Evaluation of the Bundle “Zero Surgical Site Infection” to Prevent Surgical Site Infection in Vascular Surgery

Risk Factors for Surgical Site Infection after Lower Limb Revascularisation Surgery: a Systematic Review and Meta-Analysis of Prognostic Studies

OBJECTIVE

To systematically review and meta-analyse adjusted risk factors for surgical site infection (SSI) after lower limb revascularisation surgery.

DATA SOURCES

MEDLINE, Embase, Evidence Based Medicine Reviews, and the Cochrane Central Register of Controlled Trials (inception to 28 April 2022).

REVIEW METHODS

Systematic review and meta-analysis conducted according to PRISMA guidelines. After protocol registration, databases were searched. Studies reporting adjusted risk factors for SSI in adults who underwent lower limb revascularisation surgery for peripheral artery disease were included. Adjusted odds ratios (ORs) were pooled using random effects models. GRADE was used to assess certainty.

RESULTS

Among 6 377 citations identified, 50 studies (n = 271 125 patients) were included. The cumulative incidence of SSI was 12 (95% confidence interval [CI] 10 - 13) per 100 patients. Studies reported 139 potential SSI risk factors adjusted for a median of 12 (range 1 - 69) potential confounding factors. Risk factors that increased the pooled adjusted odds of SSI included: female sex (pooled OR 1.41, 95% CI 1.20 - 1.64; high certainty); dependent functional status (pooled OR 1.18, 95% CI 1.03 - 1.35; low certainty); being overweight (pooled OR 1.82, 95% CI 1.29 - 2.56; moderate certainty), obese (pooled OR 2.20, 95% CI 1.44 - 3.36; high certainty), or morbidly obese (pooled OR 1.65, 95% CI 1.08 - 2.52; moderate certainty); chronic obstructive pulmonary disease (pooled OR 1.42, 95% CI 1.17 - 1.71; high certainty); chronic limb threatening ischaemia (pooled OR 1.67, 95% CI 1.22 - 2.29; moderate certainty); chronic kidney disease (pooled OR 2.13, 95% CI 1.18 - 3.83; moderate certainty); intra-operative (pooled OR 1.23, 95% CI 1.02 - 1.49), peri-operative (pooled OR 1.92, 95% CI 1.27 - 2.90), or post-operative (pooled OR 2.21, 95% CI 1.44 - 3.39) blood transfusion (moderate certainty for all); urgent or emergency surgery (pooled OR 2.12, 95% CI 1.22 - 3.70; moderate certainty); vein bypass and or patch instead of endarterectomy alone (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty); an operation lasting ≥ 3 hours (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty) or ≥ 5 hours (pooled OR 1.60, 95% CI 1.18 - 2.17; moderate certainty); and early or unplanned re-operation (pooled OR 4.50, 95% CI 2.18 - 9.32; low certainty).

CONCLUSION

This systematic review identified evidence informed SSI risk factors following lower limb revascularisation surgery. These may be used to develop improved SSI risk prediction tools and to identify patients who may benefit from evidence informed SSI prevention strategies.

Incorporation of skin preparation guidelines in local surgical facility protocols: what kind of barriers does it face? A multi-centre study in France

BACKGROUND

Surgical site infection (SSI) is the most frequent and severe adverse event after surgery. Among preventive measures, the preoperative skin preparation (PSP) is known to be heterogeneously implemented in routine practice. A prerequisite would be the actual incorporation of guidelines in French surgical local protocols.

AIM

To assess whether PSP recommendations have been incorporated in local protocols and to identify the reasons for the non-incorporation.

METHODS

An online survey was proposed to all infection control teams (ICTs) in facilities participating in the French national surveillance and prevention of SSI network Spicmi. The reference recommendations were based on the French Society for Hospital Hygiene guidelines.

FINDINGS

In all, 485 healthcare facilities completed the questionnaire. The incorporation of recommendations in the facility protocol varied between 30% and 98% according to the recommendation. The measures most frequently incorporated were antisepsis with an alcoholic product and cessation of systematic hair removal. The least frequently incorporated were the use of plain soap for preoperative shower and the non-compulsory skin cleaning in the operating room. Barriers reported were either specific to PSP (e.g. 'Concern about an increase of SSI', 'Scepticism about recommendations', 'Force of habit') or non-specific (e.g. 'The protocol not yet due to be updated').

CONCLUSION

We suggest that although some major prevention measures have been incorporated in the local protocol of most facilities, local protocols still frequently include some non-evidence based former recommendations. Communication about evolution of SSI rates, diffusion of guidelines by learned societies, and exchange with judiciary experts could make clear the conditions for applying recommendations.

Frequency and Risk Factors of Surgical Site Infection among Sudanese Patients with Oral Squamous Cell Carcinoma

Background

In Sudan, patients with oral squamous cell carcinoma (OSCC) presented lately in advanced stages. Surgical site infection (SSI) is one of the most common complications of surgical treatment of OSCC which significantly affects the clinical outcomes. The present study aimed to assess the frequency and risk factors of postoperative surgical site infection among OSCC patients underwent surgery at Khartoum Teaching Dental Hospital (KTDH).

Methods

This is a prospective, analytical, hospital-based study conducted at KTDH during the period from 2022 to 2023. Patients with OSCC were surgically treated and assessed carefully for the development of the SSI.

Results

Sixty patients were enrolled in the present study. Twenty-nine (48.3%) patients were above 61 years, with the predominance of males with 42 (70%) patients. The most involved site of OSCC was the lower gingivolabial region in 35 (39.3%) patients. Forty-seven (78%) patients were in advanced stages III and IV. Forty-five (80%) patients had modified radical neck dissection. Blood transfusion was administered in 50 (83.3%) patients. Twenty-six (43.4%) patients developed SSI; 15 (57.7%) patients of them were Toombak dippers. Development of SSI was found to be significantly associated with the tumour site (P value 0.9), clinical stage (P value 0.6), the number of transfused blood units (P value 0.04), and the duration of hospital stay (P value 0.04). In contrast, use of sutures for wound closure was associated with a reduced risk of developing SSI (P value 0.005).

Conclusion

Surgical site infection was found in 43.4% of the OSCC patients. It was associated with advanced clinical stage and tumour site. Minimizing the number of blood units transfused intraoperatively, we decrease the duration of hospital stay and the use of sutures for wound closure decreases the risk of SSI significantly.

Improvement project to reduce surgical site infections: a retrospective cohort study

INTRODUCTION

Surgical site infections are one of the main problems related to health care. In Brazil, they are responsible for 14 to 16% of infections related to health care. This study sought to analyze the effect of implementing a package of measures to reduce surgical site infections (SSI) in heart surgeries, kidney transplants and herniorrhaphies and to evaluate adherence to the safe surgery checklist in a university hospital.

METHODS

this is a retrospective cohort study with data collection in a time series for the period from 2018 to 2020.

RESULTS

we analyzed 222 medical records referring to the surgeries under study performed in the year 2020, in which data were collected from the patients and the care package prevention measures. SSI data and adherence to the safe surgery checklist were analyzed in the years 2018, 2019 and 2020, totaling 268, 300 and 222 procedures analyzed, respectively.

CONCLUSION

the study showed a significant reduction in the SSI rate with greater adherence to the protocol, which was not maintained and was influenced by the COVID-19 pandemic. Thus, the sustainability of this action represents a challenge to be overcome, in order to establish a safer environment for the patient and a better quality of service.

Efficacy of Strategies Intended to Prevent Surgical Site Infection After Lower Limb Revascularization Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this study is to evaluate the efficacy of strategies intended to prevent surgical site infection (SSI) after lower limb revascularization surgery.

BACKGROUND

SSIs are common, costly complications of lower limb revascularization surgery associated with significant morbidity and mortality.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 28, 2022). Two investigators independently screened abstracts and full-text articles, extracted data, and assessed the risk of bias. We included randomized controlled trials (RCTs) that evaluated strategies intended to prevent SSI after lower limb revascularization surgery for peripheral artery disease. We used random-effects models to pool data and GRADE to assess certainty.

RESULTS

Among 6258 identified citations, we included 26 RCTs (n=4752 patients) that evaluated 12 strategies to prevent SSI. Preincision antibiotics [risk ratio (RR)=0.25; 95% CI, 0.11-0.57; n=4 studies; I2 statistic=7.1%; high certainty] and incisional negative-pressure wound therapy (iNPWT) (RR=0.54; 95% CI, 0.38-0.78; n=5 studies; I2 statistic=7.2%; high certainty) reduced pooled risk of early (≤30 days) SSI. iNPWT also reduced the risk of longer-term (>30 days) SSI (pooled-RR=0.44; 95% CI, 0.26-0.73; n=2 studies; I2 =0%; low certainty). Strategies with uncertain effects on risk of SSI included preincision ultrasound vein mapping (RR=0.58; 95% CI, 0.33-1.01; n=1 study); transverse groin incisions (RR=0.33; 95% CI, 0.097-1.15; n=1 study), antibiotic-bonded prosthetic bypass grafts (RR=0.74; 95% CI, 0.44-1.25; n=1 study; n=257 patients), and postoperative oxygen administration (RR=0.66; 95% CI, 0.42-1.03; n=1 study) (low certainty for all).

CONCLUSIONS

Preincision antibiotics and iNPWT reduce the risk of early SSI after lower limb revascularization surgery. Confirmatory trials are required to determine whether other promising strategies also reduce SSI risk.

A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.

How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence

BACKGROUND

This review aims to identify and review the current evidence for preventing postoperative surgical site infections in abdominal aortic aneurysm surgery or infrainguinal arterial surgery.

METHODS

Extended literature review of clinical trials that examined the prevention of postoperative surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. Searches were conducted on Ovid MEDLINE (1950 - 13 March 2020) using key terms for vascular surgery, surgical site infections and specific preventative techniques. Articles were included if they discussed a relationship between a preventative technique and surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. The GRADE guidelines were used to assess the quality of evidence.

RESULTS

21 techniques and 81 studies were included. Prophylactic antibiotics and negative pressure wound therapy have a high quality of evidence for the prevention of surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. A moderate quality evidence base was identified for gentamicin containing collagen implant (confined to high surgical site infection risk centers). Currently, there is a low or very low quality of evidence to suggest a reduction in the surgical site infection rate for combination therapy, glycaemic control, Methicillin-resistant Staphylococcus aureus screening and absorbable suture. Evidence suggests no beneficial effect for nutritional supplementation, chlorhexidine bath, hair removal therapy, Staphylococcus aureus nasal eradication, cyanoacrylate microsealant, silver grafts, rifampicin bonded grafts, triclosan coated suture and postoperative wound drains. Endoscopic saphenous vein harvest may reduce surgical site infection rate (very low quality of evidence) but may lower long-term patency. Autologous vein grafts may increase surgical site infections (very low quality of evidence) but may provide better long-term patency rates in above-knee infrainguinal bypass surgery. There was no identified evidence for perioperative normothermia, electrosurgical bipolar vessel sealer or Dermabond and Tegaderm for surgical site infection prevention in vascular surgery.

CONCLUSIONS

Prophylactic antibiotics and postoperative negative pressure wound therapy are effective in the prevention of postoperative surgical site infection in abdominal aortic aneurysm or infrainguinal arterial surgery. There exists a significant risk of bias in the literature for many preventative techniques and further studies are required to investigate the efficacy of gentamicin containing collagen implant, and specific combination therapies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevention of healthcare-associated infections in low- and middle-income Countries: The 'bundle approach'

Background

Healthcare-associated infections (HCAI/HAIs) are one of the most common adverse events in patient care and account for substantial morbidity and mortality. The high rates of HCAIs in a facility are an indicator of poor quality of healthcare services. According to the World Health Organization, at any time, up to 7% of patients in developed and 10% in developing countries will acquire at least one HAI. These infections also present a significant economic burden at the societal level. However, a large percentage of HAIs are preventable through effective infection prevention and control measures.

Objectives

Prevention of these infections also needs to be prioritised in view of the growing antimicrobial resistance in HAIs. The bundle approach to the prevention of HAIs is a relatively new concept that is revolutionising the care of high-risk patients in the Intensive Care Units. This report details the bundle approach for the prevention of HAIs, particularly the device-associated infections, for low- and middle-income countries.

Conclusion

With the escalating armamentarium of antimicrobial resistance, healthcare sector has to go back to the very basics of hospital infection control; develop, assess and implement bundles of prevention. These are cost-effective and easily adaptable, to cater to the increasing HCAIs and MDR infections in the LMICs.