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Bielicki I, Subotic U, Bielicki JA. Systematic literature review on surgical site preparation in paediatric surgery. BMC Pediatr 2022; 22:455. [PMID: 35902844 PMCID: PMC9336073 DOI: 10.1186/s12887-022-03502-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/14/2022] [Indexed: 12/04/2022] Open
Abstract
Background Surgical site infections (SSIs) in children represent a common and serious postoperative complication. Surgical skin preparation is an essential preventive measure in every surgical procedure. The most commonly used antiseptic agents for surgical skin preparation are chlorhexidine gluconate and iodophors in alcohol-based solutions. In adult patients the use of chlorhexidine-containing antiseptic solutions for preoperative skin preparation has been advocated to reduce SSI rates. Our objective was to conduct a systematic literature review on use of antiseptic agents for surgical skin preparation in children less than 16 years of age. Methods A systematic review of MEDLINE, EMBASE, CINAHL and CENTRAL was performed using both MeSH and free text terms and using the relevant Cochrane filter to identify full text randomized trials (RCTs) and comparative observational studies. Interventions of interest were the choice of main agent in antiseptic solutions (chlorhexidine/povidone-iodine/alcohol) compared with each other or with other antiseptic agents. Primary outcome was the reported rate of surgical site infections. Results In total 8 studies were included in the review; 2 RCTs and 6 observational studies. Observational studies generally did not primarily investigate the association of different antiseptics with subsequent SSI. The identified randomised controlled trials included only 61 children in total, and were of low quality. Consequently, we did not conduct a formal meta-analysis. Since the publication of a comprehensive systematic review of perioperative measures for the prevention of SSI in 2016, no randomized controlled trials comparing antiseptic agents for surgical skin preparation in paediatric surgery have been conducted. Conclusion Robust evidence on the optimal skin antisepsis to reduce SSIs in children is lacking. Direct extrapolation of effects from trials involving adults is not appropriate as physiologic characteristics and risk factors for SSIs differ between adults and children. It is therefore essential to conduct high quality RCT investigating interventions to identify optimal measures to reduce SSI rates in children. Trial registration Prospero registration (CRD42020166193). Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03502-z.
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Affiliation(s)
- Isabella Bielicki
- Department of Paediatric Surgery, University Children's Hospital Basel, Spitalstr. 33, 4056, Basel, Switzerland.
| | - Ulrike Subotic
- Department of Paediatric Surgery, University Children's Hospital Basel, Basel, Switzerland
| | - Julia Anna Bielicki
- Division of Infectious Diseases and Hospital Epidemiology, Paediatric Pharmacology Group, University Hospital Basel, Basel, Switzerland University of Basel Children's Hospital, Basel, Switzerland National Centre for Infection Prevention, SwissNoso, Bern, Switzerland
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Sheikh S, Majoka R, Tripathi CD, Verma V, Bagga D, Karim BA, Meshram GG. Variability in the serum and tissue concentrations of pre-incisional ceftriaxone for surgery in paediatric population and outcome of surgical-site infections; An open labelled, prospective, non-randomized, analytical study. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2022; 3:100082. [PMID: 35146418 PMCID: PMC8816661 DOI: 10.1016/j.crphar.2022.100082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/24/2021] [Accepted: 01/10/2022] [Indexed: 12/19/2022] Open
Abstract
Studies have determined the serum concentration of ceftriaxone in the adult population, but there are only a few studies that measured the tissue concentrations. However, no studies have concurrently evaluated the serum and tissue concentrations of ceftrixaone in elective pediatric surgery patients. Therefore, our study was planned to evaluate the serum and tissue concentrations of single dose intravenous prophylactic ceftriaxone intra-operatively during an ongoing pediatric surgery and the outcome of surgical-site infections (SSIs). We did a correlation analysis to determine the relationship of various concentrations and surgery related risk factors with the outcome of SSIs. It was an open label prospective study in 50 patients who underwent elective pediatric surgery under prophylactic cover of ceftriaxone. Serum and tissue concentration were estimated by High Pressure Liquid Chromatography (HPLC). Subjects were observed for post operative complications including SSI. Serum and tissue concentrations of ceftriaxone were significant at test value of 4 mg/L. Tissue concentrations of ceftriaxone at incision (p = 0.02) and closure (p = 0.04) were significantly correlated with SSI but there was no significant association. The measured serum ceftriaxone concentrations were more than 20 times the susceptible minimum inhibitory concentration (MIC) at any given point of the surgery. On the other hand, this target level was achieved at the tissue levels in the majority of the patient. The factors associated with SSI were duration of surgery, wound category of contaminated clean type, the use of urinary catheter and implants in the surgery. An intra-operative re-dose, extension of dose or addition of another antibiotic may be considered for such patients. Currently, no standard guidelines are available for the pre-operative prophylactic antibiotic use in pediatric surgery. This study addresses the issue about antibiotic dose and frequency in context of elective pediatric surgery patients. The tissue concentration of ceftriaxone at incision and at closure of surgery are important predictors for SSI. For optimizing the antibiotic use and re-dosing in SSI prophylaxis, tissue concentration of the antibiotic should be preferred over the plasma concentrations.
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Affiliation(s)
- Salim Sheikh
- Department of Pharmacology, Employees' State Insurance Corporation Medical College & Hospital, Faridabad, India
- Department of Pharmacology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Ravinder Majoka
- Department of Pharmacology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Chakra Dhar Tripathi
- Department of Pharmacology, Employees' State Insurance Corporation Medical College & Hospital, Faridabad, India
- Department of Pharmacology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Veena Verma
- Department of Pharmacology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Deepak Bagga
- Department of Pediatrics Surgery, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Bushra Ahmed Karim
- Associate Professor, Department of Public Health Dentistry, Jamia Millia Islamia, New Delhi, India
- Corresponding author.
| | - Girish Gulab Meshram
- Department of Pharmacology, Employees' State Insurance Corporation Medical College & Hospital, Faridabad, India
- Department of Pharmacology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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Almogbel GT, Altokhais TI, Alhothali A, Aljasser AS, Al-Qahtani KM, Arab SF, Alsweirki HMH, Albassam A. Risk Factors for Surgical Site Infections in Pediatric General Surgery: A Case–Control Study. J PEDIAT INF DIS-GER 2021. [DOI: 10.1055/s-0041-1726469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abstract
Objective Despite being the most common postoperative complication and having associated morbidity and mortality that increase health care costs, surgical site infection (SSI) has not received adequate attention and deserves further study. Previous reports in children were limited to SSI in certain populations. We conducted this retrospective case–control study to determine the incidence and possible risk factors for SSI following pediatric general surgical procedures.
Methods This was a retrospective case–control matched cohort study of all patients aged 0 to 14 years who underwent pediatric general surgical procedures between June 2015 and July 2018. The electronic medical records were searched for a diagnosis of SSI. Control subjects were randomly selected at a 4:1 ratio from patients who underwent identical procedures. Multiple risk factors were evaluated by bivariate analysis and multivariable conditional logistic regression.
Results A total of 1,520 patients underwent a general pediatric procedure during the study period, and of these, 47 (3.09%) developed SSIs. A bivariate analysis showed that patients with SSIs were younger, were admitted to the neonatal intensive care unit/pediatric intensive care unit (NICU/PICU) preoperatively, were more severely ill as measured by the ASA classification, underwent multiple procedures, had more surgical complications, and were transferred to the NICU/PICU postoperatively. A multivariate analysis identified four independent predictors of SSI: age, preoperative NICU/PICU admission, number of procedures, and ASA classification.
Conclusion Younger children with preoperative admission to the NICU/PICU, those who underwent multiple procedures and those who were severely ill as measured by their ASA classification were significantly more likely to develop SSIs.
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Affiliation(s)
- Gassan T. Almogbel
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Tariq I. Altokhais
- Division of Pediatric Surgery, Department of Surgery, King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alhothali
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Sami Aljasser
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid M. Al-Qahtani
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sadiq F. Arab
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Helmi M. H. Alsweirki
- King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Albassam
- Division of Pediatric Surgery, Department of Surgery, King Saud University Medical City & College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Lewis SL, Johnson JJ, Bergner EM, Miller JL, Bruster C'N, Atchley CB, Ernst KD. Infant Essential Fatty Acid Status Is Not Associated With Postoperative Wound Complication Severity. J Surg Res 2020; 258:435-442. [PMID: 33317758 DOI: 10.1016/j.jss.2020.08.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neonates are susceptible to postoperative wound complications (POWCs), as prematurity, hypoxia, steroid use, immunosuppression, and malnutrition are all common comorbidities. Critically ill infants, dependent on parenteral nutrition, are at even further risk of developing essential fatty acid deficiency (EFAD). We hypothesized that POWC severity and EFAD were associated because of increased susceptibility to infections and impaired wound healing seen with EFAD. METHODS Institutional review board-approved (OUHSC10554), retrospective review from our academic Level IV Neonatal Intensive Care Unit. Infants aged <1 y who underwent a fascial-compromising gastrointestinal surgery from June 1, 2015, to March 15, 2019, and who had essential fatty acids (EFAs) measured ±2 wk from surgery were included. Three blinded investigators independently categorized POWC using the World Union of Wound Healing Society Surgical Wound Grading System. Infants were categorized into three groups: no POWC, POWC Grades 1 and 2 (superficial tissue nonintegrity), and POWC Grades 3 and 4 (deep tissue nonintegrity and complete dehiscence). EFA status and other possible POWC-associated factors were analyzed to determine any association with wound severity. RESULTS Fifty infants met the inclusion criteria. Half (25/50) had no POWC, 30% (15/50) had Grade 1 or 2, and 20% (10/50) had Grade 3 or 4. We found no association between EFAD and POWC severity. CONCLUSIONS In our cohort, EFA status did not predict POWC severity. At this time, we cannot suggest delaying elective surgical procedures to correct EFAD as an approach to preventing POWC.
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Affiliation(s)
- Samara L Lewis
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
| | - Jeremy J Johnson
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Erynn M Bergner
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Jamie L Miller
- Department of Pediatrics, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma
| | - Christina 'Nicole' Bruster
- Department of Pediatrics, The Children's Hospital at OU Medical Center, Wound-Ostomy Nursing, Oklahoma City, Oklahoma
| | - Courtney B Atchley
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Kimberly D Ernst
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Surgical site infection following elective nonspinal paediatric orthopaedic surgery: a prospective review. J Pediatr Orthop B 2019; 28:89-93. [PMID: 30252792 DOI: 10.1097/bpb.0000000000000549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study was to determine the rate of surgical site infection (SSI) and the factors that predispose to it in children undergoing nonspinal orthopaedic surgery. Over a 6-month period, 326 children who underwent 334 nonspinal elective orthopaedic surgical procedures were prospectively reviewed for the development of surgical site infections. A total of 14 sites became infected, with an overall infection rate of 4.19%. All the infections were superficial, and the only causative organism detected was Staphylococcus aureus. Operating times longer than 1 h and surgical wounds greater than 10 cm in length were positively associated with SSIs. Although there were differences between male and females, type of admission, the use of prophylactic antibiotics, degree of wound contamination and the grades of surgeons, these differences were not statistically significant. The results of this prospective study provide valuable information that was not previously available to the practicing paediatric orthopaedic surgeon.
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Ciofi Degli Atti M, Alegiani SS, Raschetti R, Arace P, Giusti A, Spiazzi R, Raponi M. A collaborative intervention to improve surgical antibiotic prophylaxis in children: results from a prospective multicenter study. Eur J Clin Pharmacol 2017; 73:1141-1147. [PMID: 28593400 DOI: 10.1007/s00228-017-2270-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/22/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE The use of surgical antibiotic prophylaxis (SAP) in children is poorly characterized. Our aim was to evaluate the effectiveness of a quality improvement (QI) intervention targeting SAP in children, by means of a multicenter prospective intervention study, with a before and after design. METHODS We prospectively investigated elective surgical procedures performed in children <18 years, prior to the QI intervention, after the intervention and at 9-month follow-up. The primary outcomes were adherence to SAP indications and SAP appropriateness, defined considering antibiotic choice, timing of first dose and duration of administration. We compared SAP adherence and appropriateness prior the QI intervention, to the post-intervention and the follow-up. We considered patient and procedure characteristics as covariates in two logistic regression models to assess the effect of the QI intervention on SAP adherence and appropriateness. RESULTS We collected information on 2383 procedures (pre-intervention: 784; post-intervention: 790; follow-up: 809). The QI intervention had a significant impact on the adherence to SAP indications (86.6% in the post-intervention, compared to 82.0% prior to the intervention; p < 0.05), and on its appropriateness (35.7% compared to 19.9%; p < 0.01). The impact of the intervention on SAP appropriateness was maintained at follow-up (38.3%; p < 0.01 compared to pre-intervention). All components of SAP appropriateness significantly improved after the intervention and at follow-up. The logistic regression analyses confirmed the effect of intervention in improving adherence to SAP indications and appropriateness. CONCLUSIONS Following the QI intervention, there was a significant improvement in quality of SAP in pediatric surgery, though more efforts are needed to increase SAP appropriateness.
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Affiliation(s)
- Marta Ciofi Degli Atti
- Clinical Epidemiology Unit, Medical Direction, Bambino Gesù Children's Hospital, Piazza Sant'Onofrio 4, 00165, Rome, Italy.
| | - Stefania Spila Alegiani
- National Centre for Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Viale Regina Elena 299, 00161, Rome, Italy
| | - Roberto Raschetti
- National Centre for Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Viale Regina Elena 299, 00161, Rome, Italy
| | - Pasquale Arace
- Medical Direction, Ospedale Santobono Pausilipon, Via Della Croce Rossa 8, 80122, Naples, Italy
| | - Angela Giusti
- National Centre for Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Viale Regina Elena 299, 00161, Rome, Italy
| | - Raffaele Spiazzi
- Medical Direction, Ospedale dei Bambini di Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Massimiliano Raponi
- Medical Direction, Bambino Gesù Children's Hospital, Piazza Sant'Onofrio 4, 00165, Rome, Italy
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Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study. Ann Surg 2015; 262:397-402. [PMID: 25243561 DOI: 10.1097/sla.0000000000000938] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. BACKGROUND Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. METHODS Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI. RESULTS Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18). CONCLUSIONS In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.
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Shah GS, Christensen RE, Wagner DS, Pearce BK, Sweeney J, Tait AR. Retrospective evaluation of antimicrobial prophylaxis in prevention of surgical site infection in the pediatric population. Paediatr Anaesth 2014; 24:994-8. [PMID: 24823901 DOI: 10.1111/pan.12436] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Few studies have been conducted in pediatric patients evaluating efficacy of prophylactic antibiotics for prevention of surgical site infection (SSI). This retrospective study was undertaken to determine the effect of antibiotic prophylaxis in the prevention of SSI in children. METHODS With IRB approval, our perioperative electronic clinical information database was queried. Pediatric patients (≤18 years) undergoing general surgery, cardiac surgery, and spinal surgery at Mott Children's Hospital from January 2000 to April 2010 were included. Demographics and preoperative data were obtained from the Centricity Intraoperative Database, and any episodes of SSI were obtained by review of the infection control records. RESULTS A total 5023 pediatric patients underwent surgery from January 2000 to April 2010. The average age of the children in the sample was 4.16 ± 5.5 years, and of these, 57% were boys. Overall, 119 (2.37%) cases of SSI were identified. There were no associations between the various patient factors and the development of SSIs. Children for whom antibiotics were administered incorrectly had a 1.7-fold increased risk of SSIs compared with children who received antibiotics within the recommended guidelines (P < 0.02). Children who received antibiotics were more likely to suffer an SSI compared with those who did not. CONCLUSIONS Proper administration of preoperative antibiotics in pediatric patients is one of the few modifiable and significant factors in prevention of SSI.
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Affiliation(s)
- Goonjan S Shah
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC, USA
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Vu LT, Vittinghoff E, Nobuhara KK, Farmer DL, Lee H. Surgical site infections in neonates and infants: is antibiotic prophylaxis needed for longer than 24 h? Pediatr Surg Int 2014; 30:587-92. [PMID: 24805114 DOI: 10.1007/s00383-014-3506-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose is to determine whether use of perioperative antibiotics for more than 24 h decreases the incidence of SSI in neonates and infants. METHODS We studied neonates and infants who had clean-contaminated or contaminated gastrointestinal operations from 1996 to 2006. Patient- and operation-related variables, duration of perioperative antibiotics, and SSI within 30 days were ascertained by retrospective chart review. In assessing the effects of antibiotic duration, we controlled for confounding by indication using standard covariate adjustment and propensity score matching. RESULTS Among 732 operations, the incidence of SSI was 13%. Using propensity score matching, the odds of SSI were similar (OR 1.1, 95% CI 0.6-1.9) in patients who received ≤24 h of postoperative antibiotics compared to >24 h. No difference was also found in standard covariate adjustment. This multivariate model identified three independent predictors of SSI: preoperative infection (OR 3.9, 95% CI 1.4-10.9) and re-operation through the same incision, both within 30 days (OR 3.5, 95% CI 1.7-7.4) and later (OR 2.3, 95% CI 1.4-3.8). CONCLUSION In clean-contaminated and contaminated gastrointestinal operations, giving >24 h of postoperative antibiotics offered no protection against SSI. An adequately powered randomized clinical trial is needed to conclusively evaluate longer duration antibiotic prophylaxis.
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Affiliation(s)
- Lan T Vu
- Department of Surgery, University of California, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0570, USA,
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A preoperative stay in an intensive care unit is associated with an increased risk of surgical site infection in neonates. J Pediatr Surg 2013; 48:1503-8. [PMID: 23895963 DOI: 10.1016/j.jpedsurg.2013.01.055] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 01/28/2013] [Accepted: 01/29/2013] [Indexed: 01/15/2023]
Abstract
BACKGROUND Neonates are considered as immunologically immature. There are no specific guidelines for surgical antibiotic prophylaxis in this population since data concerning the risk factors for surgical site infection (SSI) are lacking. METHODS A 40-month retrospective single-center study that included all consecutive neonates undergoing surgery was performed. The variables that could influence the rate of SSI were analyzed by multivariate analysis in order to determine the independent risk factors for SSI. RESULTS The survey included 286 neonates (91 F/195 M). Median age, term, and weight were 10 (0-19) days, 38 (37-39) weeks, 3 (2.7-3.5) kg, respectively. Sixteen percent of the neonates were premature. Surgery was mostly abdominal (71%). Prophylactic antibiotic was given in 66.4% of the cases and was highly variable (amoxicillin-clavulanate 20.3%, first generation cephalosporin 26.2%, second generation cephalosporin 11.9%, imidazole derivatives 13.6%, aminoglycosides 12.6%, vancomycin 0.7%, and ticarcillin-clavulanate 3.1%). The rate of SSI was 3.8%. Only two variables were identified as independent risk factors for SSI: gestational age OR: 0.821 (0.690-0.977) and preoperative hospitalization in an intensive care unit OR: 8.433 (1.031-69.005). CONCLUSION Preoperative stay in an intensive care unit and, to a lesser degree, low gestational age are associated with an increased SSI rate.
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Pediatric surgical site infection in the developing world: a Kenyan experience. Pediatr Surg Int 2012; 28:523-7. [PMID: 22297835 DOI: 10.1007/s00383-012-3058-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2012] [Indexed: 10/14/2022]
Abstract
BACKGROUND The purpose of the current study was to determine the incidence of pediatric surgical site infections(SSIs) at an academic children’s hospital in rural sub-Saharan Africa and to identify potentially modifiable risk factors. METHODS Prospectively collected data from 1,008 surgical admissions to Bethany Kids Kijabe Hospital (Kijabe, Kenya) were analyzed retrospectively. Follow-up data were available in 940 subjects. RESULTS SSIs occurred in 6.8% of included subjects(N = 64). Superficial (69%) and deep (29%) infections of the back (38%) and head (25%) were most common. When comparing children who developed SSI to those who did not, we found that wound contamination classification and duration of operation were the only variables with significant differences between groups. CONCLUSIONS Our rate of SSI among pediatric patients insub-Saharan Africa is the lowest reported in the literature to date. More work is needed to identify modifiable risk factors for pediatric SSI in low- and middle-income countries.
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Varik K, Kirsimägi Ü, Värimäe EA, Eller M, Lõivukene R, Kübarsepp V. Incidence and Risk Factors of Surgical Wound Infection in Children: A Prospective Study. Scand J Surg 2010; 99:162-6. [DOI: 10.1177/145749691009900311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and Aims: To establish the incidence and risk factors of surgical site infection (SSI) in children operated in the Department of Paediatric Surgery of the Clinic of Surgery of Tartu University Hospital. Material and Methods: The data of wound healing were obtained for 589 children operated between 15 March 2003 and 31 March 2005. The operations were divided into general surgical (451), orthopaedic (70) and urological (68). The surgical wounds were classified as clean (442), clean-contaminated (96), contaminated (36) and dirty-infected (15). Univariate and multivariate analyses were performed to identify risk factors. Results: There were 7 SSI cases, overall rate being 1.2%. Superficial wound infection occurred in 5 cases and deep wound infection occurred in 2 cases. There was no organ/space infection. SSI was significantly more frequent in the case of contaminated and dirty-infected compared with clean or clean—contaminated operations, 7.8% and 0.6%, respectively (p = 0.0008). Wound infection endangered more children who had operation related complications compared with non-complicated cases, 11.1% and 0.4%, respectively (p < 0.0001).
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Affiliation(s)
- K. Varik
- Tartu University Department of Surgery, Tartu, Estonia
| | - Ü. Kirsimägi
- Tartu University Department of Surgery, Tartu, Estonia
| | - E.-A. Värimäe
- Tartu University Department of Surgery, Tartu, Estonia
| | - M. Eller
- Tartu University Department of Surgery, Tartu, Estonia
| | - R. Lõivukene
- Tartu University Department of Surgery, Tartu, Estonia
| | - V. Kübarsepp
- Tartu University Department of Surgery, Tartu, Estonia
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Abstract
Background In the limited literature concerning abdominal wound dehiscence after laparotomy in children, reported incidences range between 0.2–1.2% with associated mortality rates of 8–45%. The goal of this retrospective case-control study was to identify major risk factors for abdominal wound dehiscence in the pediatric population. Methods Patients younger than aged 18 years who developed abdominal wound dehiscence in three pediatric surgical centers during the period 1985–2005 were identified. For each patient with abdominal wound dehiscence, four controls were selected by systematic random sampling. Patients with (a history of) open abdomen treatment or abdominal wound dehiscence were excluded as control subjects. Putative relevant patient-related, operation-related, and postoperative variables for both cases and control subjects were evaluated in univariate analyses and subsequently entered in multivariate stepwise logistic regression models to identify major independent predictors of abdominal wound dehiscence. Results A total number of 63 patients with abdominal wound dehiscence and 252 control subjects were analyzed. Mean presentation of abdominal wound dehiscence was at postoperative day 5 (range, 1–15) and overall mortality was 11%. Hospital stay was significantly longer (p < 0.001) in the case group (median, 42 vs. 10 days). Major independent risk factors for abdominal wound dehiscence were younger than aged 1 year, wound infection, median incision, and emergency surgery. Incisional hernia was reported in 12% of the patients with abdominal wound dehiscence versus 3% in the control group (p = 0.001). Conclusions Abdominal wound dehiscence is a serious complication with high morbidity and mortality. Median incisions should be avoided whenever possible.
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Abstract
BACKGROUND/PURPOSE This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations. METHODS This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as "clean," "clean-contaminated," "contaminated," or "dirty or infected," and specified duration of perioperative antibiotics as "none," "single preoperative," "24 hours," or ">24 hours." Unweighted kappa score was calculated to estimate interrater reliability. RESULTS Overall interrater reliability for wound classification was poor (kappa = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis. CONCLUSIONS There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis.
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Abstract
BACKGROUND Sepsis is a threatening postoperative complication especially in small infants. Regarding the advances in perinatal medicine, its incidence is unknown to date. We aimed to investigate the incidence, risk factors, laboratory findings and outcome of postoperative sepsis in infants younger than 6 months old. METHODS We examined postoperative sepsis in babies below 6 months of age during a 4-year period at a tertiary pediatric institution. RESULTS The rate of postoperative sepsis was 6.9%. Laparotomy with enterotomy, thoracotomy and diaphragmatic hernia repair (P<0.05, respectively) as well as low postnatal age and long operation time (P<0.001, respectively) were correlated with the incidence of sepsis. Significant independent predictors for the development of sepsis were the presence of a central venous catheter and perioperative antibiotic treatment (P<0.001, respectively). Coagulase negative Staphylococci were the major infecting organism associated with postoperative sepsis, accounting for 53% of monomicrobial infections. Complete blood counts with differential were not different between infants with sepsis and controls, who had undergone the same surgical procedures. Outcome was favorable in all cases; however, the length of hospital stay was significantly longer in sepsis patients (P<0.05). CONCLUSIONS Postoperative sepsis syndrome is a frequent complication in infants below 6 months of age and causes significant prolongation of hospital stay. Adequate prevention and therapeutic strategies warrant further prospective investigations.
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Ameh EA, Mshelbwala PM, Nasir AA, Lukong CS, Jabo BA, Anumah MA, Nmadu PT. Surgical Site Infection in Children: Prospective Analysis of the Burden and Risk Factors in a Sub-Saharan African Setting. Surg Infect (Larchmt) 2009; 10:105-9. [DOI: 10.1089/sur.2007.082] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Emmanuel A. Ameh
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Philip M. Mshelbwala
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Abdulrasheed A. Nasir
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Christopher S. Lukong
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Basheer A. Jabo
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Mark A. Anumah
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Paul T. Nmadu
- Division of Pediatric Surgery, Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
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Taylor GS, Cartwright PC, Snow BW. Incidence of postoperative infections in non-immunocompromised pediatric patients with low absolute neutrophil counts preoperatively. Surg Infect (Larchmt) 2008; 9:179-82. [PMID: 18426350 DOI: 10.1089/sur.2006.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To discover the incidence of postoperative surgical site infections in non-immunocompromised pediatric patients with an absolute neutrophil count (ANC) < or = 1,000 preoperatively. METHODS Office and hospital charts of consecutive patients with preoperative ANC < or = 1,000 undergoing elective surgery over a three-year period were reviewed for evidence of postoperative surgical site infection. RESULTS Six of 200 patients with preoperative ANCs < or = 1,000 developed a postoperative surgical site infection, an infection rate of 3.0%. One of 35 patients with preoperative ANCs < or = 500 developed a surgical site infection. The mean ANC of the study population was 800 (range 200 to 1,000); the mean ANC of the group with postoperative infection likewise was 800 (range 500 to 1,000). CONCLUSIONS There was a postoperative surgical site infection rate of 3.0% in non-immunocompromised children who had a preoperative ANC < or = 1,000, similar to the overall surgical site infection rate in children. Cancellation of elective procedures in non-immunocompromised children with ANC < or = 1,000 is not warranted on the grounds of concern about postoperative infection.
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Affiliation(s)
- Gregory S Taylor
- Department of Pediatric Urology, Primary Children's Medical Center, Salt Lake City, UT 84113, USA
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18
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Abstract
OBJECT Bandages and dressings are commonly applied to incisional scalp wounds to prevent complications, particularly infection, during the early stages of wound healing. Bandaging cranial incisional wounds requires resources, consumes healthcare workers' time, and incurs expense; it is therefore important to examine its efficacy. METHODS All cranial operations (excluding shunt placements, procedures on the scalp alone, and bur hole procedures) performed between June 30, 2001 and January 1, 2006, by two neurosurgeons at either of two hospitals, one adult and one pediatric institution, were reviewed. Surgical site infections (SSIs) and other postoperative complications were investigated with respect to the use of bandaging for incisional wounds and other aspects of postoperative wound management. The operations were classified into four categories based on wound type: "clean," "clean-contaminated," "contaminated," and "dirty," according to the criteria of the Centers for Disease Control and Prevention. CONCLUSIONS A total of 702 operations were performed in 577 patients; only five patients received any type of surgical bandaging. There were four SSIs (0.57%; 95% confidence interval [CI] 0.16-1.45). The postoperative infection rate in the 626 clean cases was 0.48% (95% CI 0.10-1.39) and was 2.63% (95% CI 0.07-13.81) in the 38 clean-contaminated cases. The data obtained in this investigation is consistent with the position that bandaging incisional scalp wounds after cranial surgery adds little if any benefit beyond the easier, simpler, and cheaper practice of using antibiotic ointment as a dressing without bandaging.
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Affiliation(s)
- Ken R Winston
- Department of Neurosurgery, The University of Colorado Health Sciences Center, The Children's Hospital, Denver, Colorado, USA.
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Ichikawa S, Ishihara M, Okazaki T, Warabi K, Kato Y, Hori S, Lane GJ, Hiramatsu K, Inada E, Kobayashi H, Yamataka A. Prospective study of antibiotic protocols for managing surgical site infections in children. J Pediatr Surg 2007; 42:1002-7; discussion 1007. [PMID: 17560210 DOI: 10.1016/j.jpedsurg.2007.01.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE We adopted antibiotic (Ab) protocols for managing surgical site infections in children and assessed their effectiveness. METHODS We used our protocols on 1313 children between 2004 and 2005. All wounds were monitored for 30 days and classified as clean, clean-contaminated, contaminated, or dirty-infected. Infections were defined as superficial, deep, or organ/space. A retrospective study involving 721 children who had surgery in 2003 was also performed. Chi2 statistical analysis was performed. RESULTS Postprotocol, all Abs were administered accurately by anesthesiologists and infections developed in only 22 cases (1.7%): 0.2% (clean), 2.6% (clean-contaminated), 5.8% (contaminated), and 20.8% (dirty-infected), respectively; 21 were superficial or deep and 1 was organ/space. Age at surgery and sex did not influence incidence, neither did length of surgery for clean-contaminated, contaminated, and dirty-infected wounds; clean wounds were excluded because all surgery was minor. Overall, incidence of infections was 1.2% for elective surgery and 4.5% for emergency surgery (P < .01). Preprotocol, only 67% had Ab and infections developed in 27 cases (3.7%), which is significantly higher than in postprotocol (P < .01). CONCLUSIONS Accurate administration of Ab and careful supervision by an infection control team appear to be effective for preventing wound infections in children.
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Affiliation(s)
- Satoko Ichikawa
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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Koga H, Kobayashi H, Yamataka A, Lane GJ, Miyano T. Intercellular adhesion molecule (ICAM-1) response after major neonatal surgery. Pediatr Surg Int 2005; 21:695-700. [PMID: 16096795 DOI: 10.1007/s00383-005-1494-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2005] [Indexed: 10/25/2022]
Abstract
Surgical stress induces systemic endocrine-metabolic responses that influence the function of endothelial cells (EC) to cause various systemic reactions. Intercellular adhesion molecule (ICAM)-1 is an adhesion molecule that plays an important role in inflammation, and increased expression of ICAM-1 on EC is a reflection of EC activation. In this study, we investigated the ICAM-1 response to surgical stress in neonates undergoing major surgery. Fifteen neonates (mean age at surgery: 3.5 +/- 1.2 days) were divided into two groups according to indications for surgery: Group I: Congenital diaphragmatic hernia without persistent pulmonary hypertension (n = 5); Group II: Gastrointestinal surgery [n = 10: duodenal atresia (n = 3), intestinal atresia (n = 6), and esophageal atresia (n = 1)]. Serum samples were obtained preoperatively, immediately after completion of surgery (time zero), and 24, 48, 72, 96, and 120 h after surgery to measure ICAM-1 levels using an enzyme-linked immunosorbent assay, C-reactive protein (CRP), and white blood cell count (WBC). Postoperative recovery was uneventful in all cases. ICAM-1 levels in both groups increased significantly within 24 h of surgery (Group I: P = 0.0038, Group II: P = 0.0320). In Group I, ICAM-1 peaked 72 h postoperatively while in Group II it continued to rise until 96 h postoperatively. The difference between peak levels reached was not significant. CRP was first detected 24 h postoperatively in both groups and continued to increase until 48 h postoperatively. Again, the difference between peak levels reached was not significant. No significant changes in WBC were observed in either group. We found that ICAM-1 increases in response to surgical stress in neonates, although there was no significant difference in levels. However, surgical stress as represented by serum ICAM-1 would appear to last longer with intestinal surgery than with non-intestinal surgery. Further research is required to establish the usefulness of ICAM-1 as an easily detectable substance associated with endothelial damage that reflects the host's response to major surgical stress.
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Affiliation(s)
- Hiroyuki Koga
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
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Kaabachi O, Letaief I, Nessib MN, Jelel C, Ben Abdelaziz A, Ben Ghachem M. Prévalence et facteurs de risque de l’infection postopératoire en chirurgie orthopédique pédiatrique. ACTA ACUST UNITED AC 2005; 91:103-8. [PMID: 15908878 DOI: 10.1016/s0035-1040(05)84286-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF THE STUDY The incidence of postoperative infection in pediatric surgery has been studied little in the literature. It would be lower than in adults. In the present work, we attempted to define the incidence of postoperative infection in orthopedic pediatric surgery and identify risk factors. MATERIAL AND METHODS This was a retrospective analysis of 458 children who underwent surgery between 1998 and 1999 for the following conditions: talipes equinus, congenital hip dislocation, supracondylar fracture of the elbow, and femur shaft fracture. We noted the prevalence of infection of the surgical site, the type of infection and its course as well as the principal risk factors incriminated: age, condition, surgical modalities (emergency setting, hour, bleeding) and use of antibiotic prophylaxis. RESULTS Mean age at surgery was 5.4+/-3.5 years. The sex ratio was 1.6 boys/1 girl. Forty-two patients developed an infection of the surgical site, giving an incidence of 9.2% of the patients and 8.3% of the surgical sites. Postoperative infection was more frequent in the talipes equinus group (19.4% versus 5.8% for supracondylar fractures of the elbow, 2% for femur shaft fractures, and 0% for congenital hip displacement). In 78.6% of the cases, the infection was superficial. The analysis of risk factors showed that talipes equinus is an independent risk factor. The absence of antibiotic prophylaxis increased the risk of infection of the surgical site significantly only in the talipes equinus group (40.7% versus 14%). DISCUSSION The incidence of infection of the surgical site in pediatric orthopedic surgery was high in our series, 8.3% versus 0.4% and 5.6% reported in the literature. Talipes equinus surgery exposes the child to a significant risk of infection. The principal risk factors related to surgery would be: ischemia, inflammation of cutaneous and subcutaneous tissue due to detachment, the tourniquet, and the absence of antibiotic prophylaxis.
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Affiliation(s)
- O Kaabachi
- Service d'Orthopédie Pédiatrique, Hôpital d'Enfants de Tunis, 1007 Tunis, Tunisie.
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22
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Abstract
BACKGROUND/PURPOSE The covering of the sutured surgical wound with a sterile dressing is usually considered a routine conclusion to an aseptic operation. The wound is usually left dressed for a minimum of 3 to 5 days. The main purpose of dressing is protection of the wound against bacterial contamination that remains a significant source of postoperative morbidity. The aim of this study was to compare the infectious local risk when the clean pediatric surgical wounds were dressed or left exposed without dressing after the completion of wound closure. METHODS Four hundred fifty-one patients with clean surgical wounds were randomized prospectively to receive dressing (n = 216) or have their wounds left exposed without any dressing (n = 235) after the completion of wound closure. RESULTS In the group that received wound dressing, wound infection developed in 3 patients (1.4%), whereas in the group that had wounds exposed without any dressing, 4 patients (1.7%) developed wound infection. CONCLUSIONS In children, there was no significant difference in terms of wound infection after applying dressing or leaving the clean surgical wounds exposed without any dressing after completion of wound closure. Dressing clean surgical wounds may be unnecessary.
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Affiliation(s)
- Jamal M Merei
- Department of Pediatric Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Duque-Estrada EO, Duarte MR, Rodrigues DM, Raphael MD. Wound infections in pediatric surgery: a study of 575 patients in a university hospital. Pediatr Surg Int 2003; 19:436-8. [PMID: 12883851 DOI: 10.1007/s00383-002-0735-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2001] [Indexed: 10/26/2022]
Abstract
Surgical wound infections (WI) remain a significant source of postoperative morbidity. This epidemiologic study was undertaken to determine retrospectively the incidence of postoperative WI in children in a university hospital and include critical comparisons of pediatric surgery WI rates between different international reports. As few data exist on postoperative WIs in pediatric patients, in contrast to numerous reports in adults, all infants and children undergoing operations in the pediatric surgical service in our institution during a 7-year period were reviewed for development of a WI, a total of 537 patients who underwent 575 operations. WIs occurred in 39 cases (6.7%). Clean wounds (56.8% of patients) had an infection rate of 2.7%, clean-contaminated (23.1%) 10.5%, contaminated (12.9%) 13.5%, and dirty/infected (7.2%) 14.6%. Increasing duration of operation ( P < 0.001), contamination at operation ( P < 0.001), and a new element in the operation - a resident or intern - ( P < 0.001) were all associated with a higher incidence of infection, despite efforts at infection-control practices including improved sterilization methods and barriers, surgical technique, and availability of antimicrobial prophylaxis. The total incidence of wound infection in this population was comparable to that in other reports. Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs operating room), the presence of a coexisting disease or remote infection, or the use of perioperative antibiotics. These baseline data may aid in forming strategies to lower the risk of WI in children. Our results suggest that WIs in children are related more to factors at operation than to the patients overall physiologic status.
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Affiliation(s)
- E O Duque-Estrada
- Hospital das Clínicas de Teresópolis, Av. Alberto Torres, s/n, Teresópolis, Rio de Janeiro, Brazil, 25950-000.
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24
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Porras-Hernández JD, Vilar-Compte D, Cashat-Cruz M, Ordorica-Flores RM, Bracho-Blanchet E, Avila-Figueroa C. A prospective study of surgical site infections in a pediatric hospital in Mexico City. Am J Infect Control 2003; 31:302-8. [PMID: 12888767 DOI: 10.1067/mic.2003.85] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pediatric surgical site infection (SSI) rates in the United States range from 2.5% to 4.4%. There is little data regarding their risk factors among children. We quantified SSI rates and identified risk factors of SSI in a tertiary care pediatric teaching hospital in Mexico City. METHODS All neurosurgical, cardiovascular, and general surgical patients who underwent operation between Aug 1, 1998, and Jan 31, 1999, were followed-up daily during hospitalization. On postoperative day 30, a full review of microbiology reports and medical records was performed. Univariate and multivariate analyses were done to identify risk factors. RESULTS Four hundred twenty-eight of 530 children completed follow-up. The overall SSI rate was 18.7%. Forty percent of SSI were superficial incisional, 21% were deep incisional, and 39% were organ/space infections. For clean, clean-contaminated, contaminated, and dirty procedures, SSI infection rates were 12.4%, 24.4%, 14.3%, and 32.4%, respectively. Open drains (OR = 2.3; 95% CI = 1.3-4.2; P <.005) and surgery that lasted 90 or more minutes (OR = 2.9; 95% CI = 1.6-5.1; P <.001) were associated with infection. CONCLUSIONS Our rates are greater than comparable reported data among children. Duration of surgery and use of open drains were associated with SSI.
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Erez E, Sharoni E, Ovadia B, Vidne BA, Dagan O. Septic emboli caused by vascular catheters after surgery for congenital heart disease. Crit Care Med 2000; 28:845-7. [PMID: 10752840 DOI: 10.1097/00003246-200003000-00039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the incidence, diagnosis, and management of septic emboli caused by vascular catheters after surgery for congenital heart disease. DESIGN Retrospective clinical review. All patients were computer registered. Our database includes daily follow-up and every sign of infection registered. SETTING Pediatric cardiac surgery intensive care unit in a university hospital. PATIENTS A total of 720 consecutive pediatric cardiac operations performed in 108 neonates and 612 older children from 1995 to 1997 are reviewed. MEASUREMENTS AND MAIN RESULTS Septic emboli were defined as erythematous non-tender papulonodular hemorrhagic lesions restricted to the limb and distal to the monitoring catheter. Four patients (0.55%) with catheter-related septic emboli after congenital heart surgery were identified, three neonates (0.41%) and one older infant (0.14%). The incidence of catheter-related septic emboli in our patients was significantly higher in the neonatal group compared with older infants (p = .0076; odds ratio=17.45). All infants with catheter-associated septic emboli were severely ill and required prolonged intensive care management postoperatively for periods ranging from 27 to 90 days (mean, 50 days). The catheters involved were in place for periods ranging from 5 to 7 days. All patients were treated by catheter removal and intravenous antibiotics without surgical intervention in the vascular access area. The affected limbs healed well without residual damage. CONCLUSIONS Septic emboli are a rare complication of infected vascular catheters in neonates and small infants undergoing prolonged postoperative intensive care management (0.55%). They may indicate the source of unexplained sepsis involving mainly Gram-negative bacilli. Generally, treatment consists of removal of the offending catheter and antibiotic administration with no need for surgical intervention.
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Affiliation(s)
- E Erez
- Department of Cardiothoracic Surgery, Schneider Medical Center for Children, Tel-Aviv University, Petah-Tikva, Israel
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Erez E, Katz M, Sharoni E, Katz Y, Leviav A, Vidne BA, Dagan O. Pectoralis major muscle flap for deep sternal wound infection in neonates. Ann Thorac Surg 2000; 69:572-7. [PMID: 10735701 DOI: 10.1016/s0003-4975(99)01075-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep sternotomy wound infections during the neonatal period, their management utilizing the pectoralis major muscle flap (PMF), and their follow-up are reported. METHODS Seven hundred-twenty consecutive pediatric cardiac operations performed from 1995 to mid 1998 in 108 neonates and 612 infants are reviewed. Nine children (1.25%), 6 neonates and 3 infants, developed deep sternotomy wound infections and underwent PMF reconstruction. The 6 neonates are reviewed. Their follow-up includes growth and development reports, physical examination, and computerized tomographic scans of the chest. RESULTS The incidence of sternal wound complications in our neonatal patients (5.5%, 6 of 108) was significantly higher than in the infantile group (0.5%, 3 of 612), (p = 0.0001, odds ratio = 11.94). Five neonates were treated with a unilateral, turnover PMF reconstruction. One patient was treated by a bilateral rotational PMF. All sternal wounds healed successfully, and all patients survived. In a follow-up period, ranging from 6 to 31 months (mean 16.5 months), the growth and development of all operated neonates was as expected for their age. There were no signs of chronic sternal infection in any of them. CONCLUSIONS Early recognition of sternal wound complications should facilitate surgical treatment. Utilizing the PMF promotes rapid wound healing and preservation of life in these severely ill neonates, with minimal developmental problems.
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Affiliation(s)
- E Erez
- Department of Cardiothoracic Surgery, Imaging and Roentgenology Institute, Schneider Medical Center for Children, Petah-Tikva, Israel
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999. [PMID: 10196487 DOI: 10.1016/s0196-6553(99)70088-x] [Citation(s) in RCA: 1926] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie
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Affiliation(s)
- A J Mangram
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia 30333, USA
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Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20:250-78; quiz 279-80. [PMID: 10219875 DOI: 10.1086/501620] [Citation(s) in RCA: 2736] [Impact Index Per Article: 109.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis.
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Affiliation(s)
- A J Mangram
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, GA 30333, USA
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Horwitz JR, Chwals WJ, Doski JJ, Suescun EA, Cheu HW, Lally KP. Pediatric wound infections: a prospective multicenter study. Ann Surg 1998; 227:553-8. [PMID: 9563545 PMCID: PMC1191312 DOI: 10.1097/00000658-199804000-00017] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Surgical wound infections remain a significant source of postoperative morbidity. This study was undertaken to determine prospectively the incidence of postoperative wound infections in children in a multi-institutional fashion and to identify the risk factors associated with the development of a wound infection in this population. SUMMARY BACKGROUND DATA Despite a large body of literature in adults, there have been only two reports from North America concerning postoperative wound infections in children. METHODS All infants and children undergoing operation on the pediatric surgical services of three institutions during a 17-month period were prospectively followed for 30 days after surgery for the development of a wound infection. RESULTS A total of 846 of 1021 patients were followed for 30 days. The overall incidence of wound infection was 4.4%. Factors found to be significantly associated with a postoperative wound infection were the amount of contamination at operation (p = 0.006) and the duration of the operation (p = 0.03). Comparing children who developed a wound infection with those who did not, there were no significant differences in age, sex, American Society of Anesthesiologists (ASA) preoperative assessment score, length of preoperative hospitalization, location of operation (intensive care unit vs. operating room), presence of a coexisting disease or remote infection, or the use of perioperative antibiotics. CONCLUSIONS Our results suggest that wound infections in children are related more to the factors at operation than to the overall physiologic status. Procedures can be performed in the intensive care unit without any increase in the incidence of wound infection.
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Affiliation(s)
- J R Horwitz
- University of Texas-Houston Medical School and Hermann Children's Hospital, USA
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31
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Abstract
Cytokines are early responders in the cascade of host mediators after injury. The cytokine response in neonates following surgery and its prognostic significance were studied prospectively. Twenty-one patients (oesophageal atresia [5], congenital diaphragmatic hernia [4], exomphalos [4], patent vitellointestinal duct [1], anorectal anomaly [2], choledochal cyst [1], renal cyst [1], ovarian cyst [1], myelomeningocoele [1], and pyloric stenosis [1]) operated on at a median age of 3 days (range, 1 to 24 days) and 12 age-matched controls were included in the study. Plasma samples were obtained once in the controls, and serially preoperatively and at 1, 3, 6, 12, 24, 36, and 48 hours postoperatively in the patients. The levels of the cytokines, interleukin-6 (IL-6), and interleukin-8 (IL-8) were measured using the enzyme-linked immunosorbent assay (ELISA) technique. The median plasma levels of IL-6 and IL-8 in normal controls were 2.4 pg/mL and 92.0 pg/mL, respectively. Of the 21 patients, four had postoperative complications (pulmonary consolidation [2], septicaemia [1], and oesophageal leak [1]) between days 4 and 6. All 17 uncomplicated cases had an increase in IL-6 and IL-8 in the early postoperative period, with the peak occurring within 12 hours after surgery. The mean (+/- SEM) peak levels of IL-6 and IL-8 in uncomplicated cases were of 92.6 +/- 15.8 pg/mL and 230.3 +/- 45.3 pg/mL, respectively. In the four complicated cases, there was a disproportionately higher increase in both IL-6 (peaks, 305.0, 125.0, 240.0, and 220.0 pg/mL) and IL-8 (peaks, 1500.0, 340.0, 245.0, 355.0 and pg/mL), which preceded the clinical onset of complications. The early postoperative increases in plasma IL-6 and IL-8 probably represent the stress response of neonates to surgery. Furthermore, the association of an exaggerated increase in postoperative levels of plasma IL-6 and IL-8 and postoperative complications may have prognostic significance.
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Affiliation(s)
- T M Tsang
- Paediatric Surgical Unit, John Radcliffe Hospital, Oxford, England
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32
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Abstract
In an analysis of 1,433 wounds created in 1,094 neonates admitted to a regional neonatal surgical unit during the period April 1975 to December 1987, the mean incidence of infection was 16.6%. During this time there was an increase in the incidence of infection from 12.5% in the first 6 years to 18.8% in the last 7 years (P < .01). Contaminated wounds had an infection rate of 20.7%, whereas the rate in clean wounds was 11.1% (P < .001). Gestational age and birth weight had no influence on the incidence of wound infection. Increasing wound length (P < .001), increasing duration of operation (P < .001), and contamination at operation (P < .001) were all associated with a higher incidence of infection. Staphylococcal species were the most frequently isolated organisms from all categories of infected wounds (clean, potential, and actual contamination).
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Affiliation(s)
- M Davenport
- Regional Neonatal Surgical Unit, St. Mary's Hospital, Manchester, England
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33
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Huchcroft SA, Nicolle LE, Cruse PJ. Surgical wound infection and cancer among the elderly: a case control study. J Surg Oncol 1990; 45:250-6. [PMID: 2250475 DOI: 10.1002/jso.2930450408] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Surgical wound infection occurs in fewer than 5% of operations. Nevertheless, it represents the second most common type of hospital-acquired infection and results in increased morbidity and mortality. As with all nosocomial infections, the rate of surgical wound infection increases with age. Patients over 65 years of age run an approximately 15% risk of surgical wound infection. Two-thirds of patients with invasive cancer other than non-melanotic skin cancer are aged 65 years and over. Over half of them are treated surgically for their cancer. Cancer and other chronic diseases have been cited as possible causes of the increased risk of nosocomial infection among the elderly. Using the Foothills Hospital Wound Study Data Base as the sampling frame, we conducted a case-control study of surgical wound infection and cancer among the elderly. Cancer was found not to be a risk factor for surgical wound infection. The results are discussed in relation to the role of immunity in both disorders.
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Affiliation(s)
- S A Huchcroft
- Division of Epidemiology and Preventive Oncology, Alberta Cancer Board, Calgary
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34
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Bhattacharyya N, Kosloske AM. Postoperative wound infection in pediatric surgical patients: a study of 676 infants and children. J Pediatr Surg 1990; 25:125-9. [PMID: 2299537 DOI: 10.1016/s0022-3468(05)80177-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We conducted an epidemiologic study of postoperative wound infection in pediatric patients. Over a 14-month period, 676 patients who received an operative incision on the Pediatric Surgical service were entered. Demographic, nutritional, clinical, and laboratory data were collected. The patients were followed for development of postoperative wound infection. Cultures were taken from wounds to identify the offending organisms. Of the 676 patients, 137 were neonates, 197 infants, and 342 older children. Wound infection occurred in 17 patients (2.5%): 1 neonate (0.7%), 8 infants (4.1%), and 8 older children (2.3%). Infection rates according to wound classification were: clean 1.0%, clean-contaminated 2.9%, contaminated 7.9%, and dirty 6.3%. Heavily contaminated or dirty wounds were packed open in one third of cases, and allowed to heal by granulation. The largest group of wound infections followed operations on the gastrointestinal tract (10 patients, 267 operations, 3.7%). Staphylococcus aureus, Escherichia coli, and alpha hemolytic streptococcus were the most common wound pathogens. An increased rate of wound infection was associated with operative procedures longer than 1 hour, with the presence of an associated illness, and with emergency operations. Age, sex, nutritional status, and duration of preoperative hospital stay did not significantly alter the wound infection rate. It could be concluded that the incidence of wound infection was lower among pediatric surgical patients than the reported incidence in adult surgical patients. The greatest risk factors were those associated with local contamination of the surgical wound.
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Affiliation(s)
- N Bhattacharyya
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque
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35
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Madden NP, Levinsky RJ, Bayston R, Harvey B, Turner MW, Spitz L. Surgery, sepsis, and nonspecific immune function in neonates. J Pediatr Surg 1989; 24:562-6. [PMID: 2738824 DOI: 10.1016/s0022-3468(89)80506-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
An audit of 143 neonatal surgical operations identified low birth weight infants as being at particular risk of developing post-operative sepsis following major surgical trauma. Activity of the nonspecific immune system was examined pre- and post-operatively in order to elucidate the susceptibility to post-operative sepsis of these infants. A chemiluminescence micro-method was developed specifically for this purpose. Neonatal plasma was shown to have significantly impaired opsonising activity, and activity was further reduced in low birth weight infants. Levels of immunoglobulin and complement factors were also reduced, particularly in the low birth weight infant. Following major surgical trauma polymorph activity was significantly lower in low birth weight infants than in mature neonates.
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Affiliation(s)
- N P Madden
- Department of Paediatric Surgery, Institute of Child Health, London, England
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