Influence of surgeons' experience on postoperative sepsis

[Study of early relaparotomies at the University Hospitals of Lubumbashi: epidemiological clinical and therapeutic features]

Les relaparotomies précoces pour péritonite post opératoire (PPO) sont des urgences chirurgicales de pronostic grave. L'objectif de la présente étude est de décrire le profil épidémiologique, clinique et thérapeutique des relaparatomisés précoces soignés dans les hôpitaux universitaires de LUBUMBASHI. Il s'agit d'une étude descriptive transversale réalisée dans deux hôpitaux du district sanitaire du haut KATANGA; à savoir les cliniques Universitaires(CUL) et l'hôpital général de référence JASON SENDWE (HGR JS). Cette étude a porté sur 56 patients réopérés à l'abdomen 68 fois du 01/Janvier/2012 au 31/Décembre/2013. Ont été inclus, les dossiers des patients réopérés d'abdomen précoce deux fois de suite au moins, de sexe confondu, âgés de 07 jours à 83 ans qui ont été réopérés de l'abdomen. Les données épidémiologiques, cliniques, thérapeutiques et les suites opératoires ont été recueillies puis saisies et analysées grâce au logiciel Epi info 2011. Au cours de cette étude 304 patients avaient subi une laparotomie dont 248 avaient évolué normalement; 56 patients par contre avaient été relaparatomisés 68 fois (38 hommes et 18 femmes). L'âge moyen était de 34,6±19 ans. Le séjour moyen d'hospitalisation était de 56,26 ± 51,82 jours. Les comorbidités associées ont été l'hypertension artérielle, le cancer et le mauvais état général d'avant la laparotomie classifié ASA 3 et 4 avec respectivement 34,62% (n = 9); 26,92% (n = 7) et 41,38% (n = 12). Les malaises généraux, la circonférence abdominale avec augmentation de plus de 2 cm par jour au niveau de l'ombilic ainsi que la douleur abdominale diffuse et provoquée ont été retrouvées respectivement dans 94,64% (n = 53), 98,21% (n = 55) et 83,93% (n = 47) des cas. Pour laparotomie initiale 51 (91,07%) patients étaient opérés en urgences. Les infections associées avaient constitué l'indication principale de réintervention avec 55,36% des cas (n = 31). La laparotomie initiale été conduit par un chirurgien non qualifié dans 60,71% des cas (n = 34). Douze patients réopérés sont décédés soit un taux de létalité de 17,65%. Les relaparotomies précoces pour PPO sont couramment pratiquées dans les hôpitaux universitaires du HAUT KATANGA. Le retard dans le diagnostic aggrave le prognostic.

Surgical Site Infection (SSI) Rates Among Patients Who Underwent Mastectomy After the Introduction of SSI Prevention Policies

Objective.

To describe the results of an intervention program to reduce the rate of surgical site infection (SSI) in the breast tumor department of a referral teaching hospital for patients with cancer.

Methods.

Preventive measures introduced in the Breast Tumor Department of the study hospital included the following: starting in July 2000, use of sterile technique for wound care; starting in 2001, use of closed antireflux silicone evacuation systems, use of perioperative antimicrobial prophylaxis, provision of feedback to surgeons, and remodeling of the ambulatory wound care clinic. We conducted surveillance of all patients who underwent mastectomy between February 1 and December 31, 2001, and the SSI rate was calculated. A case-control analysis was performed for risk factors known to be associated with SSI. Results were compared with the data from 2000.

Results.

The study included data on 385 surgeries. SSIs were registered in 52 (13.7%) of these 385, which was a rate 58.6% less than the 2000 infection rate (33.1%). Risk factors associated with SSI included concomitant chemotherapy and radiation therapy (OR, 3.6 [95% confidence interval {CI}, 1.9-7.1]), surgery performed during an evening shift (OR, 1.9 [95% CI, 1.1-3.6]), and insertion of a second drainage tube during the late postoperative period (OR, 2.8 [95% CI, 1.4-5.7]). The mean number (± SD) of postoperative visits to the outpatient wound care clinic was reduced from 11.6 ± 7.1 in 2000 to 9.2 ± 4.4 in 2001 (P< .001, Student's t test). The mean number of days that the evacuation systems were used was reduced from 19.0 to 16.0 days (P =.001, Student's t test).

Conclusions.

Continuous wound surveillance, along with feedback to surgeons, use of closed antireflux evacuation systems, and standardized practices in wound and drainage-tube care, decreased by 58.6% the rate of SSI in a breast surgical department with high rates of infection.

Surgical Site Infection following Cesarean Delivery: Patient, Provider, and Procedure-Specific Risk Factors

OBJECTIVE

This study aims to identify risk factors for cesarean delivery (CD) surgical site infection (SSI). study design: Retrospective analysis of 2,739 CDs performed at the University of Pittsburgh in 2011. CD SSIs were defined using National Healthcare Safety Network (NHSN) criteria. Chi-square test and t-test were used for bivariate analyses and multivariate logistic regression was used to identify SSI risk factors.

RESULTS

Of 2,739 CDs, 178 (6.5%) were complicated by SSI. Patients with a SSI were more likely to have Medicaid, have resident physicians perform the CD, an American Society of Anesthesiologists (ASA) class of ≥ 3, chorioamnionitis, tobacco use, and labor before CD. In multivariable analysis, labor (odds ratio [OR], 2.35; 95% confidence interval [95% CI], 1.65-3.38), chorioamnionitis (OR, 2.24; 95% CI, 1.25-3.83), resident teaching service (OR, 2.15; 95% CI, 1.54-3.00), tobacco use (OR, 1.70; 95% CI, 1.04-2.70), ASA class ≥ 3 (OR, 1.61; 95% CI, 1.06-2.39), and CDs performed for nonreassuring fetal status (OR, 0.43; 95% CI, 0.26-0.67) were significantly associated with CD SSI.

CONCLUSION

Multiple patient, provider, and procedure-specific risk factors contribute to CD SSI risk which may be targeted in infection-control efforts.

Risk Factors for Surgical Site Infection After Low Transverse Cesarean Section

Background.

Independent risk factors for surgical site infection (SSI) after cesarean section have not been well documented, despite the large number of cesarean sections performed and the relatively common occurrence of SSI.

Objective.

To determine independent risk factors for SSI after low transverse cesarean section.

Design.

Retrospective case-control study.

Setting.

Barnes-Jewish Hospital, a 1,250-bed tertiary care hospital.

Patients.

A total of 1,605 women who underwent low transverse cesarean section during the period from July 1999 to June 2001.

Methods.

Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for SSI or wound complication and/or data on antibiotic use during the surgical hospitalization or at readmission to the hospital or emergency department, we identified potential cases of SSI in a cohort of patients who underwent a low transverse cesarean section. Cases of SSI were verified by chart review using the definitions from the Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System. Control patients without SSI or endomyometritis were randomly selected from the population of patients who underwent cesarean section. Independent risk factors for SSI were determined by logistic regression.

Results.

SSIs were identified in 81 (5.0%) of 1,605 women who underwent low transverse cesarean section. Independent risk factors for SSI included development of subcutaneous hematoma after the procedure (adjusted odds ratio [aOR], 11.6 [95% confidence interval {CI}, 4.1–33.2]), operation performed by the university teaching service (aOR, 2.7 [95% CI, 1.4–5.2]), and a higher body mass index at admission (aOR, 1.1 [95% CI, 1.0–1.1]). Cephalosporin therapy before or after the operation was associated with a significantly lower risk of SSI (aOR, 0.2 [95% CI, 0.1–0.5]). Use of staples for skin closure was associated with a marginally increased risk of SSI.

Conclusions.

These independent risk factors should be incorporated into approaches for the prevention and surveillance of SSI after surgery.

Epidemiology, management, and prognosis of secondary non-postoperative peritonitis: a French prospective observational multicenter study

BACKGROUND

Despite improvements in treatment, secondary peritonitis still is associated with high morbidity and mortality rates. Better knowledge of real-life clinical practice might improve management.

METHODS

Prospective, observational study (January-June 2005) of 841 patients with non-postoperative secondary peritonitis.

RESULTS

Peritonitis originated in the colon (32% of patients), appendix (31%), stomach/duodenum (18%), small bowel (13%), or biliary tract (6%). Most patients (78%) presented with generalized peritonitis and 26% with severe peritonitis (Simplified Acute Physiology Score [SAPS] II score>38). Among the 841 patients, 27.3% underwent laparoscopy alone; 11% underwent repeat surgery, percutaneous drainage, or both. A SAPS II score>38 and the presence of Enterococcus spp. were predictive of abdominal and non-surgical infections (odds ratio [OR]=1.84; p=0.013 and OR=2.93; p<0.0001, respectively). A SAPS II score>38 also was predictive of death (OR=10.5; p<0.0001). The overall mortality rate was high (15%). Patients receiving inappropriate initial antimicrobial therapy had significantly higher morbidity and mortality rates than patients receiving appropriate therapy (44 vs. 30%; p=0.004 and 23% vs. 14%; p=0.015, respectively). The SAPS II score and rates of severe peritonitis, morbidity, and mortality were significantly lower in patients with appendiceal peritonitis.

CONCLUSIONS

Patients with non-postoperative peritonitis should be considered high risk and should receive appropriate initial therapy. The presence of Enterococcus spp. in peritoneal cultures significantly increased morbidity but not the mortality rate. Appendiceal peritonitis that was less severe and had a better prognosis than peritonitis originating in other sites should be considered a special case in future studies.

Is there a current role for preoperative non-absorbable oral antimicrobial agents for prophylaxis of infection after colorectal surgery?

BACKGROUND

In numerous scientific studies, oral antibiotic bowel preparation has reduced surgical site infections in patients undergoing colorectal surgery. The historical evolution of antibiotic bowel preparation is presented with a review of the scientific basis of its effectiveness.

METHODS

Review of the pertinent English language literature.

RESULTS

Successful oral antibiotic bowel preparation requires effective mechanical preparation. The progressive shift of preoperative preparation to the outpatient setting has led to a reduction in the use of oral antibiotics. Such preparation, however, continues to be effective although in current surgical practice is often augmented with perioperative, parenteral antimicrobials.

CONCLUSION

Oral antibiotic bowel preparation has a role in the prevention of surgical site infection in the patient undergoing colorectal surgery.

Surgical site infection (SSI) rates among patients who underwent mastectomy after the introduction of SSI prevention policies

OBJECTIVE

To describe the results of an intervention program to reduce the rate of surgical site infection (SSI) in the breast tumor department of a referral teaching hospital for patients with cancer.

METHODS

Preventive measures introduced in the Breast Tumor Department of the study hospital included the following: starting in July 2000, use of sterile technique for wound care; starting in 2001, use of closed antireflux silicone evacuation systems, use of perioperative antimicrobial prophylaxis, provision of feedback to surgeons, and remodeling of the ambulatory wound care clinic. We conducted surveillance of all patients who underwent mastectomy between February 1 and December 31, 2001, and the SSI rate was calculated. A case-control analysis was performed for risk factors known to be associated with SSI. Results were compared with the data from 2000.

RESULTS

The study included data on 385 surgeries. SSIs were registered in 52 (13.7%) of these 385, which was a rate 58.6% less than the 2000 infection rate (33.1%). Risk factors associated with SSI included concomitant chemotherapy and radiation therapy (OR, 3.6 [95% confidence interval {CI}, 1.9-7.1]), surgery performed during an evening shift (OR, 1.9 [95% CI, 1.1-3.6]), and insertion of a second drainage tube during the late postoperative period (OR, 2.8 [95% CI, 1.4-5.7]). The mean number (+/- SD) of postoperative visits to the outpatient wound care clinic was reduced from 11.6+/-7.1 in 2000 to 9.2+/-4.4 in 2001 (P<.001, Student's t test). The mean number of days that the evacuation systems were used was reduced from 19.0 to 16.0 days (P=.001, Student's t test).

CONCLUSIONS

Continuous wound surveillance, along with feedback to surgeons, use of closed antireflux evacuation systems, and standardized practices in wound and drainage-tube care, decreased by 58.6% the rate of SSI in a breast surgical department with high rates of infection.

Hospital-related determinants for surgical-site infection following hip arthroplasty

OBJECTIVE

To determine hospital-related risk factors for surgical-site infection (SSI) following hip arthroplasty.

DESIGN

Prospective, multicenter cohort study based on surveillance data and data collected through a structured telephone interview. With the use of multilevel logistic regression, the independent effect of hospital-related characteristics on SSI was assessed.

SETTING

Thirty-six acute care hospitals in the Dutch surveillance network for nosocomial infections (PREZIES), from 1996 to 2000.

PATIENTS

Thirteen thousand six hundred eighty patients who underwent total or partial hip arthroplasty.

RESULTS

A high annual volume of operations was associated with a reduced risk of SSI (risk-adjusted risk ratio [RR] per 50 extra operations, 0.85; 95% confidence interval [CI95], 0.74-0.97). With each extra full-time-equivalent infection control staff member per 250 beds available for prevention of SSI, the risk for SSI was decreased (RR, 0.48; CI95, 0.16-1.44), although the decrease was not statistically significant. Hospital size, teaching status, university affiliation, and number of surgeons and their years of experience showed no important association with the risk of SSI.

CONCLUSION

Undergoing surgery in a hospital with a low volume of operations increases a patient's risk of SSI.

Prophylaxis of Infection for Elective Colorectal Surgery

BACKGROUND

Influenced by the key results of the clinical trials conducted in the early 1970s by Condon, Nichols, and Gorbach, surgeons have adopted the routine use of mechanical bowel prep and antimicrobial prophylaxis prior to elective colorectal procedures as a widely established practice. Recent clinical trial data, however, led us to reexamine the benefits of mechanical bowel preparation, methods of antimicrobial prophylaxis and to assess the role of new, specific risk factors for surgical site infection after colorectal operations.

METHODS

Pertinent studies on antimicrobial prophylaxis for elective colorectal surgery were identified from a Medline search of English language publications since 1966.

RESULTS

We found credible clinical trial data that mechanical bowel preparation prior to elective colorectal surgery may not be essential. Timing of the administration of prophylactic antimicrobials is often inaccurate in current practice and suggests the need for a long-acting, broad-spectrum agent that would deemphasize precision in time of preoperative infusion. New risk factors have been identified that increase infection after colorectal surgery, including patient core temperature and tissue oxygenation. Independent observers identify postoperative surgical site infection at a higher rate than physician self-reporting and should be incorporated into future clinical trials.

CONCLUSION

The once settled area of antimicrobial prophylaxis for colorectal surgery is again controversial. Cooperative clinical trials will be needed to resolve key questions such as the efficacy for bowel preparation and how to obtain effective timing of antimicrobial prophylaxis.

Pathophysiology of infection--a theoretical approach

The manifestation of postoperative wound infection has a tri-factorial basis: the overall systemic trauma and the additional effects of premorbidity (age, diabetes, etc.), the local host damage resulting from both the accident and surgery, and the bacterial contamination of the wound. The first factor is only moderately open to intervention, however, the amount of local host damage caused during the operation can be influenced directly by the surgeon who must ensure that his operating techniques are non-aggressive and in line with current knowledge. The factor of the intraoperative bacterial inoculum can be modified by attention to hygiene. The latter two factors are in direct relation to the following two hypotheses: Every wound is able to tolerate some local host damage and some bacterial inoculum without manifestation of infection. The bacterial wound flora is the product of the bacterial invasion force and the local wound conditions. The bacterial wound flora and the local condition of the wound are interrelated. If either factor exceeds the tolerable threshold, infection will become manifest, i.e. there will be an uncontrollable proliferation of bacteria. The level of this breaking point may depend upon certain systemic host factors such as age, diabetes, or immunodeficiency. Consequently, the prevention of infection must focus simultaneously on minimizing the local bacterial inoculum and optimizing local wound conditions. Future studies should concentrate on identifying the exact nature of the individual factors promoting infection, their quantification, and their relative importance.