An analysis of 3,954 cases to determine surgical wound classification accuracy: Does your institution need a monday morning quarterback?

Risk Factors, Pathogens, and Outcomes of Ventilator-Associated Pneumonia in Non-Cardiac Surgical Patients: A Retrospective Analysis

Ventilator-associated pneumonia (VAP) is a critical hospital-acquired infection following non-cardiac surgeries, leading to poor outcomes. This study identifies VAP risk factors in non-cardiac surgical patients and determines the causative pathogens. A retrospective analysis with 1:4 propensity-score matching was conducted on patients in a surgical intensive care unit (ICU) from 2010 to 2020 at a private tertiary medical center. Among 99 VAP patients, the mortality rate was 64.7%. VAP risk factors included prolonged mechanical ventilation (odds ratio [OR] 6.435; p < 0.001), repeat intubation (OR 6.438; p < 0.001), lower oxygenation levels upon ICU admission (OR 0.950; p < 0.001), and undergoing gastrointestinal surgery (OR 2.257; p = 0.021). The 30-day mortality risk factors in the VAP group were late-onset VAP (OR 3.450; p = 0.022), inappropriate antibiotic treatment (OR 4.083; p = 0.041), and undergoing gastrointestinal surgeries (OR 4.776; p = 0.019). Nearly half of the Gram-negative infections were resistant strains, and a third were polymicrobial infections. Non-cardiac surgical patients with VAP face adverse hospital outcomes. Identifying high-risk patients and understanding VAP's resistant and microbial nature are crucial for appropriate treatment and improved health outcomes.

Preoperative Prediction of Postoperative Infections Using Machine Learning and Electronic Health Record Data

OBJECTIVE

To estimate preoperative risk of postoperative infections using structured electronic health record (EHR) data.

BACKGROUND

Surveillance and reporting of postoperative infections is primarily done through costly, labor-intensive manual chart reviews on a small sample of patients. Automated methods using statistical models applied to postoperative EHR data have shown promise to augment manual review as they can cover all operations in a timely manner. However, there are no specific models for risk-adjusting infectious complication rates using EHR data.

METHODS

Preoperative EHR data from 30,639 patients (2013-2019) were linked to the American College of Surgeons National Surgical Quality Improvement Program preoperative data and postoperative infection outcomes data from 5 hospitals in the University of Colorado Health System. EHR data included diagnoses, procedures, operative variables, patient characteristics, and medications. Lasso and the knockoff filter were used to perform controlled variable selection. Outcomes included surgical site infection, urinary tract infection, sepsis/septic shock, and pneumonia up to 30 days postoperatively.

RESULTS

Among >15,000 candidate predictors, 7 were chosen for the surgical site infection model and 6 for each of the urinary tract infection, sepsis, and pneumonia models. Important variables included preoperative presence of the specific outcome, wound classification, comorbidities, and American Society of Anesthesiologists physical status classification. The area under the receiver operating characteristic curve for each model ranged from 0.73 to 0.89.

CONCLUSIONS

Parsimonious preoperative models for predicting postoperative infection risk using EHR data were developed and showed comparable performance to existing American College of Surgeons National Surgical Quality Improvement Program risk models that use manual chart review. These models can be used to estimate risk-adjusted postoperative infection rates applied to large volumes of EHR data in a timely manner.

Single-use negative pressure wound therapy versus conventional dressings for the reduction of surgical site infections in closed surgical incisions: Systematic literature review and meta-analysis

BACKGROUND

To evaluate whether a single-use negative pressure wound therapy (sNPWT) device can reduce the incidence of surgical site infection (SSI) in at-risk patients with closed surgical incisions across a range of surgical specialties, compared with standard care.

METHODS

PubMed, Embase, Cochrane Library and ClinicalTrials.gov were searched from the period January 2011 to April 2021.

RESULTS

Out of 15,283 articles identified, 19 were included. A statistically significant improvement (p ​< ​0.05) in the composite SSI (odds ratio [OR]: 0.36; 95 ​% confidence interval [CI]: 0.27-0.49), superficial SSI (OR: 0.30; 95 ​% CI: 0.17-0.53), and deep SSI (OR: 0.67; 95 ​% CI: 0.46-0.96) outcomes was observed with the sNPWT device compared with standard care in a pooled analysis of all surgical specialties.

CONCLUSION

A -80 ​mmHg sNPWT device reduces the incidence of composite, superficial, and deep SSIs when compared with standard care across a heterogenous at-risk surgical population containing a variety of surgical specialties.

Improving surgical wound classification accuracy through education and audit processes

Precise wound classification is essential for surgical site infection risk stratification and appropriate hospital reimbursement. We instituted a multifaceted approach to improve institutional wound class identification including an education and awareness bundle, as well as a formal audit process. Overall, we saw significant improvements in wound class accuracy, interprofessional collaboration and provider compliance.

Self-Reported Diagnosis and Management of Surgical Site Infection Highlights Lack of Objective Measures and Treatment Guidance

Background: There is little guidance regarding empiric therapy for superficial surgical site infections (SSIs). Management of incisions with signs of SSI lacks consensus and management is variable among individual surgeons. Methods: The Surgical Infection Society was surveyed regarding management of SSIs. Cases were provided with varying wound descriptions, initial wound class (WC), post-operative day, and presence of a prosthesis. Responses were in multiple-choice format; statistics: χ2; α = 0.05. Results: Seventy-eight members responded. For appearance scenarios, respondents believed that both mild erythema (55%) and clear drainage (64%) could be observed, whereas substantial (>3 cm) erythema or purulence should be treated with complete (22% and 50%) or partial (55% and 40%) opening of the incision. Degree of erythema did not influence administration of antibiotic agents, but purulence was more likely than clear drainage to be treated with antibiotics (38% vs. 6%; p < 0.001). There were no differences based on WC, except that clean cases were more likely than higher WC scenarios to be treated with gram-positive coverage alone (WC 1 [26%] vs. 2 [10%] vs. 3 [13%] vs. 4 [4%]; p < 0.001). Post-operative day (POD) three appeared to be an inflection point for more aggressive treatment of suspected incisional SSI, with fewer (POD 0 [86%] vs. POD day 3 [54%]; p < 0.001) reporting observation. Respondents were more likely to obtain imaging, start broad-spectrum antibiotic agents, and return to the operating room for purulence in the presence of a mesh. Conclusions: Presented with escalating possibility of SSI, respondents reported lower rates of observation, increased use of antibiotic agents, and increased surgical drainage. Many scenarios lack consensus regarding appropriate therapy. The complete elimination of SSIs is unlikely to be accomplished soon, and this study provides a framework for understanding how surgeons approach SSIs, and potential areas for further research or pragmatic guidance.

Different Surgeon, Different Closure: Lack of Consensus on Appropriate Closure Technique for Various Case Scenarios

Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ² test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.

Risk factors and mortality associated with multidrug-resistant gram-negative bacterial infection in adult patients with abdominal surgery

BACKGROUND

Multidrug-resistant (MDR) gram-negative bacterial (GNB) infections remain a significant cause of morbidity and mortality among surgical patients. The objective of our study was to recognize the risk factors for MDR GNB infection in patients with abdominal surgery and determine the predictors independently associated with death.

METHODS

From 2010 to 2017, a retrospective cohort study was conducted among patients with abdominal surgery admitted in surgical intensive care unit (ICU). Patients with GNB infections were included for analyses.

RESULTS

A total of 364 patients with abdominal surgery experienced GNB infections, among them, 117 (32.1%) were MDR GNB infection. Of 133 MDR GNB isolates, the most frequent isolate was Escherichia coli (45.1%). Patients with MDR GNB infection had significantly longer ventilator days and hospital stay, as well as higher 30-day and in-hospital mortality compared to non-MDR GNB patients. Multivariable analysis showed longer length of pre-ICU stay, surgical re-exploration, receipt of group 2 carbapenems (e.g. imipenem, meropenem and doripenem) and fluoroquinolones, and higher total bilirubin were independent risk factors for the acquisition of MDR GNB infection. Predictors for 30-day mortality among patients with MDR GNB infection were chronic kidney disease, receipt of group 2 carbapenems and inappropriate empirical antimicrobial therapy.

CONCLUSIONS

This study provides important information about the risk factors for subsequent MDR GNB infection and 30-day mortality among the patients with abdominal surgery.