSI but not superficial SSI. Spine surgeons can safely consider antibiotics for 24 hours, which is equally as effective as long-term administration for prophylaxis against deep SSI.

Clean and Confident: Impact of Sterile Instrument Processing Workshops on Knowledge and Confidence in Five Low- and Middle-Income Countries

Background: Proper sterilization of surgical instruments is essential for safe surgery, yet re-processing methods in low-resource settings can fall short of standards. Training of Trainers (TOT) workshops in Ethiopia and El Salvador instructed participants in sterile processing concepts and prepared participants to teach others. This study examines participants' knowledge and confidence post-TOT workshop, and moreover discusses subsequent non-TOT workshops and observed sterile processing practices. Methods: Five TOT workshops were conducted between 2018 and 2020 in Ethiopia and Central America. Participant trainers then led nine non-TOT workshops in El Salvador, Guatemala, Honduras, and Nicaragua. Interactive sessions covered instrument cleaning, packaging, disinfection, sterilization, and transportation. Participants completed pre- and post-tests, demonstrated skill competencies, and shared feedback. Peri-operative sterile processing metrics were also observed in Ethiopian hospitals pre- and post-workshops. Results: Ninety-five trainees participated in TOT workshops, whereas 169 participated in non-TOT workshops. Knowledge on a 10-point scale increased substantially after all training sessions (+2.3 ± 2.8, +2.9 ± 1.7, and 2.7 ± 2.5 after Ethiopian, Central American, and non-TOT workshops, respectively; all p < 0.05). Scores on tests of sterile processing theory also increased (Ethiopian TOT, +68% ± 92%; Central American TOT, +26% ± 20%; p < 0.01). Most respondents felt "very confident" about teaching (Ethiopian TOT, 72%; Central American TOT, 83%; non-TOT, 70%), whereas fewer participants felt "very confident" enacting change (Ethiopian TOT, 36%; Central American TOT, 58%; non-TOT, 38%). Reasons included resource scarcity and inadequate support. Nonetheless, observed instrument compliance improved after Ethiopian TOT workshops (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.21-1.78; p < 0.01). Conclusions: Sterile processing workshops can improve knowledge, confidence, and sterility compliance in selected low- and middle-income countries. Training of Trainers models empower participants to adapt programs locally, enhancing sterile processing knowledge in different communities. However, national guidelines, physical and administrative resources, and long-term follow-up must improve to ensure effective sterile processing.

Indian Society of Pediatric Neurosurgery Consensus Guidelines on Preventing and Managing Shunt Infection: Version 2020-21

Background

Shunt infection is the most significant morbidity associated with shunt surgery. Based on the existing literature for the prevention and management of shunt infection, region and resource-specific recommendations are needed.

Methods

In February 2020, a Guidelines Development Group (GDG) was created by the Indian Society of Paediatric Neurosurgery (IndSPN) to formulate guidelines on shunt infections, which would be relevant to our country and LMIC in general. An initial email survey identified existing practices among the membership of the IndSPN, and eight broad issues pertaining to shunt infection were identified. Next, members of the GDG performed a systematic review of the literature on the prevention and management of shunt infection. Then, through a series of virtual meetings of the GDG over 1 year, evidence from the literature was presented to all the members and consensus was built on different aspects of shunt infection. Finally, the guidelines document was drafted and circulated among the GDG for final approval. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to grade the evidence and strength of recommendation.

Results

The guidelines are divided into eight sections. Level I and Level II evidence was available for only five recommendations and led to a moderate level of recommendations. Most of the available evidence was at Level III and below, and hence the level of recommendation was low or very low. A consensus method was used to provide recommendations for several issues.

Conclusions

Although most of the recommendations for the prevention and management of shunt infections are based on a low level of evidence, we believe that this document will provide a useful reference to neurosurgeons not only in India but also in other low and middle income countries. These guidelines need to be updated as and when new evidence emerges.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Prophylactic incisional negative pressure wound therapy for gynaecologic malignancies

Wound complications are an important cause of postoperative morbidity among patients with gynaecologic malignancies. We evaluated whether the placement of closed-incisional negative pressure therapy (ciNPT) at the time of laparotomy for gynaecologic cancer surgery reduced wound complication rates. A retrospective cohort study with primary wound closure performed by a gynaecologic oncologist was carried out. We evaluated two cohorts of patients who underwent surgery in 2017 with standard closure and patients who underwent surgery in 2019 with the placement of prophylactic ciNPT. Postoperative outcomes were examined. A total of 143 patients were included, 85 (59.4%) vs 58 (40.6%) with standard closure and ciNPT, respectively. The total complication rate in our sample was 38.71%. The rate of surgical complications in patients treated with ciNPT was 6.9% compared with 31.8% (P = .000) in patients treated with standard closure. In the analysis of complications, a significant reduction in infections (17.1%), seromas (15.4%), and wound dehiscence (17.1%) were observed when ciNPT was applied. The median hospital stay was 8 vs 6 days in the standard closure vs ciNPT groups (P = .048). The use of the prophylactic ciNPT following a laparotomy may decrease wound complications and hospital stays in oncological patients. ciNPT could be considered as part of clinical practice in patients at high risk of wound complications, such as patients with gynaecological malignancies.

A symmetric anchor designed barbed suture versus conventional interrupted sutures in total knee arthroplasty: A multicenter, randomized controlled trial

OBJECTIVE

This randomized controlled study was designed to compare the wound closure efficacy and safety of barbed suture in comparison to the conventional interrupted suture for total knee arthroplasty (TKA).

METHODS

This multicenter, single-blind, randomized controlled trial enrolled 184 patients who underwent elective TKA between June 2017 and April 2018. The subjects were randomized between two groups. Surgical incision closure time was considered as the primary end point.

RESULTS

A total of 184 patients participated in this randomized controlled trial; 91 patients had wound closure that involved barbed suture and 93 patients underwent conventional treatment-that is interrupted suturing with nonbarbed sutures. The surgical incision closure time was shorter (p < 0.0001) in the barbed suture group compared with the control group (15.5 ± 4.88 vs. 20.9 ± 6.30 min). However, both groups were found to be equal in terms of the rate of postoperative complications.

CONCLUSION

Usage of the symmetric anchor designed barbed suture is safe, efficacious, and demonstrates a decrease in surgical incision closure time in patients undergoing TKA compared to interrupted closure using conventional sutures. Future studies are warranted to demonstrate clinical and economic benefits of barbed sutures.

Closed incision negative pressure wound therapy is associated with reduced surgical site infection after emergency laparotomy: A propensity matched-cohort analysis

BACKGROUND

Surgical site infection contributes to a significant proportion of postoperative morbidity in patients undergoing emergency laparotomy. Surgical site infections cause significant patient burden, increase duration of stay, and have economic implications. Closed incision negative pressure therapy has been shown to reduce surgical site infection rates in patients undergoing elective laparotomy; however, there is limited evidence for their use in the emergency setting. This study aims to compare rates of surgical site infection between patients receiving closed incision negative pressure therapy and standard surgical dressing after emergency laparotomy through a propensity matched analysis.

METHODS

A registry-based, prospective cohort study was undertaken using data from the National Emergency Laparotomy Audit database at our center. The primary outcome measure was surgical site infection as defined by the Centers for Disease Control criteria. Secondary outcomes included 30-day postoperative morbidity and grade, duration of stay, 30-day mortality, and readmission rates. A propensity-score matching was performed in a 1:1 ratio to mitigate for selection bias.

RESULTS

A total of 1,484 patients were identified from the National Emergency Laparotomy Audit data set, and propensity-score matching resulted in 2 equally matched cohorts with 237 patients in each arm. The rate of surgical site infection was significantly lower in the closed incision negative pressure therapy cohort (16.9% vs 33.8%, P < .001). There were no overall differences in 30-day morbidity, Clavien-Dindo grade, Comprehensive Complication Index severity, length of hospital stay, reoperation rates, and 30-day mortality between the 2 groups.

CONCLUSIONS

Prophylactic closed incision negative pressure therapy in emergency laparotomy patients is associated with a reduction in surgical site infection rates.

A nomogram prediction model for sternal incision problems

Presently, the incidence and mortality rates of sternal incision problems (SIPs) after thoracotomy remain high, and no effective preventive measures are available. The data on 23 182 patients at Xinqiao Hospital, Army Medical University treated with median sternotomy from 1 August 2009 to 31 July 2019 were retrospectively reviewed. A prediction model of SIPs after median thoracotomy was established using R software and then validated using the bootstrap method. Next, the validity and accuracy of the model were tested and evaluated. In total, 15 426 cases met the requirements of the present study, among which 309 cases were diagnosed with SIPs, with an incidence rate of 2%. The body mass index (BMI), intensive care unit (ICU) time, diabetes mellitus, and revision for bleeding were identified as independent risk factors for postoperative SIPs. The nomogram model achieved good discrimination (73.9%) and accuracy (70.2%) in predicting the risk of SIPs after median thoracotomy. Receiver operating characteristic curve analysis showed that the area under curve of the model was 0.705 (95% confidence interval [CI]: 0.746-0.803); the Hosmer-Lemeshow test showed that χ²  = 6.987 and P = 0.538, and the fitting degree of the calibration curve was good. Additionally, the clinical decision curve showed that the net benefit of the model was greater than 0, and the clinical application value was high. The nomogram based on BMI, ICU time, diabetes mellitus, and revision for bleeding can predict the individualised risk of SIPs after median sternotomy, showing good discrimination and accuracy, and has high clinical application value. It also provides significant guidance for screening high-risk populations and developing intervention strategies.

The risk factors and care measures of surgical site infection after cesarean section in China: a retrospective analysis

Background

Surgical site infections after cesarean section are very common clinically, it is necessary to evaluate the risk factors of surgical site infections after cesarean section, to provide evidences for the treatment and nursing care of cesarean section.

Methods

This study was a retrospective cohort study design. Patients undergone cesarean section in a tertiary hospital of China from May 2017 to May 2020 were identified, we collected the clinical data of the included patients, and we analyzed the infection rate, etiological characteristics and related risk factors of surgical site infection after caesarean section.

Results

A total of 206 patients with cesarean section were included, and the incidence of surgical site infection in patients with cesarean section was 23.30%. A total of 62 cases of pathogens were identified, Enterococcus faecalis (33.87%) and Escherichia coli (29.03%) were the most common pathogens. Both Enterococcus faecalis and Escherichia coli were highly sensitive to Cefoperazone, Meropenem, and Levofloxacin. Logistic regression analyses indicated that Age ≥ 30y (OR 4.18, 95%CI: 1.23–7.09), BMI ≥ 24 (OR 2.39, 95%CI: 1.02–4.55), duration of cesarean section ≥ 1.5 h (OR 3.90, 95%CI: 1.28–5.42), estimated blood loss ≥ 400 ml (OR 2.35, 95%CI: 1.10–4.37) and the duration of urinary catheter ≥ 24 h (OR 3.18, 95% CI: 1.21–5.71) were the independent risk factors of surgical site infection after cesarean section (all p < 0.05).

Conclusions

Age, BMI, duration of surgery, blood loss and urinary catheter use were associated with higher risk of the surgical site infection after cesarean section. Clinical preventions and interventions are warranted for those population to reduce the occurrence of surgical site infection.

Risk factors for surgical site infection after major oral oncological surgery: the experience of a tertiary referral hospital in China

Objective

To identify risk factors associated with surgical site infection (SSI) after major oral oncological surgery.

Methods

This retrospective study reviewed data from patients that underwent major surgery for oral cancer at a tertiary referral hospital in China between January 2005 and July 2016. SSI was diagnosed within 30 days. Demographic, cancer-related, preoperative, perioperative and postoperative data were analysed using descriptive statistics and univariate and multivariate analyses of the risk factors for SSI.

Results

A total of 786 patients were enrolled, of whom 125 had SSI (15.9%), which were all incisional. Independent risk factors for SSI, identified by multivariate analysis, were diabetes mellitus (odds ratio [OR] 2.147, 95% confidence interval [CI] 1.240, 3.642), prior radiotherapy (OR 4.595, 95% CI 1.293, 17.317) and oral–neck communication (OR 2.838, 95% CI 1.263, 7.604); and factors reflecting large extent resections were tracheostomy (OR 2.235, 95% CI 1.435, 3.525), anterolateral thigh flap (OR 1.971, 95% CI 1.103, 3.448) and latissimus dorsi flap (OR 4.178, 95% CI 1.325, 13.189).

Conclusions

Multiple risk factors were associated with SSI after major oral oncological surgery. To minimize SSI risk, surgeons managing oral cancer patients should have a better understanding of the risk factors, including diabetes mellitus, prior radiotherapy, tracheostomy, oral–neck communication and flap reconstruction.

Effect of perioperative hypothermia on surgical site infection in abdominal surgery: A prospective cohort study

AIM

To estimate the incidence rates of surgical site infection and identify the independent effect of perioperative hypothermia on the incidence of this type of infection in patients undergoing abdominal surgery.

BACKGROUND

Around the world, surgical site infection is a frequent complication in surgical patients, mainly causing increased morbidity and mortality rates and health service costs.

DESIGN

A prospective cohort study.

METHODS

The 484 patients were recruited from a large private philanthropic hospital in the state of São Paulo, Brazil, from July 2016 to May 2017. Crude and adjusted models were constructed for the hypothermia indicators to assess the effect of this exposure on surgical site infection.

RESULTS

The incidence rate of surgical site infection was 20.25% (n = 98). The attributable fraction to exposed to hypothermia was >40%. A greater probability of developing surgical site infection (relative risk = 1.89) was found for patients who experienced body temperatures <36.0°C (from entry time into the operating room until the end of the surgery) for more than five hypothermic episodes or longer than 75 min.

CONCLUSION

Perioperative hypothermia was an independent risk factor for surgical site infection.

SUMMARY STATEMENT

What is already known about this topic? Around the world, surgical site infection is a complication that leads to damage to the patient and increased costs for the health services. Despite recent advances in surgical techniques, surgical site infection remains one of the most frequent complications in abdominal surgery. Perioperative hypothermia can increase the incidence rates of surgical site infection. There is evidence that perioperative hypothermia is associated with surgical site infection in abdominal surgery, but most studies were conducted in developed countries using retrospective designs. What this paper adds? Perioperative hypothermia was identified as an independent risk factor for surgical site infection in patients undergoing abdominal surgery. The attributable fraction to the exposed indicated that, if the main exposure of interest (perioperative hypothermia) could be prevented during surgical anaesthetic procedures, more than 40% of surgical site infection cases would be avoided. The classification of the American Society of Anaesthesiologists was independently associated with the surgical site infection and presented a dose-response effect among its categories. Spinal anaesthesia served as an independent protective factor for surgical site infection. The implications of this paper: The health service managers need to be aware of potential cost-savings associated with perioperative hypothermia prevention as a measure to reduce the incidence of surgical site infection. During the perioperative period, health professionals need to implement effective measures to maintain patients' normothermia, promoting improved care and surgical patient safety. In this context, the nurse's role is fundamental. Future research projects using a prospective design and developed to address the reality of developing countries can contribute to the strengthening and consistency of the findings with a view to a global understanding of the surgical site infection problem.

COVID-19 knowledge, attitude, and precautionary practices among health professional students in Oman

Assessing knowledge, attitude, and practices of healthcare students regarding any infectious outbreak became a fundamental step to set an effective plan related to their preparedness. The purpose of this study was to assess COVID-19 knowledge, attitude, and precautionary practices among health professional students in Oman. Data were collected using the Web-based survey method. The sample was recruited from the largest college of Medicine in Oman, while the nursing sample was recruited from two different nursing colleges in Oman. The study tool was developed based on the most recent advisory COVID-19 recommendations from the WHO and the CDC. A total of 222 students filled the survey, of which 55% were medical students and 59.9% were females. The mean knowledge score was 16.5 (SD = 4.2), which represents 66% of the highest possible score, with 25.7% were classified as ‘excellent knowledge’. Participants reported a high level of public precautionary practices (M = 44.1, SD = 5.0), which represents 84.6% of the highest score, with 61.3% were classified as ‘high compliance. The mean attitude score was 40.3 (SD = 5.9), which represents 67% of the highest possible score. According to the classification categories, most students (81%, n = 180) expressed a positive attitude toward COVID-19. More efforts should be done toward preparing the healthcare students to deal with the outbreak. Preparing healthcare students with the right knowledge, attitude, and precautionary practices during the COVID-19 outbreak is very essential to patient and public safety. Healthcare students can play a major role in increasing public awareness about COVID-19 precautionary practices.

Preparación de la piel para la prevención de la Infección del Sitio Operatorio: Revisión de Alcance

Introducción: La Infección del sitio operatorio genera un impacto económico y social debido a los altos costos durante la recuperación, la estancia hospitalaria y la afectación de la calidad de vida, por esto, es necesario identificar las intervenciones y recomendaciones para la preparación de la piel, encaminadas a la prevención de la infección del sitio operatorio, basado en la evidencia científica. Materiales y Métodos: Se realizó una revisión sistemática de alcance en el marco del Instituto Joanna Briggs y los parámetros Prisma-P. En las bases de datos Medline, OVID, Pubmed, Scielo, BVS y Cochrane, publicadas entre los años 2010–2019, en los idiomas inglés, portuges y español. Resultados: Se analizaron 28 artículos. De estos, se identificaron 6 de la categoría general incluidas las guías de prevención de infección del sitio operatorio, 6 para el baño preoperatorio, 6 para la realización del rasurado y 10 de asepsia y antisepsia. Discusión: Con respecto al baño preoperatorio, es una práctica recomendada internacionalmente, la evidencia demuestra que esta actividad no representa ningún beneficio; en la categoría de rasurado, la recomendación es no remover el vello a menos que sea absolutamente necesario. Frente a la asepsia del sitio quirúrgico, el aporte es más que todo informativo acerca de los antisépticos y se recomienda el uso de la clorhexidina. Conclusiones: De acuerdo a la revisión sistemática de alcance de la literatura, no se evidencia una estandarización en las recomendaciones e intervenciones, para la preparación de la piel en la prevención de Infección del Sitio Operatorio.

Surgical revision strategies for postoperative spinal implant infections (PSII)

Over the last years the number of spine surgeries with instrumentation has grown to an indispensable column in the treatment for different pathologies of the spine. A further increase in the incidence of instrumented spinal surgery is expected throughout the next years. Although the implementation and development of new techniques offer faster and more minimal invasive procedures, shortening surgery time, reducing soft tissue injury and revision due to hardware misplacement, the incidence of postoperative spinal implant infections (PSII) remains high. PSII related complications and revision procedures pose an enormous socioeconomic burden. Therefore, standardized strategies and protocols for treatment of PSII are urgently needed. While in former times hardware exchange or hardware removal was common practise in the field of spine surgery this approach has changed over the last years. Although the evidence from clinical studies in the field of PSII is of limited evidence, critical variables for revision strategies of PSII have been identified. Further, to quickly advance in the field of PSII it is certainly important to extrapolate and learn using data regarding the management from other fields of prosthetic joint infections. This should include clinical as well as experimental work in particular in the context of the biofilm, sonication as well as microbiological concepts. Over the last years, at our institution standardized procedures for diagnostic, surgical as well as antimicrobial treatment have been developed, based on the latest recommendations in peer-reviewed literature and our own data. Here we give an overview about surgical revision strategies for PSII and discuss the key points of our standardized protocol.

The Role of Anesthetic Management in Surgical Site Infections After Pediatric Intestinal Surgery

BACKGROUND

Although surgical site infections (SSIs) remain a significant health care issue, a limited number of studies have analyzed risk factors for SSIs in children, particularly the role of intraoperative anesthetic management. Pediatric patients are less likely to have major adult risk factors for SSIs such as smoking and diabetes. Thus children may be more suitable as a cohort for examining the role of intraoperative anesthetics in SSIs.

AIM

We examined an association between SSI incidence and anesthetic management in children who underwent elective intestinal surgery in a single institution.

METHODS

We performed a retrospective study of 621 patients who underwent elective intestinal surgery under general anesthesia between January 2017 and September 2019, with primary outcome as the incidence of SSIs. We compared patients who were dichotomized in accordance with the median of the sevoflurane dose. We used propensity score (PS) pairwise matching of these patients to avoid selection biases. PS matching yielded 204 pairs of patients.

RESULTS

We found that higher doses of sevoflurane were associated with a higher incidence of SSIs (9.8% versus 3.9%, P = 0.019). We adjusted for intraoperative factors that were not included in the PS adjustment factors, and multivariate regression analysis after PS matching showed compatible results (odds ratio: 2.58, 95% confidence interval: 1.11-6.04, P = 0.028).

CONCLUSIONS

Higher doses of sevoflurane are associated with increased odds of SSIs after pediatric elective intestinal surgery. A randomized controlled study of volatile anesthetic-based versus intravenous anesthetic-based anesthesia will be needed to further determine the role of anesthetic drugs in SSI risk.

Benefits of a Pediatric Antimicrobial Stewardship Program in Antimicrobial Use and Quality of Prescriptions in a Referral Children's Hospital

OBJECTIVES

To evaluate the results of the first 24 months of a postprescription review with feedback-based antimicrobial stewardship program in a European referral children's hospital.

STUDY DESIGN

We performed a pre-post study comparing antimicrobial use between the control (2015-2016) and the intervention periods (2017-2018) expressed in days of therapy/100 days present. Quality of prescriptions was evaluated by quarterly cross-sectional point-prevalence surveys. Length of stay, readmission rates, in-hospital mortality rates, cost of systemic antimicrobial agents, and antimicrobial resistance rates were included as complementary outcomes.

RESULTS

Total antimicrobial use and antibacterial use significantly decreased during the intervention period (P = .002 and P = .001 respectively), and total antifungal use remained stable. A significant decline in parenteral antimicrobial use was also observed (P < .001). In 8 quarterly point-prevalence surveys (938 prescriptions evaluated), the mean prevalence of use of any antimicrobial among inpatients was 39%. An increasing trend in the rate of optimal prescriptions was observed after the first point-prevalence survey (P = .0898). Nonoptimal prescriptions were more common in surgical than in medical departments, in antibacterial prescriptions with prophylactic intention, and in empirical more than in targeted treatments. No significant differences were observed in terms of mortality or readmission rates. Only minor changes in antimicrobial resistance rates were noted.

CONCLUSIONS

Our antimicrobial stewardship program safely decreased antimicrobial use and expenditure, and a trend toward improvement in quality of prescription was also observed.