Mapping national surveillance of surgical site infections in England: needs and priorities

ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine

BACKGROUND

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

METHODS

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

RESULTS

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

CONCLUSIONS

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Preoperative MRSA screening using a simple questionnaire prior elective total joint replacement

INTRODUCTION

The purpose of this study was to evaluate the management and results of our standarized protocol for preoperative identification of MRSA colonisation in patients undergoing primary total hip and knee replacement procedures.

METHODS

Following hospital protocol, between January 2016 and June 2019 37,745 patients awaiting elective joint replacement underwent a standardized questionnaire to assess the risk of MRSA infection, identifying patients requiring preoperative MRSA screening. An evaluation of the questionnaire identified effective questions for identifying infected patients. Furthermore, an analysis evaluated the impact of comorbidities or Charlson Comorbidity Index scores on positive MRSA colonization. Additionally, we evaluated the cost savings of targeted testing compared to testing all surgery patients.

RESULTS

Of the 37,745 patients, 8.057 (21.3%) were swabbed, with a total of 65 (0.81%) positive tests. From this group 27 (36.48%) who were treated were negative before surgery. Some of the questionnaire results were consistently associated with a higher chance of colonization, including hospitalization during the past year (47,7%), previous history of MRSA (44,6%), and agriculture or cattle farming related work (15,4%). By selectively testing high-risk patients identified through the questionnaire, we achieved a 79% reduction in costs compared to universal MRSA screening.

CONCLUSION

Our results suggest that the simple and standardized questionnaire is a valuable tool for preoperative screening, effectively identifying high-risk patients prone to MRSA colonisation. The risk of periprosthetic joint infection (PJI) and its associated sequelae may be reduced by this approach.

Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models

BACKGROUND

Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk.

METHODS

Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively.

RESULTS

The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits.

CONCLUSIONS

The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.

Quality improvement study on the effectiveness of intranasal povidone-iodine decolonization on surgery patients

Background

Surgical site infection prevention and treatment remains a challenge in healthcare settings globally. The routine use of intranasal mupirocin for decolonization has challenges and preoperative intranasal povidone-iodine decolonization is another option. The purpose of this quality improvement study was to assess if a one-time preoperative intranasal povidone-iodine application could reduce the risk of the likelihood of nasal carriage of Staphylococcus aureus after surgery.

Methods

Ambulatory Surgery Center patients were enrolled in an intranasal povidone-iodine decolonization quality improvement study as they reported at the pre-operative holding area. Pre-decolonization intranasal samples were collected, followed by intranasal application of povidone-iodine. Patients waited for a minimum of 20 minutes after application before proceeding with surgery. Nasal samples were again collected after surgery. Each sample was tested for S. aureus colonization using the 16S rRNA-mecA-nuc triplex polymerase chain reaction, standard biochemical tests, and qualitative culturing.

Findings

In the 98 patients enrolled, 36% of these patients had intranasal colonization with S. aureus by 16S rRNA-mecA-nuc triplex polymerase chain reaction before surgery. Using a qualitative culture technique, 28% of patients tested positive for S. aureus before surgery and 20% of patients tested positive for S. aureus after surgery (P = 0.039).

Conclusion

Intranasal preoperative povidone-iodine is an effective strategy in the decolonization of S. aureus from the nares if properly implemented.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the "primary effects" of AMR. Previous estimates of the burden of AMR have largely ignored the potential "secondary effects," such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the “primary effects” of AMR. Previous estimates of the burden of AMR have largely ignored the potential “secondary effects,” such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Use of Feedback Data to Reduce Surgical Site Infections and Optimize Antibiotic Use in Surgery: A Systematic Scoping Review

OBJECTIVE

Surgical site infection (SSI) prevention remains significant, particularly in the era of antimicrobial resistance. Feedback on practices and outcomes is known to be key to reduce SSI rates and optimize antibiotic usage. However, the optimal method, format and frequency of feedback for surgical teams remains unclear. The objective of the study is to understand how data from surveillance and audit are fed back in routine surgical practice.

METHODS

A systematic scoping review was conducted, using well-established implementation science frameworks to code the data. Two electronic health-oriented databases (MEDLINE, EMBASE) were searched to September 2019. We included studies that assessed the use of feedback as a strategy either in the prevention and management of SSI and/or in the use of antibiotics perioperatively.

RESULTS

We identified 21 studies: 17 focused on SSI rates and outcomes and 10 studies described antimicrobial stewardship for SSI (with some overlap in focus). Several interventions were reported, mostly multimodal with feedback as a component. Feedback was often provided in written format (62%), either individualized (38%) or in group (48%). Only 25% of the studies reported that feedback cascaded down to the frontline perioperative staff. In 65% of the studies, 1 to 5 implementation strategies were used while only 5% of the studies reported to have utilized more than 15 implementation strategies. Among studies reporting antibiotic usage in surgery, most (71%) discussed compliance with surgical antibiotic prophylaxis.

CONCLUSIONS

Our findings highlight the need to provide feedback to all levels of perioperative care providers involved in patient care. Future research in this area should report implementation parameters in more detail.

Incidence and Risk Factors for Surgical Site Infection following Emergency Cesarean Section: A Retrospective Case-Control Study

OBJECTIVE

To assess the incidence, risk, and associated factors that contribute to an acquired surgical site infection (SSI) after emergency cesarean section (CS).

METHODS

This retrospective case-control study was conducted in an acute district general hospital in England with 206 patients (101 SSI patients and 105 non-SSI patients) who had an emergency CS in 2017. Grade of surgeon, smoking status, preoperative vaginal swab status (positive or negative), diabetes status, age, body mass index, membrane rupture to delivery interval, and length of surgery were recorded. Risk factors were identified using simple and multiple logistic regression.

RESULTS

Body mass index was significantly associated with SSI (odds ratio, 1.17; 95% confidence interval, 1.11 to 1.24; P < .001). Further, substantive nonsignificant associations were recorded between SSI and patient age and vaginal swab status.

CONCLUSIONS

Body mass index was the only significant risk factor for the development of an SSI after emergency CS, possibly because of the impact of excessive adipose tissue on the immune system and reduced effectiveness of antibiotics. Diabetes status, patient age, and preoperative vaginal swab status were not significantly associated with SSI. Improved guidelines and strategies for managing at-risk patients would enable clinicians to reduce the risk of SSI development. The importance of wound management including frequent wound cleaning, appropriate dressings, dressing changes, and education is highlighted. Future research on larger samples should be conducted to validate these findings.

Cost of septic and aseptic revision total knee arthroplasty: a systematic review

BACKGROUND

The increasing incidence of primary total knee arthroplasty (TKA) has led to an increase in both the incidence and the cost burden of revision TKA procedures. This study aimed to review the literature on the cost of revision TKA for septic and aseptic causes and to identify the major cost components contributing to the cost burden.

METHODS

We searched MEDLINE (OvidSp), Embase, Web of Science, Cochrane Library, EconLit, and Google Scholar to identify relevant studies. Selection, data extraction and assessment of the risk of bias and cost transparency within the studies were conducted by two independent reviewers, after which the cost data were analysed narratively for 1- or 2-stage septic revision without re-revision; 2-stage septic revision with re-revision; and aseptic revision with and without re-revision, respectively. The major cost components identified in the respective studies were also reported.

RESULTS

The direct medical cost from the healthcare provider perspective for high-income countries for 2-stage septic revision with re-revision ranged from US$66,629 to US$81,938, which can be about 2.5 times the cost of 1- or 2-stage septic revision without re-revision, (range: US$24,027 - US$38,109), which can be about double the cost of aseptic revision without re-revision (range: US$13,910 - US$29,213). The major cost components were the perioperative cost (33%), prosthesis cost (28%), and hospital ward stay cost (22%).

CONCLUSIONS

Septic TKA revision with re-revision for periprosthetic joint infection (PJI) increases the cost burden of revision TKA by 4 times when compared to aseptic single-stage revision and by 2.5 times when compared to septic TKA revision that does not undergo re-revision. Cost reductions can be achieved by reducing the number of primary TKA that develop PJI, avoidance of re-revisions for PJI, and reduction in the length of stay after revision.

TRIAL REGISTRATION

PROSPERO; CRD42020171988 .

Incidence and root causes of surgical site infections after gastrointestinal surgery at a public teaching hospital in Sudan

Background

Surgical site infections (SSIs) are common healthcare-associated infections and associated with prolonged hospital stays, additional financial burden, and significantly hamper the potential benefits of surgical interventions. Causes of SSIs are multi-factorials and patients undergoing gastrointestinal tract procedures carry a high risk of bacterial contamination. This study aimed to determine the prevalence, associated factors, and causing microorganisms of SSIs among patients undergoing gastrointestinal tract surgeries.

Methods

A hospital based, cross-sectional study conducted at Soba University Hospital in Khartoum, Sudan. We included all patients from all age groups attending the gastrointestinal tract surgical unit between 1st September and 31st December 2017. We collected data about the socio-demographic characteristics, risk factors of SSI, and isolated microorganisms from patients with SSIs. A Chi-square test was conducted to determine the relationship between the independent categorical variables and the occurrence of SSI. The significance level for all analyses was set at p < .05.

Results

A total of 80 participants were included in the study. The mean age was 51 +/- 16 years and most of the patients (67.5%) did not have any chronic illness prior to the surgical operation. Most of them (46.3%) of them underwent large bowel surgery. Twenty-two patients (27.5%) developed SSI post operatively and superficial SSI was the most common type of SSIs (81.8%). Occurrence of SSI was found to be associated with long operation time (p > .001), malignant nature of the disease (p > .001), intra-operative blood loss (p > .001), and intra-operative hypotension (p = .013). The most prevalent microorganism isolated from SSI patients was E coli (47.8%), followed by Enterococcus fecalis (13.0%) and combined Pseudomonas aeruginosa + E coli infection (13.0%).

Conclusions

The results showed a high prevalence of SSIs among patients attending the gastrointestinal tract surgical unit and the most prevalent microorganism isolated from them was E coli. Measures should be taken to reduce the magnitude of SSI by mitigating the identified associated factors.

The Relationship Between Serum 25[OH]D Concentration and Orthopaedic Infection: A Case-Control Study

Background

An estimated one in two healthy adults in the United Kingdom suffer from low levels of 25[OH]D. Vitamin D is involved in modulating immune response, but there is less clarity over its role in orthopaedic infection. This study assesses the relationship between serum 25[OH]D concentration and orthopaedic infection.

Methods

A total of 205 patients in a tertiary referral centre for orthopaedic infection were included in the study. They were divided into groups based on their infection status, matched by age and gender. Data were statistically analysed to determine presence and direction of relationship.

Results

A total of 114 patients had an infection. There was no statistically significant difference in age or gender between the two groups. Mean serum 25[OH]D concentration was 39 nmol/L in the group with infection and 59 nmol/L in the group without an infection (p<0.01). Overall mean serum 25[OH]D concentration was 48 nmol/L. There was a correlation between low serum 25[OH]D concentration and rate of infection (odds ratio, 5.94; 95% confidence interval [CI], 3.24 to 10.92) with a bivariate correlation of −0.338 (p<0.01).

Conclusion

This study demonstrates an association between low levels of serum 25[OH]D and increased orthopaedic infection. Orthopaedic inpatients suffered from vitamin D insufficiency, and there was a correlation between higher levels of serum 25[OH]D and lower rates of infection. This suggests that prophylactic supplementation of 25[OH]D may improve outcomes, and provides a foundation for randomized controlled trials to assess its effectiveness in practice.

The current scope of healthcare-associated infection surveillance activities in hospitalized immunocompromised patients: a systematic review

BACKGROUND

Immunocompromised patients are at increased risk of acquiring healthcare-associated infections (HAIs) and often require specialized models of care. Surveillance of HAIs is essential for effective infection-prevention programmes. However, little is known regarding standardized or specific surveillance methods currently employed for high-risk hospitalized patients.

METHODS

A systematic review adopting a narrative synthesis approach of published material between 1 January 2000 and 31 March 2018 was conducted. Publications describing the application of traditional and/or electronic surveillance of HAIs in immunocompromised patient settings were identified from the Ovid MEDLINE®, Ovid Embase® and Elsevier Scopus® search engines [PROSPERO international prospective register of systematic reviews (registration ID: CRD42018093651)].

RESULTS

In total, 2708 studies were screened, of whom 17 fulfilled inclusion criteria. Inpatients diagnosed with haematological malignancies were the most-represented immunosuppressed population. The majority of studies described manual HAI surveillance utilizing internationally accepted definitions for infection. Chart review of diagnostic and pathology reports was most commonly employed for case ascertainment. Data linkage of disparate datasets was performed in two studies. The most frequently monitored infections were bloodstream infections and invasive fungal disease. No surveillance programmes applied risk adjustment for reporting surveillance outcomes.

CONCLUSIONS

Targeted, tailored monitoring of HAIs in high-risk immunocompromised settings is infrequently reported in current hospital surveillance programmes. Standardized surveillance frameworks, including risk adjustment and timely data dissemination, are required to adequately support infection-prevention programmes in these populations.

Surgical Site Infection after Digestive Surgery: Diagnosis and Treatment in a Context of Limited Resources

Background: Surgical site infections (SSIs) are responsible for substantial morbidity in patients who undergo digestive surgery. However, very little is known about the aspects of SSIs in sub-Saharan Africa. Methods: The purpose of this study was to assess the prevalence and identify the risk factors of SSI in patients who were treated in the Department of Digestive Surgery of Tenkodogo Hospital in Burkina Faso. We performed a prospective study from January 1, 2016 to December 31, 2016. All patients who underwent digestive tract surgery during this period were included and followed. Patients whose post-operative surgical sites were complicated by infection were identified. Surgical site infection was diagnosed according to the U.S. Centers for Disease Control and Prevention (CDC) definition. Bacteriologic sampling was performed in all included patients. Results: A total 964 patients underwent surgery during the study period and were included in the study. Seven hundred thirty-seven were females (76.4%), and 227 were males. The mean age of the included patients was 47.5 years (standard deviation [SD] = 9 years). One hundred fourteen patients presented with SSI, the incidence of which was 11.8%. The incidence of SSI was substantially higher in females than in males (63.2 vs. 36.8%, p < 0.05). The incidence was also higher in patients living below the poverty line (71.1 vs. 28.9%, p < 0.05). Clinically, the incidence of SSI was higher in emergency surgery than in scheduled surgery (84.2 vs. 15.8%, p < 0.05). Contaminated or dirty surgery was more risky than clean surgery (p < 0.05). With respect to bacteria, the most commonly isolated microbes were Escherichia coli (66.7%) and Staphylococcus aureus (15%). Treatment mainly consisted of appropriate antibiotic therapy and local care. Three deaths were recorded for a mortality rate of 2.6%. Conclusions: Surgical site infections are frequent in sub-Saharan environments. The risk factors seem to be clinical and social.

How do surgeons feel about the 'Getting it Right First Time' national audit? Results from a qualitative assessment

The implementation of the national 'Getting It Right First Time' was assessed by interviewing six surgeons involved at various levels in surgical site infection (SSI) audit. The positive impacts were to create new professional collaboration, improve stakeholder engagement, and increase the profile of SSIs. One particular knowledge gap highlighted was that some participants had been unaware until that point of the criteria for diagnosing an SSI. The quality of data collected was felt to be poor due to methodological flaws. The audit was described as highly time-consuming and unsustainable if leaning on junior surgeons, without protected time and designated responsibility.

Understanding determinants of infection control practices in surgery: the role of shared ownership and team hierarchy

Background

Despite a large literature on surgical site infection (SSI), the determinants of prevention behaviours in surgery remain poorly studied. Understanding key social and contextual components of surgical staff behaviour may help to design and implement infection control (IC) improvement interventions in surgery.

Methods

Qualitative semi-structured interviews were conducted with surgeons (n = 8), nurses (n = 5) theatre personnel (n = 3), and other healthcare professionals involved in surgery (n = 4) in a 1500-bed acute care London hospital group. Participants were approached through established mailing lists and snowball sampling. Interviews were recorded and transcribed verbatim. Transcripts were coded and analysed thematically using a constant comparative approach.

Results

IC behaviour of surgical staff was governed by factors at individual, team, and wider hospital level. IC practices were linked to the perceived risk of harm caused by an SSI more than the development of an SSI alone. Many operating room participants saw SSI prevention as a team responsibility. The sense of ownership over SSI occurence was closely tied to how preventable staff perceived infections to be, with differences observed between clean and contaminated surgery. However, senior surgeons claimed personal accountability for rates despite feeling SSIs are often not preventable. Hierarchy impacted on behaviour in different ways depending on whether it was within or between professional categories. One particular knowledge gap highlighted was the lack of awareness regarding criteria for SSI diagnosis.

Conclusions

To influence IC behaviours in surgery, interventions need to consider the social team structure and shared ownership of the clinical outcome in order to increase the awareness in specialties where SSIs are not seen as serious complications.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0565-8) contains supplementary material, which is available to authorized users.

A compilation of antimicrobial susceptibility data from a network of 13 Lebanese hospitals reflecting the national situation during 2015-2016

Background

There is a lack of official national antimicrobial resistance (AMR) data in Lebanon. Individual hospitals generate their own antibiotic susceptibility data in the form of yearly pamphlets.

Methods

In this study, antibiotic susceptibility data from 13 hospitals distributed across different governorates of Lebanon were collected to conduct a compilation-based surveillance of AMR in Lebanon for the years 2015-2016. The findings were compared with those of a previous nationwide study in this country conducted between 2011 and 2013 as well as with similar data obtained from the 2015 and 2016 European surveillance reports of AMR. To provide a clear presentation of the AMR situation, mean percent susceptibility of different antibiotic-microbe combinations was calculated.

Results

During 2015-2016, the percent susceptibility of Enterobacteriaceae to third-generation cephalosporins and to carbapenems was 59 and 97%, respectively. Among Pseudomonas aeruginosa and Acinetobacter spp., carbapenem susceptibility reached 70 and 12%, respectively. Among Gram positive organisms, the percent susceptibility to methicillin in Staphylococcus aureus was 72%, that to vancomycin in Enterococcus spp. was 98% and that to penicillin in Streptococcus pneumoniae was 75%. Compared with results of 2011-2013, there was an overall trend of decreased susceptibility of bacteria to the tested antibiotics, with a variation of 5 to 10%. The antibiotic susceptibility data from Lebanon were found to be comparable with those from Eastern and South-eastern European countries.

Conclusion

This study highlights the need to establish a robust national AMR surveillance system that enables data from Lebanon to be included in global AMR maps.