Worldwide incidence of surgical site infections in general surgical patients: A systematic review and meta-analysis of 488,594 patients

Associations between pre-operative iron deficiency and postoperative infection in patients undergoing major surgery (CARIPO): a prospective observational study

INTRODUCTION

Iron deficiency, with or without anaemia, is common during the peri-operative period. It has been hypothesised that pre-operative iron deficiency is associated with an increased incidence of postoperative infection. We designed the CARIPO prospective observational study to assess the incidence of postoperative infection in patients with and without iron deficiency undergoing a variety of major surgeries.

METHODS

We conducted a single-centre study in a tertiary, university-affiliated hospital in France. Iron deficiency was defined as a ferritin < 100 μg.l-1 or < 300 μg.l-1 with a transferrin saturation < 20%. The primary outcome was incidence of any postoperative infectious complication measured at 90 days after surgery. Secondary endpoints included the incidence of individual infectious complications: surgical site infection; bacteraemia; pneumonia; urinary tract infection; peripheral line-associated bacterial infection; and all-cause postoperative complication.

RESULTS

We recruited 390 patients. Of these, 170 (44%) had pre-operative iron deficiency and 220 (66%) were iron replete; 27 (16%) patients in the iron deficient group developed a postoperative infection compared with 26 (12%) in the iron replete group (p = 0.25). Surgical site infections occurred in 11 (7%) iron deficient patients and 3 (1%) iron replete patients (p = 0.01). Other types of infectious complication and all-cause postoperative complication were similar between groups.

DISCUSSION

Iron deficiency was not associated with a higher rate of postoperative infection relative to an iron replete state. While iron deficiency was associated with a higher rate of surgical site infection, this result is hypothesis-generating, and further prospective studies are required.

Nurses' knowledge and its determinants in surgical site infection prevention: A comprehensive systematic review and meta-analysis

OBJECTIVE

The objective of this systematic review and meta-analysis is to assess and synthesize the global evidence on the level of nurses' knowledge and its determinants regarding the prevention of surgical site infections.

METHODS

This systematic review and meta-analysis were conducted following strict methodological guidelines to ensure accuracy and reliability. Adhering to the 2020 PRISMA checklist, a systematic review and meta-analysis sought to establish the pooled proportion of nurse's knowledge and its determinants regarding surgical site infection prevention globally. MeSH terms and keywords were included in the search. Data extraction, quality assessment, and analysis followed established protocols. Heterogeneity and publication bias was assessed using STATA version 17.0.

RESULTS

A total of seventeen observational studies, with sample sizes ranging from 30 to 515 participants, were included in the final analysis in a global context. In this systematic review and meta-analysis, the pooled proportion of nurses with good knowledge of surgical site infection prevention is 62% (95% CI: 50-74%) when assessed using a dichotomous scale. However, when knowledge is measured using a three-point Likert scale, the pooled proportion of those with good knowledge drops to 46% (95% CI: 21-72%), with an additional 27% (95% CI: 16-38%) demonstrating fair or moderate knowledge.

CONCLUSION AND RECOMMENDATION

This systematic review and meta-analysis is the first to synthesize data on nurses' knowledge of surgical site infection (SSI) prevention. The findings reveal poor knowledge levels, highlighting the need for targeted educational interventions globally. While the pooled odds ratio is not statistically significant, training, longer service years, and higher education improve SSI prevention knowledge by enhancing critical thinking, boosting confidence, and fostering adherence to evidence-based practices. Future research should focus on identifying factors influencing nurses' knowledge, particularly through longitudinal and interventional studies. Policymakers should incorporate international guidelines such as those recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) into nursing curricula, supported by robust assessment tools and educator training, to improve knowledge transfer and implementation of best practices.

Synthesizing evidence to guide the design and implementation of effective strategies for discontinuing postoperative antibiotic prophylaxis in surgical settings: an umbrella review post-WHO 2018 recommendations

BACKGROUND

Postoperative antibiotic prophylaxis (PAP) involves using antibiotics after surgery to prevent surgical site infections (SSIs). However, studies have shown that PAP offers no additional benefits compared to discontinuation after surgical incision closure, prompting its de-implementation to prevent unnecessary antibiotic use that may contribute to antibiotic resistance. We conducted this review to synthesize evidence for guiding the design and implementation of effective strategies for discontinuing PAP practice and optimizing antibiotic use in surgical settings.

METHODS

This umbrella review searched for articles from PubMed/MEDLINE and Scopus, focusing on reviews conducted on human subjects on PAP to prevent SSIs, published in English language from 2019 to 5th July 2024. This review followed guidelines from PRISMA-P and PRIOR. The risk of bias (methodological quality) was assessed using AMSTAR-2. The pooled risk ratio (RR) was estimated using a fixed-effects model (Mantel-Haenszel method), while I2 was used to assess the heterogeneity between reviews. This review was registered with PROSPERO (CRD42024566124).

RESULTS

In our umbrella review, we screened 1156 articles, with 28 review articles found eligible for final analysis, involving over 457 primary studies. About 80,483 patients were involved in 9 meta-analysis reviews, which were used to estimate the pooled RR. We found no significant benefits to patients from continuing PAP beyond 24-h post-surgery compared to immediate discontinuation, RR: 1.07 (95% CI: 0.97-1.17, I2: 25%, p-value: 0.22). Strategies such as regularly assessing and refining guidelines to fit specific surgical settings and patients' characteristics, multidisciplinary collaboration, availability of resources needed for best practices, education and training healthcare workers on SSI prevention and antibiotic stewardship, and patient education in SSI prevention and proper antibiotic use were recommended to improve best practices in surgical settings.

CONCLUSIONS

Prolonging antibiotic prophylaxis beyond 24-h post-surgery did not show significant protective benefits against SSIs. Our findings support the 2018 WHO recommendation for the immediate discontinuation of PAP following surgical incision closure in clean and clean-contaminated procedures. Further de-implementation research studies are needed to guide the effective discontinuation of PAP practice.

Comparison of antimicrobial efficacy and therapeutic index properties for common wound cleansing solutions, focusing on solutions containing PHMB

Background

Surgical site infections (SSIs) have been shown to increase patient morbidity and mortality, impact on quality of life and place a significant economic burden on healthcare systems worldwide. Irrigation using wound cleansing and antiseptic effective solutions during surgical procedures is a key part of SSI prevention. The optimal solution would have minimal cytotoxicity to the patient while maintaining a minimum concentration required for antimicrobial activity necessary to prevent opportunistic pathogens and biofilm formation.

Method

A variety of common wound irrigation products, including polyhexanide in various concentrations and compositions, iodine and hypochlorous acid-based solutions, were tested and compared for their activity against pathogens according to the ESKAPE group of nosocomial relevant microbes. The antimicrobial efficacy of the solutions was tested against planktonic cells using a time-kill assay. Its minimal bactericidal concentration (MBC) and its cytotoxicity against mouse fibroblast cells were determined. Finally, the Therapeutic Index (TI) was compared and the biofilm activity of a selected solution containing 0.1% polyhexanide (PHMB) was tested.

Results

Irrigation solutions containing 0.1% PHMB demonstrated rapid inactivation against planktonic cultures, achieving >4 lg reduction within 60 seconds. When comparing the TI of all irrigation solutions tested, the combination of 0.1% PHMB and poloxamer as an additive showed the best results in killing nosocomial pathogens and also to be less cytotoxic to mammalian fibroblasts, as demonstrated for PREVENTIA® Surgical Irrigation. When exposed to five single-species biofilms, PREVENTIA® Surgical Irrigation showed a 3 lg reduction (average) after 60 minutes; this was supported by microscopy showing significant biofilm disruption and an abundance of non-viable microcolony formations.

Conclusion

This study highlights the impact of irrigation solutions containing PHMB. It also demonstrated the effect of using different concentrations of PHMB in combination with surfactants as additives. The combination of 0.1% PHMB and poloxamer as a surfactant demonstrated effective benefits in eradicating established biofilm combined with a relatively high Therapeutic Index (TI), indicating low cytotoxicity and high bactericidal activity.

Systematic evaluation of machine learning models for postoperative surgical site infection prediction

BACKGROUND

Surgical site infections (SSIs) lead to increased mortality and morbidity, as well as increased healthcare costs. Multiple models for the prediction of this serious surgical complication have been developed, with an increasing use of machine learning (ML) tools.

OBJECTIVE

The aim of this systematic review was to assess the performance as well as the methodological quality of validated ML models for the prediction of SSIs.

METHODS

A systematic search in PubMed, Embase and the Cochrane library was performed from inception until July 2023. Exclusion criteria were the absence of reported model validation, SSIs as part of a composite adverse outcome, and pediatric populations. ML performance measures were evaluated, and ML performances were compared to regression-based methods for studies that reported both methods. Risk of bias (ROB) of the studies was assessed using the Prediction model Risk of Bias Assessment Tool.

RESULTS

Of the 4,377 studies screened, 24 were included in this review, describing 85 ML models. Most models were only internally validated (81%). The C-statistic was the most used performance measure (reported in 96% of the studies) and only two studies reported calibration metrics. A total of 116 different predictors were described, of which age, steroid use, sex, diabetes, and smoking were most frequently (100% to 75%) incorporated. Thirteen studies compared ML models to regression-based models and showed a similar performance of both modelling methods. For all included studies, the overall ROB was high or unclear.

CONCLUSIONS

A multitude of ML models for the prediction of SSIs are available, with large variability in performance. However, most models lacked external validation, performance was reported limitedly, and the risk of bias was high. In studies describing both ML models and regression-based models, one modelling method did not outperform the other.

Patients' Ability to Self-Manage Their Surgical Wound to Prevent Wound Complications: A Cross-Sectional Study

AIMS

To provide insights into postdischarge patients' experiences and preferences regarding surgical wound care education at discharge in the Netherlands.

BACKGROUND

Patient involvement in wound care practices postdischarge is beneficial for the prevention of surgical site infections and has become an essential component in reducing the burden on healthcare systems. Surgical wound care discharge education is crucial to achieve this.

METHODS

A cross-sectional survey was conducted using the 18-item Surgical Wounds And Patient Participation Questionnaire on patients who underwent surgery between January and May 2022. The survey was administered 2 weeks postoperatively.

RESULTS

In total, 213 patients completed the survey. Most patients preferred verbal instructions about their surgical wound care (n = 146; 84.9%) at the time of discharge, with 52.3% indicating a preference for multiple forms of information. Approximately three-quarters of patients (n = 99; 76.7%) responded that they were able to successfully take care of their wounds at home and 16.3% indicated wound self-care inability.

CONCLUSION

Our study highlighted patients' preferences for verbal instructions about their surgical wound care at the time of discharge. Notably, half of the patients expressed a desire for multiple forms of information. Furthermore, we identified gaps in the information provided to patients, indicating areas for improvement in discharge communication.

IMPLICATIONS

The identified gaps in surgical wound care discharge education offer opportunities to enhance in-hospital education by aligning it more closely with patient preferences and providing education of topics often missed. This could ultimately improve their ability to self-manage their surgical wound at home. Future research should delve deeper into understanding the factors influencing patients' ability to self-manage their wounds.

IMPACT

Despite the acknowledged importance of patient education on surgical wound care, there is limited literature regarding patients' experiences and preferences in this area. The findings of this study highlight patients' preferences for verbal instructions and reveal gaps in the information provided to patients about surgical wound care at the time of discharge. The identified gaps in information provided to surgical patients offer opportunities to enhance in-hospital education by healthcare professionals.

REPORTING METHOD

We adhered to the STROBE guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Surgical site infections in caesarean wounds

The increasing incidence of surgical site infections (SSIs) following caesarean sections highlights the necessity for updated protocols that address risk factors throughout the preoperative, intraoperative, and postoperative stages. Negative Pressure Wound Therapy (NPWT) and hydrocolloid dressings have demonstrated potential for improving wound management and reducing complications, particularly by enhancing dressing integrity. Nevertheless, the application of NPWT requires careful consideration and adherence to local trust guidelines to ensure both its safety and efficacy.

Wireless implantable bioelectronics with a direct electron transfer lactate enzyme for detection of surgical site infection in orthopaedics

Periprosthetic infection is one of the most devastating complications following orthopaedic surgery. Rapid detection of an infection can change the treatment pathway and improve outcomes for the patient. In here, we propose a miniaturized lactate biosensor developed on a flexible substrate and integrated on a small-form bone implant to detect infection. The methods for lactate biosensor fabrication and integration on a bone implant are fully described within this study. The system performance was comprehensively electrochemically characterised, including with L-lactate solutions prepared in phosphate-buffered saline and culture medium, and interferents such as acetaminophen and ascorbic acid. A proof-of-concept demonstration was then conducted with ex vivo ovine femoral heads incubated with and without exposure to Staphylococcus epidermidis. The sensitivity, current density and limit-of-detection levels achieved by the biosensor were 1.25 μA mM-1, 1.51 μA.M-1.mm-2 and 66 μM, respectively. The system was insensitive to acetaminophen, while sensitivity to ascorbic acid was half that of the sensitivity to L-lactate. In the ex vivo bone model, S. epidermidis infection was detected within 5 h of implantation, while the control sample led to no change in the sensor readings. This pioneering work demonstrates a pathway to improving orthopaedic outcomes by enabling early infection diagnosis.

Nurses' knowledge, perceived practice, and associated factors towards sterile techniques in major operation rooms at public hospitals in Addis Ababa, Ethiopia, 2022: a cross-sectional study

INTRODUCTION

A sterile technique is a standard to reduce microorganism transmission during surgery. Gaps in knowledge and practice in sterile techniques by nurses are common causes of surgical site infections for surgical patients. Even though surgical site infection is a global problem due to lack of knowledge and practice, almost no study has been done in Ethiopia regarding nurses' knowledge and practice of sterile techniques in the operating room. Therefore, this study aimed to assess nurses' knowledge, practice, and associated factors of sterile techniques in Addis Ababa public hospitals, Ethiopia.

METHOD

An institutional-based cross-sectional study was conducted on 423 nurses who were working in sixty-six operation rooms at seven public hospitals in Addis Ababa, Ethiopia, from May 11 to June 26/2022. A simple random sampling method was employed to select study participants. A pre-tested, self-administered questionnaire was used to collect data. Data were entered by Epi-data version 4.6 and analyzed by SPSS version 25. Descriptive statistics were presented by text, table, and figure. Multivariable analysis was used to identify the association between the dependent variable and independent variables. Variables with a P-value < 0.05 were considered statistically significant.

RESULT

Nearly three-fifths (58.1%; 95%CI: 53.2 to 63.7) of respondents had good knowledge, and 56.1% with 95%CI (51.5 to 61.1) had good practice with respect to sterile techniques in the operation room. Training [AOR = 1.989; 95%CI (1.120 to 3.530)], availability of guidelines [AOR = 6.4; 95%CI (3.773 to 10.856)], and supervision [AOR = 2.963; 95%CI (1.693 to 5.184)] were associated with nurses' knowledge about sterile techniques in the operating room. Availability of guidelines [AOR = 1.890, 95%CI (1.123 to 3.182)], presence of supervision [AOR = 4.732; 95%CI (2.643 to 8.471)], and having good knowledge of sterile techniques [AOR = 5.419; 95%CI (3.087 to 9.512)] were associated with nurses' practice of sterile techniques in the operation room.

CONCLUSION

Operative theater nurses' knowledge and practice of sterile techniques were found inadequate. Training, supervision, availability of guidelines, and knowledge of nurses towards sterile techniques are factors associated with sterile techniques in the operating room. So, it is better to strengthen training, equip wards with standardized guidelines, and provide supervision, which is crucial to enhancing their knowledge and practice.

Influence of dental status on postoperative complications in major visceral surgical and organ transplantation procedures-the bellydent retrospective observational study

PURPOSE

The significance of dental status and oral hygiene on a range of medical conditions is well-recognised. However, the correlation between periodontitis, oral bacterial dysbiosis and visceral surgical outcomes is less well established. To this end, we study sought to determine the influence of dental health and oral hygiene on the rates of postoperative complications following major visceral and transplant surgery in an exploratory, single-center, retrospective, non-interventional study.

METHODS

Our retrospective non-interventional study was conducted at the Department of General, Visceral, and Transplant Surgery, University Hospital Heidelberg, Germany. Patients operated on between January 2018 and December 2019 were retrospectively enrolled in the study based on inclusion (minimum age of 18 years, surgery at our Department, intensive care / IMC treatment after major surgery, availability of patient-specific preoperative dental status assessment, documentation of postoperative complications) and exclusion criteria (minor patients or legally incapacitated patients, lack of intensive care or intermediate care (IMC) monitoring, incomplete documentation of preoperative dental status, intestinal surgery with potential intraoperative contamination of the site by intestinal microbes, pre-existing preoperative infection, absence of data regarding the primary endpoints of the study). The primary study endpoint was the incidence of postoperative complications. Secondary study endpoints were: 30-day mortality, length of hospital stay, duration of intensive care stay, Incidence of infectious complications, the microbial spectrum of infectious complication. A bacteriology examination was added whenever possible (if and only if the examination was safe for the patient)for infectious complications.

RESULTS

The final patient cohort consisted of 417 patients. While dental status did not show an influence (p = 0.73) on postoperative complications, BMI (p = 0.035), age (p = 0.049) and quick (p = 0.033) were shown to be significant prognostic factors. There was significant association between oral health and the rate of infectious complications for all surgical procedures (p = 0.034), excluding transplant surgery. However, this did not result in increased 30-day mortality rates, prolonged intensive care unit treatment or an increase in the length of hospital stay (LOS) for the cohort as a whole. In contrast there was a significant correlation between the presence of oral pathogens and postoperative complications for a group as a whole (p < 0.001) and the visceral surgery subgroup (p < 0.001). Whilst this was not the case in the cohort who underwent transplant surgery, there was a correlation between oral health and LOS in this subgroup (p = 0.040). Bacterial swabs supports the link between poor oral health and infectious morbidity.

CONCLUSIONS

Dental status was a significant predictor of postoperative infectious complications in this visceral surgery cohort. This study highlights the importance preoperative dental assessment and treatment prior to major surgery, particularly in the case of elective surgical procedures. Further research is required to determine the effect of oral health on surgical outcomes in order to inform future practice.

TRIAL REGISTRATION

Trial registered under the ethics-number S-082/2022 (Ethic Committee of the University Heidelberg).

Automated Identification of Postoperative Infections to Allow Prediction and Surveillance Based on Electronic Health Record Data: Scoping Review

BACKGROUND

Postoperative infections remain a crucial challenge in health care, resulting in high morbidity, mortality, and costs. Accurate identification and labeling of patients with postoperative bacterial infections is crucial for developing prediction models, validating biomarkers, and implementing surveillance systems in clinical practice.

OBJECTIVE

This scoping review aimed to explore methods for identifying patients with postoperative infections using electronic health record (EHR) data to go beyond the reference standard of manual chart review.

METHODS

We performed a systematic search strategy across PubMed, Embase, Web of Science (Core Collection), the Cochrane Library, and Emcare (Ovid), targeting studies addressing the prediction and fully automated surveillance (ie, without manual check) of diverse bacterial infections in the postoperative setting. For prediction modeling studies, we assessed the labeling methods used, categorizing them as either manual or automated. We evaluated the different types of EHR data needed for the surveillance and labeling of postoperative infections, as well as the performance of fully automated surveillance systems compared with manual chart review.

RESULTS

We identified 75 different methods and definitions used to identify patients with postoperative infections in studies published between 2003 and 2023. Manual labeling was the predominant method in prediction modeling research, 65% (49/75) of the identified methods use structured data, and 45% (34/75) use free text and clinical notes as one of their data sources. Fully automated surveillance systems should be used with caution because the reported positive predictive values are between 0.31 and 0.76.

CONCLUSIONS

There is currently no evidence to support fully automated labeling and identification of patients with infections based solely on structured EHR data. Future research should focus on defining uniform definitions, as well as prioritizing the development of more scalable, automated methods for infection detection using structured EHR data.

Contrasting seasonality of the incidence of incisional surgical site infection after general and gastroenterological surgery: an analysis of 8436 patients in a single institute

BACKGROUND

While seasonality of hospital-acquired infections, including incisional SSI after orthopaedic surgery, is recognized, the seasonality of incisional SSI after general and gastroenterological surgeries remains unclear.

AIM

To analyse the seasonality and risk factors of incisional SSI after general and gastroenterological surgeries.

METHODS

This was a retrospective, single-institute, observational study using univariate and multivariate analyses. The evaluated variables included age, sex, surgical approach, surgical urgency, operation time, wound classification, and the American Society of Anesthesiologists physical status (ASA-PS).

FINDINGS

A total of 8436 patients were enrolled. General surgeries (N = 2241) showed a pronounced SSI incidence in summer (3.9%; odds ratio (OR): 1.87; 95% confidence interval (CI): 1.05-3.27; P = 0.025) compared to other seasons (2.1%). Conversely, gastroenterological surgeries (N = 6195) showed a higher incidence in winter (8.3%; OR: 1.38; 95% CI: 1.10-1.73; P = 0.005) than in other seasons (6.1%). Summer for general surgery (OR: 1.90; 95% CI: 1.12-3.24; P = 0.018) and winter for gastroenterological surgery (1.46; 1.17-1.82; P = 0.001) emerged as independent risk factors for incisional SSI. Open surgery (OR: 2.72; 95% CI: 1.73-4.29; P < 0.001) and an ASA-PS score ≥3 (1.64; 1.08-2.50; P = 0.021) were independent risk factors for incisional SSI in patients undergoing gastroenterological surgery during winter.

CONCLUSION

Seasonality exists in the incisional SSI incidence following general and gastroenterological surgeries. Recognizing these trends may help enhance preventive strategies, highlighting the elevated risk in summer for general surgery and in winter for gastroenterological surgery.

Patient participation in surgical wound care in acute care settings: An integrative review

BACKGROUND

Surgical site infections can significantly impact postoperative recovery. Patient participation, which involves patients actively engaging in wound care, has been linked to improved healing and reduced wound complications. However, there is limited synthesis of the literature that explores the patient's role and participation in the context of surgical wound care.

OBJECTIVE

To explore patients' perceptions of how they participate in surgical wound care, within 30 days post-operation.

DESIGN

An integrative review guided by Whittemore and Knafl's methodology. This review was registered with PROSPERO (CRD42022363669).

DATA SOURCES

Searches were conducted in Medline (Ovid), CINAHL (Complete), and EMBASE (Elsevier) databases in October 2023, supplemented by forward and backward citation searching.

REVIEW METHODS

Based on a priori eligibility criteria, two authors independently screened articles to select relevant studies. The quality of the included research articles was critically appraised using the Mixed Methods Appraisal Tool. A descriptive and thematic synthesis was used to synthesise the findings.

RESULTS

Of the 4701 records screened for titles and abstracts, 25 studies using qualitative, quantitative, and mixed-methods designs were included. Three key themes were identified. In theme 1, 'I am healing: how my wound shapes me and my journey,' physical symptoms, psychological factors and previous experiences significantly influenced patients' engagement in wound care. Theme 2, 'Taking charge of my healing: my active engagement in wound care' described how patient participation in surgical wound care goes beyond clinical procedures and can include the use of technology and holistic self-care. Finally, theme 3, 'Navigating the path to recovery: How others shape my experience' showed that effective communication is crucial for promoting participation, yet issues like inadequate information can leave patients unprepared for wound management.

CONCLUSIONS

This review highlights opportunities to personalise and prioritise a patient-oriented approach to surgical wound care. Clinicians and educators should adopt an individualised approach by tailoring patient participation based on patient factors (i.e. physical symptoms) and adopt patient-centred communication approaches. Researchers should focus on exploring approaches to self-care and technology, as these approaches may enhance patient participation in wound care.

Evaluation of indications and efficacy of doxycycline for surgical antibiotic prophylaxis

Given medical advancements in global healthcare systems over the past decade, it may be reasonable to assume that the incidence of surgical site infections would have decreased; however, surveillance data indicate that these rates have held constant. Surgical prophylaxis guidelines from the United States and United Kingdom recommend cefazolin, vancomycin and clindamycin in most surgeries for no longer than 24 hours. As a result of medication shortages impacting the global supply chain, surgeons have needed to evaluate alternative perioperative antibiotics, such as doxycycline; however, research into using doxycycline for preventing surgical site infections is limited. The goal of this study is to retrospectively assess doxycycline's efficacy, safety and role in preventing surgical site infections.

Evaluating antibiotic prophylaxis adherence: Implications for surgical site infections and wound care management

AIM

This study aimed to evaluate adherence to an antibiotic prophylaxis protocol and its impact on incidence of surgical site infection (SSI).

MATERIALS AND METHOD

A prospective observational cohort study was conducted at a teaching hospital in São Paulo, Brazil, from September to November 2015. The population were adults who underwent surgery with surgical antibiotic prophylaxis. The main outcomes measured were incidence of SSI at 30-days postoperatively, protocol adherence and surgical wound complications. STROBE guidelines were followed.

RESULTS

Among the 527 participants recruited, a 30-day follow-up was completed by 78.7 % (n = 415). Within this cohort, 57.6 % were females aged over 60 years (36.4 %). The incidence of SSI stood at 9.4 % (n = 39), with dehiscence being the most prevalent complication at 64.1 % (n = 25), followed by increased exudate at 51.3 % (n = 20). Notably, full adherence to the antibiotic prophylaxis protocol was low at 1.7 % (n = 7). The study observed a 60 % increased risk of SSI for every protocol mistake made. Alarmingly, 17.8 % (n = 74) of participants received antibiotic treatment exceeding the stipulated protocol duration. The overall mortality rate stood at 13.5 % (n = 56), with 1 % (n = 4) of these deaths attributed to SSI.

CONCLUSION

There is a pressing global necessity to enhance antibiotic management, as underscored by this study's revelation of low adherence to the antibiotic prophylaxis protocol. This lack of adherence correlated with a notable incidence of SSI and subsequent wound complications. Nearly 20 % of participants received prolonged antibiotic treatment. Adhering strictly to the protocol could substantially impact SSI-related outcomes and enhance global antibiotic management.

Effects of povidone-iodine wound irrigation on surgical site infection in gastroenterological surgery: A randomized controlled trial

BACKGROUND

The irrigation efficacy of a povidone-iodine solution to prevent surgical site infection is still controversial. We assessed the irrigation effect with a povidone-iodine solution on the incidence of surgical site infection after gastroenterological surgery.

METHODS

This study is a single-center, prospective, randomized, blinded-end point superiority trial for surgical wound irrigation. Patients undergoing gastroenterological surgery were randomly assigned in a 1:1 replacement ratio using computer-generated randomization. Patients were grouped according to their surgical wound treatment into the control group using the normal sterile saline and the povidone-iodine group using 10% povidone-iodine solution after the NS solution. The main finding was 30-day surgical site infections assessed in the full analysis set.

RESULTS

From November 2020 to December 2022, 697 of 894 patients were eligible for the study, among which 347 were in the povidone-iodine group and 350 in the control group. Thirty-day surgical site infections occurred in 100 (14%) patients-54 (16%) in the povidone-iodine group and 46 (13%) in the control group (odds ratio, 1.229; 95% CI, 0.800-1.889; P = .406). Superficial incisional surgical site infections occurred in 30 (9%) and 15 (4%) patients, respectively (odds ratio, 2.154; 95% CI, 1.134-4.090; P = .026). Only 3 patients (1%) in the control group developed adverse skin reactions.

CONCLUSION

This study examined the irrigation efficacy of povidone-iodine for surgical site infection prevention compared to control in gastroenterological surgery. Povidone-iodine wound irrigation has shown no additional beneficial effect on the occurrence of surgical site infections.

Surgical site infection and patient-reported outcomes in surgically treated soft tissue facial injury: A meta-analysis

BACKGROUND

Soft tissue facial injuries (STFI) constitute a huge portion of craniofacial trauma, but the risk of surgical site infection (SSI) and patient-reported outcomes (PROs) following surgical management of STFI are unknown.

METHODS

A PRISMA-compliant search was conducted from January 1990 until March 2023, and meta-analysis was performed using R. Pooled effects of the outcomes were estimated using the DerSimonian and Laird random-effects model or generalised linear mixed model, when feasible.

RESULT

Among the 8897 screened studies, 38 were included. Twelve studies reported PROMs (n = 985), whereas 28 studies reported SSI rates (n = 10,996) following operative treatment for STFI. The pooled SSI rate (n = 28) was 3.30 % (95 % CI 1.89 %-5.71 %). Surgical and non-surgical closure did not differ significantly in SSI rate. PROs focused on scar outcomes, cosmetic outcomes, quality of life and psychological impact. Subgroup analysis showed lower SSI risk in operative repair for general facial trauma compared to primary repair, and in general facial trauma compared to other aetiologies. The pooled patient scar assessment scale, score at 6-12 months post-intervention (5 studies, n = 217) was 16.16 (95 % CI 15.34-16.97). Limited evidence is available on the effect and superiority of surgical treatment in cosmetic outcomes, quality of life and psychological impact.

CONCLUSION

Our findings emphasise the limited and unreliable evidence available on PROs following operative treatment for STFI. Future studies employing robust methodologies are needed to investigate optimal approaches for managing STFI.

Comparison of the Incidence of Surgical Site Infection in Abdominal Wound Closure: Antibiotic-Coated Polyglactin 910 Suture Versus Polyglactin Suture With Local Infiltration of Antibiotic Along the Incision Line

Aim and objectives The purpose of this study is to compare the incidence of surgical site infection (SSI) rates in abdominal wound closure utilizing antibacterial-coated (triclosan-coated) suture material versus conventional suture material with subcutaneous antibacterial infiltration along the incision line. Materials and method This prospective and comparative (randomized, non-blinded clinical trial) was conducted at the Postgraduate Department of Surgery, Swaroop Rani Nehru Hospital, associated with Motilal Nehru Medical College, Prayagraj, India. The sample size was calculated to be one hundred. The patients in Group A underwent laparotomy using polyglactin 910 coated with triclosan. The patients in Group B underwent normal suture closure and local infiltration of broad-spectrum antibiotics (1 gram of ceftriaxone in 10 ml distilled water, along with the incision). Results There was no discernible difference between the various groups on postoperative day (POD) 14, 21, and 30. In Group A, 100.0% of individuals had healed wound status (POD 30). Group B had healed wound status among the 96.0% of members (POD 30). Twenty percent of the people in Group A had SSI whereas 38.0% of the participants in Group B had SSI. There was no discernible difference between the two groups regarding the distribution of culture (χ² = 7.741, p = 0.127). Conclusion Triclosan-coated sutures are more effective than subcutaneous antibiotic infiltration along the incision line in lowering the frequency of SSI during primary laparotomy wound closure.

Prophylactic negative pressure wound therapy (NPWT) in laparotomy wounds (PROPEL-2): protocol for a randomized clinical trial

BACKGROUND

A proportion of patients undergoing midline laparotomy will develop surgical site infections after surgery. These complications place considerable financial burden on healthcare economies and have negative implications for patient health and quality of life. The prophylactic application of negative pressure wound therapy devices has been mooted as a pragmatic strategy to reduce surgical site infections. Nevertheless, further availability of multicentre randomized clinical trial data evaluating the prophylactic use of negative pressure wound therapy following midline laparotomy is warranted to definitely provide consensus in relation to these closure methods, while also deciphering potential differences among subgroups. The aim of this study is to determine whether prophylactic negative pressure wound therapy reduces postoperative wound complications in patients undergoing midline laparotomy.

METHODS

PROPEL-2 is a multicentre prospective randomized clinical trial designed to compare standard surgical dressings (control arm) with negative pressure wound therapy dressings (Prevena™ and PICO™ being the most commonly utilized). Patient recruitment will include adult patients aged 18 years or over, who are indicated to undergo emergency or elective laparotomy. To achieve 90% power at the 5% significance level, 1006 patients will be required in each arm, which when allowing for losses to follow-up, 10% will be added to each arm, leaving the total projected sample size to be 2013 patients, who will be recruited across a 36-month enrolment period.

CONCLUSION

The PROPEL-2 trial will be the largest independent multicentre randomized clinical trial designed to assess the role of prophylactic negative pressure wound therapy in patients indicated to undergo midline laparotomy. The comparison of standard treatment to two commercially available negative pressure wound therapy devices will help provide consensus on the routine management of laparotomy wounds. Enrolment to PROPEL-2 began in June 2023. Registration number: NCT05977816 (http://www.clinicaltrials.gov).

Plastic Wound Protector vs Surgical Gauze for Surgical Site Infection Reduction in Open GI Surgery: A Randomized Clinical Trial

Importance

Surgical site infections (SSIs) are prevalent hospital-acquired infections with significant patient impacts and global health care burdens. The World Health Organization recommends using wound protector devices in abdominal surgery as a preventive measure to lower the risk of SSIs despite limited evidence.

Objective

To examine the efficacy of a dual-ring, plastic wound protector in lowering the SSI rate in open gastrointestinal (GI) surgery irrespective of intra-abdominal contamination levels.

Design, Setting, and Participants

This multicenter, patient-blinded, parallel-arm randomized clinical trial was conducted from August 2017 to October 2022 at 13 hospitals in an academic setting. Patients undergoing open abdominal bowel surgery (eg, for bowel perforation) were eligible for inclusion.

Intervention

Patients were randomized 1:1 to a dual-ring, plastic wound protector to protect the incision site of the abdominal wall (experimental group) or a conventional surgical gauze (control group).

Main Outcomes and Measures

The primary end point was the rate of SSI within 30 days of open GI surgery.

Results

A total of 458 patients were randomized; after 1 was excluded from the control group, 457 were included in the intention-to-treat analysis (mean [SD] age, 58.4 [12.1] years; 256 [56.0%] male; 341 [74.6%] with a clean-contaminated wound): 229 in the wound protector group and 228 in the surgical gauze group. The overall SSI rate in the intention-to-treat analysis was 15.7% (72 of 458 patients). The SSI rate for the wound protector was 10.9% (25 of 229 patients) compared with 20.5% (47 of 229 patients) with surgical gauze. The wound protector significantly reduced the risk of SSI, with a relative risk reduction (RRR) of 46.81% (95% CI, 16.64%-66.06%). The wound protector significantly decreased the SSI rate for clean-contaminated wounds (RRR, 43.75%; 95% CI, 3.75%-67.13%), particularly for superficial SSIs (RRR, 42.50%; 95% CI, 7.16%-64.39%). Length of hospital stay was similar in both groups (mean [SD], 15.2 [10.5] vs 15.3 [10.2] days), as were the overall postoperative complication rates (20.1% vs 18.8%).

Conclusions and Relevance

This randomized clinical trial found a significant reduction in SSI rates when a plastic wound protector was used during open GI surgery compared with surgical gaze, supporting the World Health Organization recommendation for use of wound protector devices in abdominal surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03170843.

Incidence and Risk Factors of Surgical Site Infection in Abdominal Surgeries: A Scoping Review of Cohort and Case-Control Studies

Background

Abdominal surgery is considered a high-risk procedure for the development of surgical site infection (SSI). Few studies have evaluated the relative importance of surgical site infection risk factors in terms of consistency in abdominal surgery. Therefore, this comprehensive review article mapped and summarized the evidence aimed to determine the relative importance of the risk factors and incidence of SSIs in abdominal surgery.

Methods

A literature review was conducted using electronic databases and search engines such as Scopus, PubMed, and Web of Science up to March 16, 2023. There was no language restriction for the papers to be included in the study. The relative consistency of the risk factors was measured and evaluated using the methodology of the Joanna Briggs Institute. Original peer-reviewed cohort and case-control studies were included if all types of SSIs were included. Meta-analysis was performed to determine the pooled estimates of SSI incidences.

Results

Of 14,237 identified records, 107 articles were included in the review. The pooled incidence of SSI was 10.6% (95% CI: 9.02-12.55%, χ2=12986.44, P<0.001). Operative time and higher wound class were both significant consistent risk factors for SSI incidence. Patients' educational status, malnutrition, functional status, and history of neurological/psychiatric disorders were all candidates for consistent risk factors, with insufficient evidence.

Conclusion

The findings of the present study indicated that SSI in abdominal surgery was a multifactorial phenomenon with a considerable risk and had different risk factors with various relative importance. Determining the relative importance of the risk factors for the prevention and control of SSI is strongly recommended.This manuscript has been released as a preprint at the research square: (https://doi.org/10.21203/rs.3.rs-3219597/v1).

Incisional Wound Irrigation for the Prevention of Surgical Site Infection: A Systematic Review and Network Meta-Analysis

Importance

Surgical site infections (SSIs) are common postoperative complications and associated with significant morbidity, mortality, and costs. Prophylactic intraoperative incisional wound irrigation is used to reduce the risk of SSIs, and there is great variation in the type of irrigation solutions and their use.

Objective

To compare the outcomes of different types of incisional prophylactic intraoperative incisional wound irrigation for the prevention of SSIs in all types of surgery.

Data Sources

PubMed, Embase, CENTRAL, and CINAHL databases were searched up to June 12, 2023.

Study Selection

Included in this study were randomized clinical trials (RCTs) comparing incisional prophylactic intraoperative incisional wound irrigation with no irrigation or comparing irrigation using different types of solutions, with SSI as a reported outcome. Studies investigating intracavity lavage were excluded.

Data Extraction and Synthesis

This systematic review and network meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two reviewers independently extracted the data and assessed the risk of bias within individual RCTs using the Cochrane Risk of Bias 2 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist network meta-analysis was conducted, and relative risks (RRs) with corresponding 95% CIs were reported.

Main Outcome and Measure

The primary study outcome was SSI.

Results

A total of 1587 articles were identified, of which 41 RCTs were included in the systematic review, with 17 188 patients reporting 1328 SSIs, resulting in an overall incidence of 7.7%. Compared with no irrigation, antiseptic solutions (RR, 0.60; 95% CI, 0.44-0.81; high level of certainty) and antibiotic solutions (RR, 0.46; 95% CI, 0.29-0.73; low level of certainty) were associated with a beneficial reduction in SSIs. Saline irrigation showed no statistically significant difference compared with no irrigation (RR, 0.83; 95% CI, 0.63-1.09; moderate level of certainty).

Conclusions and Relevance

This systematic review and network meta-analysis found high-certainty evidence that prophylactic intraoperative incisional wound irrigation with antiseptic solutions was associated with a reduction in SSIs. It is suggested that the use of antibiotic wound irrigation be avoided due to the inferior certainty of evidence for its outcome and global antimicrobial resistance concerns.

An Initiative to Prevent Surgical Site Infections After Cesarean Birth With a Quality Improvement Care Bundle

OBJECTIVE

To reduce surgical site infections (SSIs) after cesarean birth through a bundled care approach.

DESIGN

Quality improvement project.

SETTING/LOCAL PROBLEM

In a community hospital obstetric unit, an increase in SSIs after cesarean birth was observed.

PARTICIPANTS

Nursing leaders, obstetricians, certified nurse-midwives, physician assistants, nurses, scrub technicians, a nursing professional development specialist, and an infection prevention practitioner.

INTERVENTIONS/MEASURES

An interdisciplinary team was formed in early 2022, and an evidence-based care bundle including practice changes, education for the team, and enhanced education for patients undergoing cesarean birth was developed and implemented after a review of the literature was completed. All cesarean births were tracked pre- and postintervention to determine the rate of SSIs per 1,000 cesarean births.

RESULTS

A decrease in the rate of SSIs after cesarean birth was observed from preintervention (18.2 per 1,000 cesarean births) to postintervention (11.8 per 1,000 cesarean births).

CONCLUSION

An evidence-based quality improvement care bundle using a multidisciplinary team approach was associated with reduced SSIs in an obstetric unit.

Superiority trial for the development of an ideal method for the closure of midline abdominal wall incisions to reduce the incidence of wound complications after elective gastroenterological surgery: study protocol for a randomized controlled trial

BACKGROUND

The recent guidelines from the European and American Hernia Societies recommend a continuous small-bite suturing technique with slowly absorbable sutures for fascial closure of midline abdominal wall incisions to reduce the incidence of wound complications, especially for incisional hernia. However, this is based on low-certainty evidence. We could not find any recommendations for skin closure. The wound closure technique is an important determinant of the risk of wound complications, and a comprehensive approach to prevent wound complications should be developed.

METHODS

We propose a single-institute, prospective, randomized, blinded-endpoint trial to assess the superiority of the combination of continuous suturing of the fascia without peritoneal closure and continuous suturing of the subcuticular tissue (study group) over that of interrupted suturing of the fascia together with the peritoneum and interrupted suturing of the subcuticular tissue (control group) for reducing the incidence of midline abdominal wall incision wound complications after elective gastroenterological surgery with a clean-contaminated wound. Permuted-block randomization with an allocation ratio of 1:1 and blocking will be used. We hypothesize that the study group will show a 50% reduction in the incidence of wound complications. The target number of cases is set at 284. The primary outcome is the incidence of wound complications, including incisional surgical site infection, hemorrhage, seroma, wound dehiscence within 30 days after surgery, and incisional hernia at approximately 1 year after surgery.

DISCUSSION

This trial will provide initial evidence on the ideal combination of fascial and skin closure for midline abdominal wall incision to reduce the incidence of overall postoperative wound complications after gastroenterological surgery with a clean-contaminated wound. This trial is expected to generate high-quality evidence that supports the current guidelines for the closure of abdominal wall incisions from the European and American Hernia Societies and to contribute to their next updates.

TRIAL REGISTRATION

UMIN-CTR UMIN000048442. Registered on 1 August 2022. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000055205.

Patients' Experience and Satisfaction Regarding the Pre-Operative Shower: The PRODOUCH Multicenter Descriptive Survey

Background: Patients' experience of the pre-operative shower remains poorly assessed in the literature although it is an essential step in the prevention of surgical site infection. For obese patients, a pre-operative shower could be challenging. The goal was to assess patient satisfaction and experience with the process of pre-operative shower, and the effect of obesity status. Patients and Methods: This study was a multicenter prospective survey of consecutive surgical patients from nine hospitals. Data on the pre-operative shower were collected via telephone interview two to four weeks after surgery, and included the place (hospital, home), time, information received, difficulties experienced, the presence or absence of a visual assessment of skin cleanliness by a healthcare professional after the pre-operative shower, and overall patient satisfaction with the pre-operative shower technique. Data on the surgical procedure and patients' characteristics were collected from patients' records, and included age, gender, and body mass index. Factors associated with patient satisfaction were assessed. Results: Among 430 patients, 91.6% declared having received information on the pre-operative shower and 94.8% were very or rather satisfied with the pre-operative shower. Two factors were independently associated with satisfaction: showering at home and having received information on the pre-operative shower, but not obesity status. Only 17% of patients reported a visual assessment of skin cleanliness by a healthcare professional after the pre-operative shower. Discussion: Overall, regardless of obesity status, patients were satisfied with the pre-operative shower and reported no difficulties. However, this survey highlights the fact that skin cleanliness was seldom assessed by healthcare professionals, which may represent an unidentified weakness in skin preparation before surgery.

Exploring surgical infection prediction: A comparative study of established risk indexes and a novel model

BACKGROUND

Surgical site infections are a major health problem that deteriorates the patients' health and increases health care costs. A reliable method to identify patients with modifiable risk of surgical site infection is necessary to reduce the incidence of them but data are limited. Hence the objective is to assess the predictive validity of a logistic regression model compared to risk indexes to identify patients at risk of surgical site infections.

METHODS

In this study, we evaluated the predictive validity of a new model which incorporates important predictors based on logistic regression model compared to three state-of-the-art risk indexes to identify high risk patients, recruited from 2016 to 2020 from a medium size hospital in North Norway, prone to surgical site infection.

RESULTS

The logistic regression model demonstrated significantly higher scores, defined as high-risk, in 110 patients with surgical site infections than in 110 patients without surgical site infections (p < 0.001, CI 19-44) compared to risk indexes. The logistic regression model achieved an area under the curve of 80 %, which was better than the risk indexes SSIRS (77 %), NNIS (59 %), and JSS-SSI (52 %) for predicting surgical site infections. The logistic regression model identified operating time and length of stay as the major predictors of surgical site infections.

CONCLUSIONS

The logistic regression model demonstrated better performance in predicting surgical site infections compared to three state-of-the-art risk indexes. The model could be further developed into a decision support tool, by incorporating predictors available prior to surgery, to identify patients with modifiable risk prone to surgical site infection.

Postoperative pulmonary complications with high versus standard FiO2 in adult patients undergoing major abdominal surgery: A noninferiority trial

BACKGROUND

Despite the possible clinical benefit of high intraoperative oxygen therapy on surgical site infection, the effect on postoperative respiratory function is debatable. However, it remains yet to be elucidated whether hyperoxia due to a high fraction of inspired oxygen used in conjunction with lung protective ventilation can lead to increased incidence of postoperative pulmonary complications.

METHODS

In this noninferiority randomized trial, an intraoperative high fraction of inspired oxygen of 0.8 (group H) was compared to a standard fraction of inspired oxygen of 0.3 to 0.4 (group S) in adult patients undergoing major elective or emergency surgery. A lung protective ventilation strategy was employed in all patients, including volume control ventilation with a tidal volume of 6 to 8 mL/kg of predicted body weight, respiratory rate of 12 beats per minute, and positive end-expiratory pressure of 5 to 8 cm H2O. Postoperative pulmonary complications were assessed on postoperative days 3 and 5 by the Melbourne group scale.

RESULTS

In this trial, n = 226 patients were randomized; among them, 130 patients underwent routine surgery, and 96 patients underwent emergency surgery. The median (interquartile range) of the patients was 48 (35-58) years, and 47.3% were female. Melbourne group scale scores at postoperative day 3 (median [interquartile range] 2 [1-4] in group S vs 2 [1-3] in group H; the difference in median [95% confidence interval] 0 [0, -1]; P = .13) and day 5 (median [interquartile range] 1 (0-3) in group S vs 1 [0-3] in group H; the difference in median [95% confidence interval] 0 [0, 0.5]; P = .34) were statistically similar in both the groups and the upper margin was within the predefined margin of 1. Incidence of surgical site infection (P = .46), postoperative hospital stay (P = .29), and days alive without antibiotic therapy at postoperative day 28 (P = .95) were similar in both groups.

CONCLUSION

High intraoperative fiO2 was noninferior to standard fiO2 in postoperative pulmonary complications in adult patients undergoing major surgery.

Machine Learning Approaches for the Image-Based Identification of Surgical Wound Infections: Scoping Review

BACKGROUND

Surgical site infections (SSIs) occur frequently and impact patients and health care systems. Remote surveillance of surgical wounds is currently limited by the need for manual assessment by clinicians. Machine learning (ML)-based methods have recently been used to address various aspects of the postoperative wound healing process and may be used to improve the scalability and cost-effectiveness of remote surgical wound assessment.

OBJECTIVE

The objective of this review was to provide an overview of the ML methods that have been used to identify surgical wound infections from images.

METHODS

We conducted a scoping review of ML approaches for visual detection of SSIs following the JBI (Joanna Briggs Institute) methodology. Reports of participants in any postoperative context focusing on identification of surgical wound infections were included. Studies that did not address SSI identification, surgical wounds, or did not use image or video data were excluded. We searched MEDLINE, Embase, CINAHL, CENTRAL, Web of Science Core Collection, IEEE Xplore, Compendex, and arXiv for relevant studies in November 2022. The records retrieved were double screened for eligibility. A data extraction tool was used to chart the relevant data, which was described narratively and presented using tables. Employment of TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis) guidelines was evaluated and PROBAST (Prediction Model Risk of Bias Assessment Tool) was used to assess risk of bias (RoB).

RESULTS

In total, 10 of the 715 unique records screened met the eligibility criteria. In these studies, the clinical contexts and surgical procedures were diverse. All papers developed diagnostic models, though none performed external validation. Both traditional ML and deep learning methods were used to identify SSIs from mostly color images, and the volume of images used ranged from under 50 to thousands. Further, 10 TRIPOD items were reported in at least 4 studies, though 15 items were reported in fewer than 4 studies. PROBAST assessment led to 9 studies being identified as having an overall high RoB, with 1 study having overall unclear RoB.

CONCLUSIONS

Research on the image-based identification of surgical wound infections using ML remains novel, and there is a need for standardized reporting. Limitations related to variability in image capture, model building, and data sources should be addressed in the future.

Antimicrobial approach of abdominal post-surgical infections

Abdominal surgical site infections (SSIs) are infections that occur after abdominal surgery. They can be superficial, involving the skin tissue only, or more profound, involving deeper skin tissues including organs and implanted materials. Currently, SSIs are large global health problem with an incidence that varies significantly depending on the United Nations' Human Development Index. The purpose of this review is to provide a practical update on the latest available literature on SSIs, focusing on causative pathogens and treatment with an overview of the ongoing studies of new therapeutic strategies.

Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics

Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.

Bioactive Suture with Added Innate Defense Functionality for the Reduction of Bacterial Infection and Inflammation

Surgical site infections (SSI) are a clinical and economic burden. Suture-associated SSI may develop when bacteria colonize the suture surface and form biofilms that are resistant to antibiotics. Thrombin-derived C-terminal peptide (TCP)-25 is a host defense peptide with a unique dual mode of action that can target both bacteria and the excessive inflammation induced by bacterial products. The peptide demonstrates therapeutic potential in preclinical in vivo wound infection models. In this study, the authors set out to explore whether TCP-25 can provide a new bioactive innate immune feature to hydrophilic polyglactin sutures (Vicryl). Using a combination of biochemical, biophysical, antibacterial, biofilm, and anti-inflammatory assays in vitro, in silico molecular modeling studies, along with experimental infection and inflammation models in mice, a proof-of-concept that TCP-25 can provide Vicryl sutures with a previously undisclosed host defense capacity, that enables targeting of bacteria, biofilms, and the accompanying inflammatory response, is shown.

Preclinical safety evaluation of continuous UV-A lighting in an operative setting

BACKGROUND

Germicidal ultraviolet (UV-C) light has been shown as an effective modality for disinfection in laboratory settings and in the operative room. Traditionally, short-wavelength UV-C devices, which have previously been shown to cause DNA damage, are utilized only for disinfection in pre- and post-operative settings and are not continuously active during operations. Continuous use of intraoperative UV light has potential to decrease pathogens and subsequent surgical site infections (SSIs), which arise in approximately 5-15% of operative cases. SSIs are a significant determinant of patient morbidity, readmission rates, and overall cost. Therefore, a method of UV light disinfection with a low risk of DNA damage is needed so that greater antimicrobial protection can be afforded to patients during the entirety of their surgical procedures. A new disinfection device that harnesses longer-wavelength UV-A light to disinfect the surgical field throughout the entirety of the procedure, including pre- and post-operation has been developed.

METHODS

This study aimed to determine if UV-A light administered intraoperatively was safe, as defined by the minimal presence of DNA damage and safe amounts of reflection upon medical personnel. Using in vitro models, we examined the differential impacts of UV-C and UV-A light on DNA damage and repair pathways. In a murine model, we looked at the production of DNA damage photoproduction in relation to UV-A versus UV-C exposure.

RESULTS

Our results show UV-A light does not induce a significant amount of DNA damage at the cellular or tissue level. Furthermore, a preclinical porcine study showed that surgical personnel were exposed to safe levels of UV-A irradiance from an overhead UV-A light used during an operation. The amount of UV-A transmitted through surgical personal protective equipment (PPE) also remained within safe levels.

CONCLUSIONS

In conclusion, we found that UV-A may be safe for intraoperative use.

PRESS survey: PREvention of surgical site infection-a global pan-specialty survey of practice protocol

Background

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices.

Methods

This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses.

Discussion

Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Comparison of olanexidine versus povidone-iodine as a preoperative antiseptic for reducing surgical site infection in both scheduled and emergency gastrointestinal surgeries: A single-center randomized clinical trial

Aim

Surgical site infection (SSI) is one of the most common postoperative complications in gastrointestinal surgery. To clarify the superiority of 1.5% olanexidine, we conducted a randomized prospective clinical trial that enrolled patients undergoing gastrointestinal surgery with operative wound classes II-IV.

Methods

To evaluate the efficacy of 1.5% olanexidine in preventing SSIs relative to 10% povidone-iodine, we enrolled 298 patients in each group. The primary outcome was a 30-day SSI, and the secondary outcomes were incidences of superficial and deep incisional SSI and organ/space SSI. In addition, subgroup analyses were performed.

Results

The primary outcome of the overall 30-day SSI occurred in 38 cases (12.8%) in the 1.5% olanexidine group and in 53 cases (18.0%) in the 10% povidone-iodine group (adjusted risk ratio: 0.716, 95% confidence interval: 0.495-1.057, p = 0.083). Organ/space SSI occurred in 18 cases (6.1%) in the 1.5% olanexidine group and in 31 cases (10.5%) in the 10% povidone-iodine group, with a significant difference (adjusted risk ratio: 0.587, 95% confidence interval: 0.336-0.992, p = 0.049). Subgroup analyses revealed that SSI incidences were comparable in scheduled surgery (relative risk: 0.809, 95% confidence interval: 0.522-1.254) and operative wound class II (relative risk: 0.756, 95% confidence interval: 0.494-1.449) in 1.5% olanexidine group.

Conclusion

Our study revealed that 1.5% olanexidine reduced the 30-day overall SSI; however, the result was not significant. Organ/space SSI significantly decreased in the 1.5% olanexidine group. Our results indicate that 1.5% olanexidine has the potential to prevent SSI on behalf of povidone-iodine.

Antimicrobial Activity of Silver-Containing Surgical Dressings in an In vitro Direct Inoculation Simulated Wound Fluid Model Against a Range of Gram-Positive and Gram-Negative Bacteria

Background: Surgical site infections can lead to serious complications and present a huge economic burden. Established wound infections can be difficult to eradicate so preventative measures, including antimicrobial dressings, are advantageous. Materials and Methods: The antimicrobial activity of an ionic silver, ethylenediaminetetraacetic acid (EDTA) and benzethonium chloride-containing (ISEB) surgical cover dressing (SCD) was compared with two other silver-containing SCDs (silver sulfate and ionic silver carboxymethylcellulose [CMC]) and a non-silver-containing CMC SCD control using an in vitro model. The dressings were tested against a range of gram-positive and gram-negative bacteria found in wound environments, including antibiotic resistant strains, using a direct inoculation simulated wound fluid (SWF) model. Dressings were fully hydrated with SWF and inoculated with a final concentration of 1 × 106 colony forming units (CFU) per 10 microliter of the challenge organisms. Dressings were incubated at 35°C ± 3°C for up to seven days; total viable counts (TVCs) were performed to determine bacterial bioburden. Results: All challenge organism levels remained high for the CMC SCD control and silver sulfate SCD throughout the test period. A greater than 95% reduction in TVCs was observed by four hours for all challenge organisms for the ISEB SCD, with non-detectable levels (<70 CFU per dressing) reached within 24 hours and sustained throughout the test period. Antimicrobial activity was less rapid with ionic silver CMC SCD, with 9 of 11 challenge organisms reaching undetectable levels within 6 to 72 hours. Conclusions: A more rapid antimicrobial activity was observed for the ISEB SCD compared with other dressings tested within this in vitro model.

Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is a health-threatening complication following caesarean section (CS); however, to the authors' knowledge, there is no worldwide estimate of the burden of post-CS SSIs. Therefore, this systematic review and meta-analysis aimed to estimate the global and regional incidence of post-CS SSIs and associated factors.

METHODS

International scientific databases were searched systematically for observational studies published from January 2000 to March 2023, without language or geographical restrictions. The pooled global incidence rate was estimated using a random-effects meta-analysis (REM), and then stratified by World-Health-Organization-defined regions as well as by sociodemographic and study characteristics. Causative pathogens and associated risk factors of SSIs were also analysed using REM. Heterogeneity was assessed with I2.

RESULTS

In total, 180 eligible studies (207 datasets) involving 2,188,242 participants from 58 countries were included in this review. The pooled global incidence of post-CS SSIs was 5.63% [95% confidence interval (CI) 5.18-6.11%]. The highest and lowest incidence rates for post-CS SSIs were estimated for the African (11.91%, 95% CI 9.67-14.34%) and North American (3.87%, 95% CI 3.02-4.83%) regions, respectively. The incidence was significantly higher in countries with lower income and human development index levels. The pooled incidence estimates have increased steadily over time, with the highest incidence rate during the coronavirus disease 2019 pandemic (2019-2023). Staphylococcus aureus and Escherichia coli were the most prevalent pathogens. Several risk factors were identified.

CONCLUSION

An increasing and substantial burden from post-CS SSIs was identified, especially in low-income countries. Further research, greater awareness and the development of effective prevention and management strategies are warranted to reduce post-CS SSIs.

Incisional negative pressure wound therapy for the prevention of surgical site infection: an up-to-date meta-analysis and trial sequential analysis

Background

The evidence on prophylactic use of negative pressure wound therapy on primary closed incisional wounds (iNPWT) for the prevention of surgical site infections (SSI) is confusing and ambiguous. Implementation in daily practice is impaired by inconsistent recommendations in current international guidelines and published meta-analyses. More recently, multiple new randomised controlled trials (RCTs) have been published. We aimed to provide an overview of all meta-analyses and their characteristics; to conduct a new and up-to-date systematic review and meta-analysis and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment; and to explore the additive value of new RCTs with a trial sequential analysis (TSA).

Methods

PubMed, Embase and Cochrane CENTRAL databases were searched from database inception to October 24, 2022. We identified existing meta-analyses covering all surgical specialties and RCTs studying the effect of iNPWT compared with standard dressings in all types of surgery on the incidence of SSI, wound dehiscence, reoperation, seroma, hematoma, mortality, readmission rate, skin blistering, skin necrosis, pain, and adverse effects of the intervention. We calculated relative risks (RR) with corresponding 95% confidence intervals (CI) using a Mantel-Haenszel random-effects model. We assessed publication bias with a comparison-adjusted funnel plot. TSA was used to assess the risk of random error. The certainty of evidence was evaluated using the Cochrane Risk of Bias-2 (RoB2) tool and GRADE approach. This study is registered with PROSPERO, CRD42022312995.

Findings

We identified eight previously published general meta-analyses investigating iNPWT and compared their results to present meta-analysis. For the updated systematic review, 57 RCTs with 13,744 patients were included in the quantitative analysis for SSI, yielding a RR of 0.67 (95% CI: 0.59-0.76, I2 = 21%) for iNPWT compared with standard dressing. Certainty of evidence was high. Compared with previous meta-analyses, the RR stabilised, and the confidence interval narrowed. In the TSA, the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, confirming the robustness of the summary effect estimate from the meta-analysis.

Interpretation

In this up-to-date meta-analysis, GRADE assessment shows high-certainty evidence that iNPWT is effective in reducing SSI, and uncertainty is less than in previous meta-analyses. TSA indicated that further trials are unlikely to change the effect estimate for the outcome SSI; therefore, if future research is to be conducted on iNPWT, it is crucial to consider what the findings will contribute to the existing robust evidence.

Funding

Dutch Association for Quality Funds Medical Specialists.

Isolation and Detection of Drug-Resistant Bacterial Pathogens in Postoperative Wound Infections at a Tertiary Care Hospital in Saudi Arabia

Background

Surgical site infections (SSIs), especially when caused by multidrug-resistant (MDR) bacteria, are a major healthcare concern worldwide. For optimal treatment and prevention of antimicrobial resistance, it is important for clinicians to be aware of local drug-resistant bacterial pathogens that cause SSIs.

Objective

To determine the frequency patterns of drug-resistant bacterial strains causing SSIs at a tertiary care hospital in Saudi Arabia.

Methods

This retrospective study was conducted at the Microbiology laboratory of Al-Noor Specialist Hospital, Makkah, Saudi Arabia, and included wound swab samples from all cases of SSI between January 01, 2017, and December 31, 2021. The swabs were processed for the identification of bacterial strains and their resistance pattern to antibiotics according to the Clinical and Laboratory Standards Institute.

Results

A total of 5409 wound swabs were analyzed, of which 3604 samples (66.6%) were from male. Most samples were from the Department of Surgery (43.3%). A total of 14 bacterial strains were isolated, of which 9 were Gram-negative bacteria. The most common isolates were Klebsiella pneumoniae, followed by Pseudomonas aeruginosa, Escherichia coli, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and vancomycin-resistant S. aureus (VRSA). In terms of MDR in 2021, the highest rate of carbapenem-resistance was in A. baumannii (97%). MDR was as follows: A. baumannii, 97%; K. pneumoniae, 81%; E. coli, 71%; MRSA, 60%; P. aeruginosa, 33%; VRE, 22%; and VRSA, 2%.

Conclusion

This study showed that in the city of Makkah, Saudi Arabia, the rates of MDR bacteria are high, with the majority being Gram-negative.

Update of risk factors for surgical site infection in clean-contaminated wounds after gastroenterological surgery: An analysis of 1,878 participants enrolled in 2 recent randomized control trials for the prevention of surgical site infection

BACKGROUND

Clean-contaminated wounds should be the main target for reducing the burden of harm caused by surgical site infection after gastroenterological surgery.

METHODS

The present study targeted 1,973 patients enrolled in 2 randomized controlled trials to evaluate the efficacy of intraoperative interventions for incisional surgical site infection prevention after gastroenterological surgery with clean-contaminated wounds. Patients were reassessed, and preoperative and postoperative variables were collected. Risk factors for surgical site infection were identified by univariate and multivariate analyses.

RESULTS

The study population included 1,878 patients, among whom 213 (11.3%) developed overall surgical site infection and 119 (6.3%) developed incisional surgical site infection. A multivariate analysis revealed that steroid or immunosuppressant use (odds ratio 3.03; 95% confidence interval 1.37-6.73, P = .0064), open surgery (odds ratio 1.77; 95% confidence interval 1.11-2.83, P = .0167), and long operative time (odds ratio 2.31; 95% confidence interval 1.5-3.56, P < .001) were independent risk factors for incisional surgical site infection. Steroid or immunosuppressant use (odds ratio 2.62; 95% confidence interval 1.29-5.33, P = .0078), open surgery (odds ratio 2.13; 95% confidence interval 1.44-3.16, P < .001), and long operative time (odds ratio 2.92; 95% confidence interval 2.08-4.10, P < .001) were also independent risk factors for overall surgical site infection in the multivariate analysis. Furthermore, a multivariate analysis revealed that a long operative time (odds ratio 3.21; 95% confidence interval 1.69-6.1, P = .00378) was an independent risk factor for incisional surgical site infection in patients who underwent laparoscopic surgery.

CONCLUSION

Even under current measures for surgical site infection prevention, surgeons should continue to make efforts to appropriately expand the indication of laparoscopic surgery and to reduce operative times even when performing laparoscopic surgery.

Patient experiences of, and preferences for, surgical wound care education

The aim of this study was to describe patients' experiences of, and preferences for, surgical wound care discharge education and how these experiences predicted their ability to self-manage their surgical wounds. A telephone survey of 270 surgical patients was conducted across two hospitals two weeks after discharge. Patients preferred verbal (n = 255, 94.8%) and written surgical wound education (n = 178, 66.2%) from medical (n = 229, 85.4%) and nursing staff (n = 211, 78.7%) at discharge. The most frequent education content that patients received was information about follow-up appointments (n = 242, 89.6%) and who to contact in the community with wound care concerns (n = 233, 86.6%). Using logistic regression, patients who perceived that they participated in surgical wound care decisions were 6.5 times more likely to state that they were able to manage their wounds at home. Also, patients who agreed that medical and/or nursing staff discussed wound pain management were 3.1 times more likely to report being able to manage their surgical wounds at home. Only 40% (107/270) of patients actively participated in wound-related decision-making during discharge education. These results uncovered patient preferences, which could be used to optimise discharge education practices. Embedding patient participation into clinical workflows may enhance patients' self-management practices once home.

Aqueous Povidone-Iodine Versus Normal Saline For Intraoperative Wound Irrigation on The Incidence of Surgical Site Infection in Clean-Contaminated Wounds After Gastroenterological Surgery: A Single-Institute, Prospective, Blinded-Endpoint, Randomized Controlled Trial

OBJECTIVE

This trial evaluated the superiority of intraoperative wound irrigation (IOWI) with aqueous povidone-iodine (PVP-I) compared with that with saline for reducing the incidence of surgical site infection (SSI).

BACKGROUND

IOWI with aqueous PVP-I is recommended for the prevention of SSI by the World Health Organization and the Centers for Disease Control and Prevention, although the evidence level is low.

METHODS

This single institute in Japan, prospective, randomized, blinded-endpoint trial was conducted to assess the superiority of IOWI with aqueous PVP-I in comparison with IOWI with saline for reducing the incidence of SSI in clean-contaminated wounds after gastroenterological surgery. Patients 20 years or older were assessed for eligibility, and the eligible participants were randomized at a 1:1 ratio using a computer-generated block randomization. In the study group, IOWI was performed for 1 minute with 40 mL of aqueous 10% PVP-I before skin closure. In the control group, the procedure was performed with 100 mL of saline. Participants, assessors, and analysts were masked to the treatment allocation. The primary outcome was the incidence of incisional SSI in the intention-to-treat set.

RESULTS

Between June 2019 and March 2022, 941 patients were randomized to the study group (473 patients) or the control group (468 patients). The incidence of incisional SSI was 7.6% in the study group and 5.1% in the control group (risk difference 0.025, 95% CI -0.006 to 0.056; risk ratio 1.484, 95% CI 0.9 to 2.448; P =0.154).

CONCLUSION

The current recommendation of IOWI with aqueous PVP-I should be reconsidered.

Postoperative negative-pressure incision therapy after liver transplant (PONILITRANS study): A randomized controlled trial

BACKGROUND

Postoperative complications of surgical incisions are frequent in liver transplantation. However, evidence justifying the use of incisional negative pressure wound therapy to improve surgical wound outcomes remains limited.

METHODS

Participating patients were randomly assigned to receive incisional negative pressure wound therapy or standard surgical dressing on the closed surgical incision of the liver transplantation. The primary endpoint was surgical site infection incidence 30 days postoperatively. The secondary endpoints included surgical site events (ie, surgical site infection, dehiscence, hematoma, and seroma) and wound quality of life.

RESULTS

Between December 2018 and September 2021, 108 patients (54 in the incisional negative pressure wound therapy group and 54 in the control group) were enrolled in this study. The incidence of surgical site infection at 30 days postoperatively was 7.4% in the treatment group and 13% in the control group (P = .34). The rate of surgical site events was similar in the treatment in the and control group (27.8% vs 29.6%, P = .83). In relation to wound quality of life, the mean score was 75.20 ± 7.27 in the incisional negative pressure wound therapy group and 72.82 ± 10.57 in the control group (P = .23).

CONCLUSION

The prophylactic use of negative pressure wound therapy on primarily closed incisions did not significantly reduce incisional surgical site infection and surgical site event rates after liver transplantation compared with standard surgical dressings.

Effectiveness of discharge education for patients undergoing general surgery: A systematic review and meta-analysis

BACKGROUND

There is some evidence to suggest that discharge education may reduce the risk of postoperative complications, however, a critical evaluation of the body of evidence is needed.

OBJECTIVE

To assess the effect of discharge education interventions versus standard education given to general surgery patients prior to, or up to 30-days of hospital discharge on clinical and patient-reported outcomes.

DESIGN

Systematic review and meta-analysis. Clinical outcomes were 30-day surgical site infection incidence and re-admission up to 28 days. Patient-reported outcomes included patient knowledge, self-confidence, satisfaction, and quality of life.

SETTING

Participants were recruited from hospitals.

PARTICIPANTS

Adult general surgical patients.

METHODS

MEDLINE (Pubmed), CINAHL (EBSCO), EMBASE (Elsevier) and the Cochrane Library were searched in February 2022. Randomised controlled trials and non-randomised studies of interventions published between 2010 and 2022, with adults undergoing general surgical procedures receiving discharge education on surgical recovery, including wound management, were eligible for inclusion. Quality appraisal was undertaken using the Cochrane Risk of Bias 2 and the Risk of Bias Assessment Tool for Nonrandomised Studies. The Grading of Assessment, Development, Recommendations, and Evaluation was used to assess the certainty of the body of evidence based on the outcomes of interest.

RESULTS

Ten eligible studies (eight randomised control trials and two non-randomised studies of interventions) with 965 patients were included. Six randomised control trials assessed the effect of discharge education interventions on 28-day readmission (Odds ratio 0.88, 95 % confidence interval 0.56-1.38). Two randomised control trials assessed the effect of discharge education interventions on surgical site infection incidence (Odds ratio = 0.84, 95 % confidence interval 0.39-1.82). The results of the non-randomised studies of interventions were not pooled due to heterogeneity in outcome measures. The risk of bias was either moderate or high for all outcomes, and the body of evidence using GRADE was judged as very low for all outcomes studied.

CONCLUSIONS

The impact of discharge education on the clinical and patient-reported outcomes of patients undergoing general surgery cannot be determined due to the uncertainty of the evidence base. Despite the increased use of web-based interventions to deliver discharge education to general surgery patients, larger samples in more rigorous multicentre randomised control trials with parallel process evaluations are needed to better understand the effect of discharge education on clinical and patient-reported outcomes.

REGISTRATION

PROSPERO CRD42021285392.

TWEETABLE ABSTRACT

Discharge education may reduce the likelihood of surgical site infection and hospital readmission but the body of evidence is inconclusive.

Awareness and Knowledge of Postoperative Surgical Site Infections in Patients from Saudi Arabia: A Multi-Regional Cross-Sectional Study

Background

Knowledge regarding surgical site infections (SSIs) can help reduce hospital stay, morbidity, and mortality associated with SSI.

Objectives

This study aimed to determine the knowledge and awareness of SSI among patients undergoing surgeries across Saudi Arabia.

Methods

This multi-center cross-sectional study included adult patients (aged >18 years) who underwent surgery at six centers located across the five regions of Saudi Arabia. A 36-item questionnaire was used to elicit data regarding demographics, patient's health status, procedures, and hospitalization history and awareness and knowledge about SSIs.

Results

A total of 375 patients were included (equally for all five regions of Saudi Arabia). Most patients were male (55.7%) and aged 18-34 years (44%). Most respondents (49.1%) had poor awareness; being illiterate and from the Northern region were significant factors (P = 0.001). Patients with no history of surgery (P = 0.001) or SSI (P = 0.003) also had poor awareness levels. In terms of knowledge, 45.8% and 35.2% of the participants had fair and poor knowledge, respectively, with the level of knowledge being significantly associated with region (P = 0.001). Patients those aged >65 years had poor knowledge (P = 0.033), while of males had good knowledge (P = 0.02). Patients with no history of surgery had poor knowledge of SSIs (P = 0.003). Only 32.8% of the patients recalled having been educated by healthcare workers. About 42% learned of SSIs from sources outside the hospital, with internet/social media platforms accounting for 48.4% of such sources.

Conclusion

A significant proportion of the patients included in this study had poor awareness and knowledge of SSIs. The study highlights the need for strengthening the preoperative patient education in Saudi Arabia to reduce the likeliness of SSIs.

Using a stacker crane for sterile storage in the operating theatre: initial environmental microbiological qualification

BACKGROUND

Adequate storage of sterile surgical devices must prevent contamination and the introduction of microbial contaminants inside the operating rooms. For functional and economic purposes, stacker cranes (STCs) could replace the traditional sterile storage room (TSSR). STCs are large multistage computer-assisted systems used to automatically store and retrieve loads from defined locations. However, their microbiological performance has not been evaluated AIM: As part of the opening of a new building that included an operating theatre, we qualified a new STC and compared its microbiological control performance to that of the previous TSSR.

METHODS

From December 2020 to March 2021, 590 environmental specimens (air, n=56; surfaces, n=534) were collected and interpreted according to the NF S90-351 French Association for Standardization standards.

FINDINGS

Thorough surface disinfection was not sufficient for controlling microbial contamination in the STC. Thus, the initial qualification testing was conducted following an aggressive aerial chemical decontamination of the STC. Despite the lack of a HEPA filtered air system, the overall non-conformity rates were lower in the STC than in TSSR (8.3% vs. 21.4%, p=0.33 for air, respectively, and 9.7% vs. 41.7% p<0.001 for surfaces). The air-controlled barrier in front of the loading zone appeared to be sufficient to prevent bacterial contamination. The presence of fungi must be carefully monitored.

CONCLUSION

This is the first study supporting the contribution of STCs in saving space and improving the maintenance of sterile surgical device storage and availability under acceptable environmental conditions. Further studies are needed to assess the long-term microbiological contamination inside the STC.