Comparison of the National Surgical Site Infection surveillance data between The Netherlands and Germany: PREZIES versus KISS

Is antibiotic prophylaxis expendable in parotid gland surgery? A retrospective analysis of surgical site infection rates

OBJECTIVES

To evaluate the rate of surgical site infection (SSI) and associated risk factors after parotid gland surgery including the impact of antibiotic prophylaxis.

DESIGN

Retrospective single-centre clinical study.

SETTING

Tertiary referral centre for head and neck surgery.

PARTICIPANTS

Seven hundred and fifty four patients who underwent parotid gland surgery at the University Hospital Heidelberg, Germany, between 2007 and 2014 were enrolled in this study. Data on patient age, American Society of Anesthesiologists (ASA) classification system, smoking status, diabetes mellitus, operation time, and antibiotic prophylaxis were collected. Additionally, the National Healthcare Safety Network (NHSN) risk index was calculated. Association of these factors with SSI was evaluated in univariate analyses and a multivariate logistic regression model.

MAIN OUTCOME MEASURES

Rate of SSI.

RESULTS

Twenty four patients (3.2%) had an SSI according to the NHSN definition. In univariate analyses, only smokers (P = .048) and male patients (P = .01) had a significantly higher rate of SSI. Since the majority of smokers were men (62.3%), the effect of male gender, smoking, together with the NHSN risk index was further investigated as predictors of SSI within a logistic regression model. All three predictors showed a significant effect on SSI.

CONCLUSIONS

Parotid gland surgery has a low rate of SSI. In our cohort, male gender, smoking and high NHSN risk index scores were significantly associated with SSI, whereas antibiotic prophylaxis had no protective effect.

The Impacts of Deep Surgical Site Infections on Readmissions, Length of Stay, and Costs: A Matched Case-Control Study Conducted in an Academic Hospital in the Netherlands

OBJECTIVE

This study aimed to evaluate the impacts of deep surgical site infections (dSSIs) regarding hospital readmissions, prolonged length of stay (LoS), and estimated costs.

PATIENTS AND METHODS

We designed and applied a matched case-control observational study using the electronic health records at the University Medical Center Groningen in the Netherlands. We compared patients with dSSI and non-SSI, matched on the basis of having similar procedures. A prevailing topology of surgeries categorized as clean, clean-contaminated, contaminated, and dirty was applied.

RESULTS

Out of a total of 12,285 patients, 393 dSSI were identified as cases, and 2864 patients without SSIs were selected as controls. A total of 343 dSSI patients (87%) and 2307 (81%) controls required hospital readmissions. The median LoS was 7 days (P₂₅-P₇₅: 2.5-14.5) for dSSI patients and 5 days (P₂₅-P₇₅: 1-9) for controls (p-value: <0.001). The estimated mean cost per hospital admission was €9,016 (SE±343) for dSSI patients and €5,409 (SE±120) for controls (p<0.001). Independent variables associated with dSSI were patient's age ≥65 years (OR: 1.334; 95% CI: 1.036-1.720), the use of prophylactic antibiotics (OR: 0.424; 95% CI: 0.344-0.537), and neoplasms (OR: 2.050; 95% CI: 1.473-2.854).

CONCLUSION

dSSI is associated with increased costs, prolonged LoS, and increased readmission rates. Elevated risks were seen for elderly patients and those with neoplasms. Additionally, a protective effect of prophylactic antibiotics was found.

Surgical Infections and Antibiotic Stewardship: In Need for New Directions

BACKGROUND AND AIMS

Patients undergoing surgery are prone to infections, either at the site of surgery (superficial or organ-space) or at remote sites (e.g. pneumonia or urinary tract). Surgical site infections are associated with substantial morbidity and mortality, increased length of hospital stay and represent a huge burden to the health economy across all healthcare systems. Here we discuss recent advances and challenges in the field of surgical site infections.

MATERIAL AND METHODS

Review of pertinent English language literature.

RESULTS

Numerous guidelines and recommendations have been published in order to prevent surgical site infections. Compliance with these evidence-based guidelines vary and has not resulted in any major decrease in the surgical site infection rate. To date, most efforts to reduce surgical site infection have focused on the role of the surgeon, but a more comprehensive approach is necessary.

CONCLUSION

Surgical site infections need to be addressed in a structured way, including checklists, audits, monitoring, and measurements. All stakeholders, including the medical profession, the society, and the patient, need to work together to reduce surgical site infections. Most surgical site infections are preventable-and we need a paradigm shift to tackle the problem.

Cross-border comparison of antimicrobial resistance (AMR) and AMR prevention measures: the healthcare workers' perspective

Background

Cross-border healthcare may promote the spread of multidrug-resistant microorganisms (MDRO) and is challenging due to heterogeneous antimicrobial resistance (AMR) prevention measures (APM). The aim of this article is to compare healthcare workers (HCW) from Germany (DE) and The Netherlands (NL) on how they perceive and experience AMR and APM, which is important for safe patient exchange and effective cross-border APM cooperation.

Methods

A survey was conducted amongst HCW (n = 574) in hospitals in DE (n = 305) and NL (n = 269), using an online self-administered survey between June 2017 and July 2018. Mann-Whitney U tests were used to analyse differences between answers of German and Dutch physicians (n = 177) and German and Dutch nurses (n = 397) on 5-point Likert Items and Scales.

Results

Similarities between DE and NL were a high awareness about the AMR problem and the perception that the possibility to cope with AMR is limited (30% respondents perceive their contribution to limit AMR as insufficient). Especially Dutch nurses scored significantly lower than German nurses on their contribution to limit AMR (means 2.6 vs. 3.1, p ≤ 0.001). German HCW were more optimistic about their potential role in coping with AMR (p ≤ 0.001), and scored higher on feeling sufficiently equipped to perform APM (p ≤ 0.003), although the mean scores did not differ much between German and Dutch respondents.

Conclusions

Although both German and Dutch HCW are aware of the AMR problem, they should be more empowered to contribute to limiting AMR through APM (i.e. screening diagnostics, infection diagnosis, treatment and infection control) in their daily working routines. The observed differences reflect differences in local, national and cross-border structures, and differences in needs of HCW, that need to be considered for safe patient exchange and effective cross-border APM.

Evaluating the direct economic burden of health care-associated infections among patients with colorectal cancer surgery in China

BACKGROUND

Little is known about the direct economic burden associated with health care-associated infection (HAI) in patients undergoing colorectal cancer surgery in China. This study aims to fill this knowledge gap.

METHODS

This study was a prospective monitoring case-control study. The direct economic burden was presented as the median of the 1:1 pair differences of various hospitalization fees and hospital length of stay. Wilcoxon signed-rank tests were used to explore the differences in the direct economic burden.

RESULTS

Out of 448 patients, 38 had acquired HAIs, with the infection incidence being 8.93%. The total direct economic burden of HAIs was $1,589.30 (P <.05). Among various infection sites, deep surgical site infection had the highest direct economic burden of $8,654.44, followed by multisite infections ($5,946.52). When it comes to various hospitalization costs, the cost for Western medicine ($846.13) constituted the highest proportion of economic burden followed by treatment cost ($145.73) and bed charge ($126.75). On average, the length of hospital stay in the infection group was 6 days longer than that in the control group (P <.05).

CONCLUSIONS

HAI was associated with considerable economic burden for patients who underwent colorectal cancer surgery in China. The study highlights the necessity of taking effective measures to decrease incidence of HAIs to reduce economic burden.

First Results of the Swiss National Surgical Site Infection Surveillance Program: Who Seeks Shall Find

OBJECTIVES

To report on the results of the Swiss national surgical site infection (SSI) surveillance program, including temporal trends, and to describe methodological characteristics that may influence SSI rates

DESIGN

Countrywide survey of SSI over a 4-year period. Analysis of prospectively collected data including patient and procedure characteristics as well as aggregated SSI rates stratified by risk categories, type of SSI, and time of diagnosis. Temporal trends were analyzed using stepwise multivariate logistic regression models with adjustment of the effect of the duration of participation in the surveillance program for confounding factors.

SETTING

The study included 164 Swiss public and private hospitals with surgical activities.

RESULTS

From October 2011 to September 2015, a total of 187,501 operations performed in this setting were included. Cumulative SSI rates varied from 0.9% for knee arthroplasty to 14.4% for colon surgery. Postdischarge follow-up was completed in &gt;90% of patients at 1 month for surgeries without an implant and in &gt;80% of patients at 12 months for surgeries with an implant. High rates of SSIs were detected postdischarge, from 20.7% in colon surgeries to 93.3% in knee arthroplasties. Overall, the impact of the duration of surveillance was significantly and independently associated with a decrease in SSI rates in herniorraphies and C-sections but not for the other procedures. Nevertheless, some hospitals observed significant decreases in their rates for various procedures.

CONCLUSIONS

Intensive post-discharge surveillance may explain high SSI rates and cause artificial differences between programs. Surveillance per se, without structured and mandatory quality improvement efforts, may not produce the expected decrease in SSI rates.

Infect Control Hosp Epidemiol 2017;38:697–704

Is It Valid to Compare Surgical Site Infections Rates Between Countries? Insights From a Study of English and Norwegian Surveillance Systems

OBJECTIVE

To assess whether differences in surveillance methods or underlying populations significantly influence internationally reported national SSI rates by comparing surveillance data from 2 countries.

DESIGN

Retrospective cohort.

SETTING

England and Norway.

METHODS

We assessed the population under surveillance and surveillance methodology to compare SSI rates in 2 countries (September 2012–January 2015) for 4 surgical categories: coronary artery bypass graft (CABG), colon surgery, cholecystectomy, and hip prosthesis (HPRO). We compared the inpatient SSI incidence using logistic regression, adjusting for the following known risk factors: sex, age, ASA score, wound class, postoperative hospital days, and operation duration. Subsequently, we restricted further analyses to the procedures reported by both countries.

RESULTS

There were important differences in case definitions for superficial infection, so we restricted our analyses to deep incisional and organ-space SSIs. For CABG, the crude odds ratio (OR) for England compared to Norway was 2.4 (95% CI, 1.4–4.4), whereas adjusted OR (aOR) lost significance (aOR, 1.1; 95% CI, 0.57–2.0). For colon surgery the decreased odds (OR, 0.68; 95% CI, 0.56–0.81) remained significant after adjustment (aOR, 0.42; 95% CI, 0.34–0.51). We found no associations for cholecystectomy. For HPRO, the crude OR suggested no significant difference (OR, 1.2; 95% CI, 0.72–2.1), whereas the aOR was significantly lower in England (aOR, 0.45; 95% CI, 0.25–0.81). Including only the subset of procedures reported by both countries yielded comparable results.

CONCLUSION

Differences in case definitions and population under surveillance in the English and Norwegian SSI surveillance systems affected SSI estimates, making the comparison of crude rates unreliable. Standardized definitions and adjustment for established risk factors are essential for European comparisons to guide related public health actions.

Infect Control Hosp Epidemiol 2017;38:162–171

Impact of surveillance technique on reported rates of surgical site infection

Surgical site infection (SSI) surveillance methods vary among infection preventionists. An online survey regarding SSI surveillance technique was administered to infection preventionists and linked to superficial and complex colon SSI rates. Higher superficial but not complex SSI rates were reported when more SSI surveillance techniques were used (P <.0001).

Complex Surgical Site Infections and the Devilish Details of Risk Adjustment: Important Implications for Public Reporting

Objective.

To validate the National Nosocomial Infection Surveillance (NNIS) risk index as a tool to account for differences in case mix when reporting rates of complex surgical site infection (SSI).

Design.

Prospective cohort study.

Setting.

Twenty-four community hospitals in the southeastern United States.

Methods.

We identified surgical procedures performed between January 1, 2005, and June 30, 2007. The Goodman-Kruskal gamma or G statistic was used to determine the correlation between the NNIS risk index score and the rates of complex SSI (not including superficial incisional SSI). Procedure-specific analyses were performed for SSI after abdominal hysterectomy, cardiothoracic procedures, colon procedures, insertion of a hip prosthesis, insertion of a knee prosthesis, and vascular procedures.

Results.

A total of 2,257 SSIs were identified during the study period (overall rate, 1.19 SSIs per 100 procedures), of which 1,093 (48.4%) were complex (0.58 complex SSIs per 100 procedures). There were 45 complex SSIs identified following 7,032 abdominal hysterectomies (rate, 0.64 SSIs per 100 procedures); 63 following 5,318 cardiothoracic procedures (1.18 SSIs per 100 procedures); 139 following 5,144 colon procedures (2.70 SSIs per 100 procedures); 63 following 6,639 hip prosthesis insertions (0.94 SSIs per 100 procedures); 73 following 9,658 knee prosthesis insertions (0.76 SSIs per 100 procedures); and 55 following 6,575 vascular procedures (0.84 SSIs per 100 procedures). All 6 procedure-specific rates of complex SSI were significantly correlated with increasing NNIS risk index score (P< .05).

Conclusions.

Some experts recommend reporting rates of complex SSI to overcome the widely acknowledged detection bias associated with superficial incisional infection. Furthermore, it is necessary to compensate for case-mix differences in patient populations, to ensure that intrahospital comparisons are meaningful. Our results indicate that the NNIS risk index is a reasonable method for the risk stratification of complex SSIs for several commonly performed procedures.

Governmental surveillance system of healthcare-associated infection in Brazil


Objective: This study aimed to describe the structure of governmental surveillance systems for Healthcare Associated Infection (HAI) in the Brazilian Southeastern and Southern States. Method: A cross-sectional, descriptive and exploratory study, with data collection by means of two-phases: characterization of the healthcare structure and of the HAI surveillance system. Results: The governmental teams for prevention and control of HAI in each State ranged from one to six members, having at least one nurse. All States implemented their own surveillance system. The information systems were classified into chain (n=2), circle (n=4) or wheel (n=1). Conclusion: Were identified differences in the structure and information flow from governmental surveillance systems, possibly limiting a nationwide standardization. The present study points to the need for establishing minimum requirements in public policies, in order to guide the development of HAI surveillance systems.


A prospective study on surgical-site infections in thyroid operation

BACKGROUND

To evaluate the incidence and the microbe spectrum of surgical-site infections (SSIs) in patients undergoing elective thyroid operation and to develop a risk factor-based predictive model.

METHODS

This prospective study included 6,778 consecutive patients who underwent thyroid operation at a single institution between 2007 and 2012. SSI was defined according to the Centers for Disease Control and Prevention. Regression models were fitted to evaluate risk factors for SSI. A predictive nomogram was constructed from relevant variables in the multivariable analysis. Discrimination and calibration of the nomogram were assessed.

RESULTS

The cumulative incidence of SSI after 30 days was 0.49%. The median time from operation to SSI was 7 days (interquartile range, 4-10.5 days). SSI was classified as superficial incisional in 30 cases (93.8%), deep incisional in 1 case (3.1%), and organ/space in 1 case (3.1%). Staphylococcus aureus was the most common isolate. In multivariable analysis, duration of operation (P = .004) and American Society of Anesthesiologists' score (P = .031) were identified as independent risk factors for SSI. These variables formed the basis of a nomogram, which was validated internally by bootstrapping and reached a predictive accuracy of 70.1%. The calibration curve showed a good agreement between predicted probability and actual observation.

CONCLUSION

The cumulative incidence of SSI in thyroid operation is <0.5%. American Society of Anesthesiologists' score and the duration of operation are independent risk factors for SSI. Antibiotic prophylaxis may be considered for selected patients based on the individual risk profile.

A comparative assessment of surgeons' tracking methods for surgical site infections

BACKGROUND

The incidence of surgical site infections (SSI) is considered increasingly to be an indicator of quality of care. We conducted a study in which daily inspection of the surgical incision was performed by an independent, trained team to monitor the incidence of SSI using U.S. Centers for Disease Control and Prevention (CDC) definitions, as a gold-standard measure of care. In the department of surgery, two registration systems for SSI were used routinely by the surgeon: An electronic and a plenary tracking system. The results of the independent team were compared with the outcomes provided by two registration systems for SSI, so as to evaluate the reliability of these systems as a possible alternative for indicating quality of care.

METHODS

The study was an incidence study conducted from May 2007 to January 2009 that included 1,000 adult patients scheduled to undergo open abdominal surgery in an academic teaching hospital. Surgical incisions were inspected daily to check for SSI according to definitions of health care-associated infections established by the CDC. Follow-up after discharge was done at the outpatient clinic of the hospital by telephone or letter in combination with patient diaries and reviews of patient charts, discharge letters, electronic files, and reported complications. Univariate and multivariable analyses were done to identify putative risk factors for missing registrations.

RESULTS

Of the 1,000 patients in the study, 33 were not evaluated. Surgical site infections were diagnosed in 26.8% of the 967 remaining patients, of which 18.0% were superficial incisional infections, 5.4% were deep incisional infections, and 3.4% were organ/space infections. More than 60% of SSIs were unreported in either of the department's two tracking systems for such infections. For these two systems, independent major risk factors for missing registrations were (1) the lack of occurrence of an SSI, (2) transplantation surgery, and (3) admission to non-surgical departments.

CONCLUSIONS

Most SSIs were not tracked with the department's two systems. These systems proved poor alternatives to the gold-standard method of quantifying the incidence of Surgical Site Infection SSI and, therefore, the quality of care. Both protocolized wound assessment and on-site documentation are mandatory for realistic quantification of the incidence of SSI.

Use of surgical-site infection rates to rank hospital performance across several types of surgery

BACKGROUND

Comparing and ranking hospitals based on health outcomes is becoming increasingly popular, although case-mix differences between hospitals and random variation are known to distort interpretation. The aim of this study was to explore whether surgical-site infection (SSI) rates are suitable for comparing hospitals, taking into account case-mix differences and random variation.

METHODS

Data from the national surveillance network in the Netherlands, on the eight most frequently registered types of surgery for the year 2009, were used to calculate SSI rates. The variation in SSI rate between hospitals was estimated with multivariable fixed- and random-effects logistic regression models to account for random variation and case mix. 'Rankability' (as the reliability of ranking) of the SSI rates was calculated by relating within-hospital variation to between-hospital variation.

RESULTS

Thirty-four hospitals reported on 13 629 patients, with overall SSI rates per surgical procedure varying between 0 and 15·1 per cent. Statistically significant differences in SSI rate between hospitals were found for colonic resection, caesarean section and for all operations combined. Rankability was 80 per cent for colonic resection but 0 per cent for caesarean section. Rankability was 8 per cent in all operations combined, as the differences in SSI rates were explained mainly by case mix.

CONCLUSION

When comparing SSI rates in all operations, differences between hospitals were explained by case mix. For individual types of surgery, case mix varied less between hospitals, and differences were explained largely by random variation. Although SSI rates may be used for monitoring quality improvement within hospitals, they should not be used for ranking hospitals.

Decreasing time trend in SSI incidence for orthopaedic procedures: surveillance matters!

BACKGROUND

Infection is the most common reason for early revision after hip and knee arthroplasty, and the revision rate is increasing. Surgical site infection (SSI) surveillance data are important to assess the true infection rate. There is little information regarding the potential time trend in SSI incidence following orthopaedic surgery.

AIM

To evaluate whether a time trend exists in SSI incidence due to surveillance following orthopaedic surgery.

METHODS

The SSI rates after hip and knee replacements and osteosynthesis of trochanteric femoral fractures and ankle fractures were recorded prospectively from May 1998 to October 2008 according to the criteria of the US Centers for Disease Control and Prevention. In total, 4177 procedures were analysed, 65.8% of which were performed on female patients. Linear regression was used to analyse trends in SSI rates.

FINDINGS

SSI incidence decreased significantly from 7% in the first year to 3% in the last year; a 57% relative reduction. The duration of surgery was the only significant predictor for infection (P < 0.001) in a logistic regression model that also included age, American Society of Anesthesiologists' score and level of emergency.

CONCLUSION

Surveillance following orthopaedic procedures showed a significant decrease in SSI incidence over the 11-year surveillance period. The causality between surveillance and SSI incidence is difficult to prove, but surveillance with feedback probably influences several procedures that affect the quality of health care, even if duration of surgery is the only significant predictor of this effect.

The impact of depth of infection and postdischarge surveillance on rate of surgical-site infections in a network of community hospitals

OBJECTIVE

To describe the epidemiology of surgical-site infections (SSIs) in community hospitals and to explore the impact of depth of SSI, healthcare location at the time of diagnosis, and variations in surveillance practices on the overall rate of SSI.

DESIGN

Retrospective cohort study.

SETTING

Thirty-seven community hospitals in the southeastern United States.

PATIENTS

Consecutive sample of patients undergoing surgical procedures between July 1, 2007, and December 31, 2008.

METHODS

ANOVA was used to compare rates of SSIs, and the F test was used to compare the distribution of rates of SSIs. Wilcoxon Signed Rank test [corrected] was used to test for differences in performance rankings of hospitals.

RESULTS

Following 177,706 surgical procedures, 1,919 SSIs were identified (incidence, 1.08 per 100 procedures). Sixty-four percent (1,223 of 1,919) of these were identified as complex SSIs; 87% of the complex SSIs were diagnosed in inpatient settings. The median proportion of superficial-incisional SSIs was 37% (interquartile range, 29.6%-49.5%). Postdischarge SSI surveillance was variable, with 58% of responding hospitals using surgeon letters. As reporting focus was narrowed from all SSIs to complex SSIs (incidence, 0.69 per 100 procedures) and, finally, to complex SSIs diagnosed in the inpatient setting (incidence, 0.51 per 100 procedures), variance in rates changed significantly ([Formula: see text]). Performance ranking of individual hospitals, based on rates of SSIs, differed significantly, depending on the reporting method utilized ([Formula: see text]).

CONCLUSIONS

Inconsistent reporting methods focused on variable depths of infection and healthcare location at time of diagnosis significantly impact rates of SSI, distribution of rates of SSI, and hospital comparative-performance rankings. We believe that public reporting of SSI rates should be limited to complex SSIs diagnosed in the inpatient setting.

French national program for prevention of healthcare-associated infections and antimicrobial resistance, 1992-2008: positive trends, but perseverance needed

OBJECTIVE

To describe the French program for the prevention of healthcare-associated infections and antibiotic resistance and provide results for some of the indicators available to evaluate the program. In addition to structures and process indicators, the 2 outcome indicators selected were the rate of surgical site infection and the proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates among the S. aureus isolates recovered.

DESIGN

Descriptive study of the evolution of the national structures for control of healthcare-associated infections since 1992. Through national surveillance networks, process indicators were available from 1993 to 2006, surgical site infection rates were available from 1999 to 2005, and prevalence rates for MRSA infection were available from 2001 to 2007.

RESULTS

A comprehensive national program has gradually been set up in France during the period from 1993 to 2004, which included strengthening of organized infection control activities at the local, regional, and national levels and developing large networks for surveillance of specific infections and antibiotic resistance. These achievements were complemented by instituting mandatory notification for unusual nosocomial events, especially outbreaks. The second phase of the program involved the implementation of 5 national quality indicators with public reporting. Surgical site infection rates decreased by 25% over a 6-year period. In France, the median proportion of MRSA among S. aureus isolates recovered from patients with bacteremia decreased from 33.4% to 25.7% during the period from 2001 to 2007, whereas this proportion increased in many other European countries.

CONCLUSIONS

Very few national programs have been evaluated since the Study on the Efficacy of Nosocomial Infection Control. Although continuing efforts are required, the French program appears to have been effective at reducing infection rates.

Post-discharge surveillance to identify colorectal surgical site infection rates and related costs

A growing number of surveillance studies have highlighted concerns with relying only on data from inpatients. Without post-discharge surveillance (PDS) data, the rate and burden of surgical site infections (SSIs) are underestimated. PDS data for colorectal surgery in the UK remains to be published. This is an important specialty to study since it is considered to have the highest SSI rate and is among the most expensive to treat. This study of colorectal SSI used a 30 day surveillance programme with telephone interviews and home visits. Each additional healthcare resource used by patients with SSI was documented and costed. Of the 105 patients who met the inclusion criteria and completed the 30 day follow-up, 29 (27%) developed SSI, of which 12 were diagnosed after discharge. The mean number of days to presentation of SSI was 13. Multivariable logistic analysis identified body mass index as the only significant risk factor. The additional cost of treating each infected patient was pound sterling 10,523, although 15% of these additional costs were met by primary care. The 5 month surveillance programme cost pound sterling 5,200 to run. An analysis of the surveillance nurse's workload showed that the nurse could be replaced by a healthcare assistant. PDS to detect SSI after colorectal surgery is necessary to provide complete data with accurate additional costs.

Risk factors for increased mortality from hospital-acquired versus community-acquired infections in febrile medical patients

BACKGROUND

Risk factors for hospital-acquired infection and attributable mortality in surgical and critically ill patients are well-known. We sought to identify factors associated with increased mortality from hospital-acquired infections as compared with community-acquired infections in patients with new-onset fever and a presumed infectious focus (n = 212), in a department of internal medicine.

METHODS

Demographic, clinical, and laboratory variables were studied for 2 days after inclusion. Septic shock and outcome were monitored for up to 7 and 28 days after inclusion, respectively.

RESULTS

Of the 212 patients, 54 had hospital-acquired and 158 community-acquired infection, with septic shock rates of 15% and 4% and mortality rates of 24% and 6% (P = .001), respectively. Prior neurologic disease was associated with death. Patients with hospital-acquired infection had more often (intravascular) devices and underwent more often interventions, had a different distribution of infectious foci, and had more often bacteremia. Bacteremia-associated septic shock was associated with nonsurvival in both infection groups. The causative agents were not associated with outcome, and the clinical and laboratory host response associated with nonsurvival generally did not differ among infection groups.

CONCLUSION

Our data suggest that hospital-acquired infections carry a higher crude mortality rate than community-acquired infection in febrile medical patients, mainly because of more frequent use of devices and hospital interventions and resultant bacteremia and septic shock, rather than by differences in underlying diseases, causative agents, and clinical and laboratory host responses. The observations thus emphasize the continued importance of preventive measures on medical wards of our hospital and can be used for comparison with future studies.

Poor functional status as a risk factor for surgical site infection due to methicillin-resistant Staphylococcus aureus

OBJECTIVE

To identify risk factors for surgical site infection (SSI) due to methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN

Prospective case-control study.

SETTING

One tertiary and 6 community-based institutions in the southeastern United States.

METHODS

We compared patients with SSI due to MRSA with 2 control groups: matched uninfected surgical patients and patients with SSI due to methicillin-susceptible S. aureus (MSSA). Multivariable logistic regression was used to determine variables independently associated with SSI due to MRSA, compared with each control group.

RESULTS

During the 5-year study period, 150 case patients with SSI due to MRSA were identified and compared with 231 matched uninfected control patients and 128 control patients with SSI due to MSSA. Two variables were independently associated with SSI due to MRSA in both multivariable regression models: need for assistance with 3 or more activities of daily living (odds ratio [OR] compared with uninfected patients, 3.97 [95% confidence interval {CI}, 2.18-7.25]; OR compared with patients with SSI due to MSSA, 3.88 [95% CI, 1.91-7.87]) and prolonged duration of surgery (OR compared with uninfected patients, 1.98 [95% CI, 1.11-3.55]; OR compared with patients with SSI due to MSSA, 2.33 [95% CI, 1.17-4.62]). Lack of independence (ie, poor functional status) remained associated with an increased risk of SSI due to MRSA after stratifying by age.

CONCLUSIONS

Poor functional status was highly associated with SSI due to MRSA in adult surgical patients, regardless of age. A patient's level of independence can be easily determined, and this information can be used preoperatively to target preventive interventions.