Implementation strategies to reduce surgical site infections: A systematic review

Heideveld-Chevalking A, Kristensen K, Huibertina Davida van Tuyl L, Põlluste K, Weynants C, Garel P, Sousa P, Talving P, Marx D, Žaludek A, Romero E, Rodríguez A, Orrego C. Improving quality and patient safety in surgical care through standardisation and harmonisation of perioperative care (SAFEST project): A research protocol for a mixed methods study

INTRODUCTION

Adverse events in health care affect 8% to 12% of patients admitted to hospitals in the European Union (EU), with surgical adverse events being the most common types reported.

AIM

SAFEST project aims to enhance perioperative care quality and patient safety by establishing and implementing widely supported evidence-based perioperative patient safety practices to reduce surgical adverse events.

METHODS

We will conduct a mixed-methods hybrid type III implementation study supporting the development and adoption of evidence-based practices through a Quality Improvement Learning Collaborative (QILC) in co-creation with stakeholders. The project will be conducted in 10 hospitals and related healthcare facilities of 5 European countries. We will assess the level of adherence to the standardised practices, as well as surgical complications incidence, patient-reported outcomes, contextual factors influencing the implementation of the patient safety practices, and sustainability. The project will consist of six components: 1) Development of patient safety standardised practices in perioperative care; 2) Guided self-evaluation of the standardised practices; 3) Identification of priorities and actions plans; 4) Implementation of a QILC strategy; 5) Evaluation of the strategy effectiveness; 6) Patient empowerment for patient safety. Sustainability of the project will be ensured by systematic assessment of sustainability factors and business plans. Towards the end of the project, a call for participation will be launched to allow other hospitals to conduct the self-evaluation of the standardized practices.

DISCUSSION

The SAFEST project will promote patient safety standardized practices in the continuum of care for adult patients undergoing surgery. This project will result in a broad implementation of evidence-based practices for perioperative care, spanning from the care provided before hospital admission to post-operative recovery at home or outpatient facilities. Different implementation challenges will be faced in the application of the evidence-based practices, which will be mitigated by developing context-specific implementation strategies. Results will be disseminated in peer-reviewed publications and will be available in an online platform.

'It depends': what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of strategies have been developed to support the implementation of research into clinical practice. The objective of this study was to update and extend two previous reviews of systematic reviews of strategies designed to implement research evidence into clinical practice.

METHODS

We developed a comprehensive systematic literature search strategy based on the terms used in the previous reviews to identify studies that looked explicitly at interventions designed to turn research evidence into practice. The search was performed in June 2022 in four electronic databases: Medline, Embase, Cochrane and Epistemonikos. We searched from January 2010 up to June 2022 and applied no language restrictions. Two independent reviewers appraised the quality of included studies using a quality assessment checklist. To reduce the risk of bias, papers were excluded following discussion between all members of the team. Data were synthesised using descriptive and narrative techniques to identify themes and patterns linked to intervention strategies, targeted behaviours, study settings and study outcomes.

RESULTS

We identified 32 reviews conducted between 2010 and 2022. The reviews are mainly of multi-faceted interventions (n = 20) although there are reviews focusing on single strategies (ICT, educational, reminders, local opinion leaders, audit and feedback, social media and toolkits). The majority of reviews report strategies achieving small impacts (normally on processes of care). There is much less evidence that these strategies have shifted patient outcomes. Furthermore, a lot of nuance lies behind these headline findings, and this is increasingly commented upon in the reviews themselves.

DISCUSSION

Combined with the two previous reviews, 86 systematic reviews of strategies to increase the implementation of research into clinical practice have been identified. We need to shift the emphasis away from isolating individual and multi-faceted interventions to better understanding and building more situated, relational and organisational capability to support the use of research in clinical practice. This will involve drawing on a wider range of research perspectives (including social science) in primary studies and diversifying the types of synthesis undertaken to include approaches such as realist synthesis which facilitate exploration of the context in which strategies are employed.

The effect of interventions on the incidence of surgical site infections in acute care settings: A systematic review

AIM

Surgical site infections (SSIs) are common healthcare associated infections with serious consequences for patients and healthcare organisations. It is critical that healthcare professionals implement prevention strategies to reduce the incidence of such infections. Prevention strategies are key to reducing the incidence of SSIs. The aim of this systematic review is to describe the effect of interventions conducted in acute care settings on the incidence of SSIs (primary outcome), length of stay, intensive care unit admission, and mortality rate (secondary outcomes).

MATERIALS AND METHODS

This review is reported using the Preferred Reporting Items for Systematic review and Meta-Analysis checklist. A search was undertaken in Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycARTICLES, PsycINFO and Web of Science for studies published between January 2017 and March 2022. Studies that focused on interventions within acute hospital settings in patients undergoing elective surgery with the aim of reducing the incidences of SSIs were included. Due to heterogeneity results were synthesised narratively.

RESULTS

In total, 23 studies were included. Findings show that interventions that are effective in reducing the incidences of SSIs have multiple components including care bundles, stakeholder engagement, targeted surveillance and education. Few studies were identified that evaluated the effect of SSI prevention interventions on length of stay and mortality, and none assessed intensive care admission rates.

CONCLUSIONS

The included interventions varied widely, which made it difficult to draw definitive conclusions regarding specific interventions that reduce SSI. Multicomponent interventions and care bundles showed promise in reducing the occurrence of SSIs. Further studies should focus on standardised evidence-based interventions and compliance using randomised controlled designs.

Scalability and Sustainability of a Surgical Infection Prevention Program in Low-Income Environments

Importance

Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low-resource settings. Clean Cut, a 6-month quality improvement program developed by the global nonprofit organization Lifebox, has demonstrated improvements in postoperative infectious complications. However, the pilot program required intense external programmatic and resource support.

Objective

To examine the improvement in adherence to infection prevention and control standards and rates of postoperative infections in hospitals in the Clean Cut program after implementation strategies were updated and program execution was refined.

Design, Setting, and Participants

This cohort study evaluated and refined the Clean Cut implementation strategy to enhance scalability based on a qualitative study of its pilot phase, including formalizing programmatic and educational materials, building an automated data entry and analysis platform, and reorganizing hospital-based team composition. Clean Cut was introduced from January 1, 2019, to February 28, 2022, in 7 Ethiopian hospitals that had not previously participated in the program. Prospective data initiated on arrival in the operating room were collected, and patients were followed up through hospital discharge and with 30-day follow-up telephone calls.

Exposure

Implementation of the refined Clean Cut program.

Main Outcomes and Measures

The primary outcome was surgical site infection (SSI); secondary outcomes were adherence to 6 infection prevention standards, mortality, hospital length of stay, and other infectious complications.

Results

A total of 3364 patients (mean [SD] age, 26.5 [38.0] years; 2196 [65.3%] female) from 7 Ethiopian hospitals were studied (1575 at baseline and 1789 after intervention). After controlling for confounders, the relative risk of SSIs was reduced by 34.0% after program implementation (relative risk, 0.66; 95% CI, 0.54-0.81; P < .001). Appropriate Surgical Safety Checklist use increased from 16.3% to 43.0% (P < .001), surgeon hand and patient skin antisepsis improved from 46.0% to 66.0% (P < .001), and timely antibiotic administration improved from 17.8% to 39.0% (P < .001). Surgical instrument (38.7% vs 10.2%), linen sterility (35.5% vs 12.8%), and gauze counting (89.2% vs 82.5%; P < .001 for all comparisons) also improved significantly.

Conclusions and Relevance

A modified implementation strategy for the Clean Cut program focusing on reduced external resource and programmatic input from Lifebox, structured education and training materials, and wider hospital engagement resulted in outcomes that matched our pilot study, with improved adherence to recognized infection prevention standards resulting in a reduction in SSIs. The demonstration of scalability reinforces the value of this SSI prevention program.

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Influence of closed-incision negative-pressure wound therapy on the incidence of surgical site wound infection in patients undergoing spine surgery: A meta-analysis

The present meta-analysis was conducted to comprehensively assess the impact of closed-incision negative-pressure wound therapy (ciNPWT) on the incidence of surgical site infections (SSIs) in patients undergoing spinal fusion surgery, thereby aiming to provide evidence-based support for the prevention of postoperative wound infections during spinal surgery. Relevant studies pertaining to the application of ciNPWT in spinal surgery were retrieved through searches of the PubMed, Embase, MEDLINE and Cochrane Library databases, spanning from their inception to May 2023. The literature screening and data extraction were performed by two researchers based on predefined inclusion and exclusion criteria, followed by a quality assessment of the included studies. Meta-analyses were performed using the odds ratios (ORs) and standardised mean differences (SMDs) as effect variables. RevMan 14.0 and STATA 17.0 were employed for meta-analysis of the extracted data. In total, eight articles involving 1198 patients, including 391 in the experimental group and 807 in the control group, were included. The meta-analysis results revealed that ciNPWT significantly reduced the incidence of SSIs in patients undergoing spinal fusion surgery (OR, 0.39; 95% CI: 0.22-0.67, p = 0.0007); however, it did not lead to a reduction in hospital stay duration (SMD: -0.48, 95% CI: -0.98 to 0.01, p = 0.06). Existing evidence suggests that ciNPWT has a positive impact on patients undergoing spinal fusion surgery, as it significantly reduces the incidence of postoperative surgical site wound infections; however, it does not result in a shorter hospital stay for patients.

Barriers and facilitators for surgical site infection surveillance for adult cardiac surgery in a high-income setting: an in-depth exploration

BACKGROUND

Surgical site infection (SSI) surveillance aims to facilitate a reduction in SSIs through identifying infection rates, benchmarking, triggering clinical review and instituting infection control measures. Participation in surveillance is, however, variable suggesting opportunities to improve wider adoption.

AIM

To gain an in-depth understanding of the barriers and facilitators for SSI surveillance in a high-income European setting.

METHODS

Key informant interviews with 16 surveillance staff, infection prevention staff, nurses and surgeons from nine cardiac hospitals in England. Data were analysed thematically.

FINDINGS

SSI surveillance was reported to be resource intensive. Barriers to surveillance included challenges associated with data collection: data being located in numerous places, multiple SSI data reporting schemes, difficulty in finding denominator data, lack of interface between computerized systems, 'labour intensive' or 'antiquated' methods to collect data (e.g., using postal systems for patient questionnaires). Additional reported concerns included: relevance of definitions, perceived variability in data reporting, lack of surgeon engagement, unsupportive managers, low priority of SSIs among staff, and a 'blame culture' around high SSI rates. Facilitators were increased resources, better use of digital technologies (e.g., remote digital wound monitoring), integrating surveillance within routine clinical work, having champions, mandating surveillance, ensuring a closer relationship between surveillance and improved patient outcomes, increasing the focus on post-discharge surveillance, and integration with primary care data.

CONCLUSION

Using novel interviews with 'front-line' staff, identified opportunities for improving participation in SSI surveillance. Translating these findings into action will increase surveillance activity and bring patient safety benefits to a larger pool of surgical patients.

Application of the Expert Recommendations for Implementing Change (ERIC) compilation of strategies to health intervention implementation in low- and middle-income countries: a systematic review

BACKGROUND

The Expert Recommendations for Implementing Change (ERIC) project developed a compilation of implementation strategies that are intended to standardize reporting and evaluation. Little is known about the application of ERIC in low- and middle-income countries (LMICs). We systematically reviewed the literature on the use and specification of ERIC strategies for health intervention implementation in LMICs to identify gaps and inform future research.

METHODS

We searched peer-reviewed articles published through March 2023 in any language that (1) were conducted in an LMIC and (2) cited seminal ERIC articles or (3) mentioned ERIC in the title or abstract. Two co-authors independently screened all titles, abstracts, and full-text articles, then abstracted study, intervention, and implementation strategy characteristics of included studies.

RESULTS

The final sample included 60 studies describing research from all world regions, with over 30% published in the final year of our review period. Most studies took place in healthcare settings (n = 52, 86.7%), while 11 (18.2%) took place in community settings and four (6.7%) at the policy level. Across studies, 548 distinct implementation strategies were identified with a median of six strategies (range 1-46 strategies) included in each study. Most studies (n = 32, 53.3%) explicitly matched implementation strategies used for the ERIC compilation. Among those that did, 64 (87.3%) of the 73 ERIC strategies were represented. Many of the strategies not cited included those that target systems- or policy-level barriers. Nearly 85% of strategies included some component of strategy specification, though most only included specification of their action (75.2%), actor (57.3%), and action target (60.8%). A minority of studies employed randomized trials or high-quality quasi-experimental designs; only one study evaluated implementation strategy effectiveness.

CONCLUSIONS

While ERIC use in LMICs is rapidly growing, its application has not been consistent nor commonly used to test strategy effectiveness. Research in LMICs must better specify strategies and evaluate their impact on outcomes. Moreover, strategies that are tested need to be better specified, so they may be compared across contexts. Finally, strategies targeting policy-, systems-, and community-level determinants should be further explored.

TRIAL REGISTRATION

PROSPERO, CRD42021268374.

Incidence of surgical site infections after cervical spine surgery: results of a single-center cohort study adhering to multimodal preventive wound control protocol

PURPOSE

The incidence of surgical site infections is considered a relevant indicator of perioperative and postoperative care quality. The aim of this study is to analyze and evaluate SSIs after elective cervical spine surgery under the guidance of our preventive multimodal wound protocol.

METHODS

A monocentric observational cohort study analyzed 797 patients who underwent cervical spine surgery from 2005 to 2010 (mean age 51.58 ± 11.74 year, male 56.09%, mean BMI 26.87 ± 4.41, ASA score 1-2 in 81.68% of patients), fulfilling the entry criteria: (1) cervical spine surgery performed by neurosurgeons (degenerative disease 85.19%, trauma 11.04%, tumor 3.76%), (2) elective surgery, (3) postoperative care in our neurointensive care unit. Our preventive wound control protocol management focused mainly on antibiotic prophylaxis, wound hygiene regime, and drainage equipment. All wound complications and surgical site infections were monitored up for 1 year after surgery.

RESULTS

We had only 2 (0.25%) patients with SSI after cervical spine surgery-one organ/space infection (osteomyelitis, primary due to liquorrhea) after anterior surgical approach, and one deep surgical site infection (due to dehiscence) after posterior approach. We had 17 (2.13%) patients with some wound complications (secretion 7, dehiscence 4, hematoma 1, edema 3, and liquorrhea 2) that were not classified as SSI according to the CDC guidelines.

CONCLUSION

Concerning our study population of patients undergoing elective cervical surgery, with ASA scores 1-2 in 81.68% of our patients, the incidence of SSI was 0.14% after anterior surgical approach, 1.4% after posterior surgical approach, and 0.25% altogether in the referred cohort.

Healthcare professionals' knowledge and attitudes of surgical site infection and surveillance: A narrative systematic review

AIM

This systematic review reports on healthcare professionals' knowledge and attitudes of surgical site infection and surgical site infection surveillance as well as interventions aimed at enhancing healthcare professionals' knowledge and attitudes.

BACKGROUND

Surgical site infection is a serious adverse outcome following surgery. Despite the presence of international guidelines, the prevention of surgical site infections remains a challenge for patients and hospitals. It is critical that healthcare professionals have sufficient knowledge on surgical site infection and on their role in implementing evidence-based prevention strategies.

DESIGN

This review is reported using the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines.

METHODS

A search was undertaken in the following databases: Academic Search Complete, CINAHL, ERIC, MEDLINE, PsycARTICLES, PsycINFO and Web of Science for studies published between January 2010 and March 2022. Studies that examined healthcare professionals' knowledge and attitudes in relation to surgical site infection, surgical site infection surveillance and risk factors for their development were included. We also included studies that examined interventions that aimed to enhance healthcare professionals' knowledge and attitude in relation to surgical site infection, surveillance, and risk factors. We also described the impact of such interventions on the incidence of surgical site infections.

RESULTS

A total of 26 studies were included. Results were synthesised narratively according to the review objectives. Findings from this review show that knowledge of what surgical site infection is and its prevention was poor amongst healthcare professionals, while attitudes were positive particularly in relation to healthcare professionals' role in prevention. Only three studies examined the effects of interventions on healthcare professionals' knowledge of surgical site infection and surgical site infection prevention. Of those, two used multimodal educational interventions and found statistically significant improvement in knowledge.

CONCLUSIONS

Overall knowledge of surgical site infection and its prevention is poor amongst healthcare professionals, while attitudes were positive particularly in relation to healthcare professionals' role in prevention. There is a need for more experimental research to evaluate interventions which aim to address healthcare professionals' knowledge and attitudes towards surgical site infection prevention and surveillance. Such studies should include all healthcare professionals involved in the care of a surgical patient.

TWEETABLE ABSTRACT

Knowledge and attitudes of surgical site infection prevention amongst healthcare professionals.

Antibiotic Utilization Patterns for Different Wound Types among Surgical Patients: Findings and Implications

Antimicrobial prophylaxis is effective in reducing the rate of surgical site infections (SSIs) post-operatively. However, there are concerns with the extent of prophylaxis post-operatively, especially in low- and middle-income countries (LMICs). This increases antimicrobial resistance (AMR), which is a key issue in Pakistan. Consequently, we conducted an observational cross-sectional study on 583 patients undergoing surgery at a leading teaching hospital in Pakistan with respect to the choice, time and duration of antimicrobials to prevent SSIs. The identified variables included post-operative prophylactic antimicrobials given to all patients for all surgical procedures. In addition, cephalosporins were frequently used for all surgical procedures, and among these, the use of third-generation cephalosporins was common. The duration of post-operative prophylaxis was 3-4 days, appreciably longer than the suggestions of the guidelines, with most patients prescribed antimicrobials until discharge. The inappropriate choice of antimicrobials combined with prolonged post-operative antibiotic administration need to be addressed. This includes appropriate interventions, such as antimicrobial stewardship programs, which have been successful in other LMICs to improve antibiotic utilization associated with SSIs and to reduce AMR.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

An interactive feedback system for increasing hand antisepsis adherence in stationary intensive care

BACKGROUND

Pathogens causing infections are in many cases transmitted via the hands of personnel. Thus, hand antisepsis has strong epidemiological evidence of infection prevention. Depending on various factors, hand antisepsis adherence ranges between 9.1% and 85.2%.

AIM

To evaluate a new transponder system that reminded medical staff to use an alcohol-based hand rub based on indication by giving real-time feedback, to detect hand antisepsis adherence.

METHODS

The monitoring system consisted of three components: a portable transponder detecting alcohol-based hand rub and able to give feedback; a beacon recognizing entries to and exits from the patient's surroundings; and a sensor placed at the hand-rub dispensers to count the number of hand rubs. With these components, the system provided feedback when hand antisepsis was not conducted although it was necessary according to moments 1, 4, and 5 of hand antisepsis. Adherence was measured in two use-cases with five phases, starting with the baseline measurement followed by intervention periods and phases without intervention to test the sustainability of the feedback.

FINDINGS

Using the monitoring system, hand antisepsis adherence was increased by up to 104.5% in comparison to the baseline measurement. When the intervention ceased, however, hand antisepsis adherence decreased to less than or equal to the baseline measurement.

CONCLUSION

A short-term intervention alone is not sufficient to lead to a long-term change in hand antisepsis adherence. Rather, permanent feedback and/or the integration in a multi-modal intervention strategy are necessary.

Analysis of Italian requests for compensation in cases of responsibility for healthcare-related infections: A retrospective study

Introduction

The aim of this study was to examine the type of compensation claims for alleged medical malpractice in the field of healthcare-related infections in Italy.

Methods

It was analyzed which was the most frequent clinical context, the characteristics of the disputes established, which were the alleged damages most often complained of, which were the possibly censurable behaviors of the health professionals, and which were the reasons for acceptance or rejection of the request for compensation.

Results

In 90.2%, the issue questioned regarded surgical site infections. The most common pathogens involved were coagulase-negative Staphylococci (34.1%) and Staphylococcus aureus (24.4%). The lack or non-adherence to protocols of prophylaxis and/or prevention of healthcare-related infections was the most reported cause of acceptance of the request of compensation.

Discussion

According to our data, a stronger effort should be made in terms of risk management perspective in order to ensure the develop and application of protocols for prevention of Gram-positive healthcare-related infections and strengthen infection control and antimicrobial stewardship programs.

Evaluating the effect of air purifier Novarerus NV800 during orthopedic operations to reduce bioburden in the air

A locally installed air purifier Novaerus Protect 800 has recently been shown to reduce the air bioburden in an intensive care unit and the incidence of healthcare-associated infections (HAI). The aim of this study was to explore whether the same type of local air purifying unit could reduce bacterial concentrations in the air of an operating room (OR) during ongoing orthopedic operations, thereby reducing the risk of surgical site infections (SSI). Three air purifying units were installed in an OR in a Swedish hospital in 2018 in this prospective experimental study. The air was actively sampled during 11 operations by a slit-to-slit agar impactor with the air purifying units either in operation or switched off. Air movements were visualized with aid of smoke in mock-up studies. There was no statistically significant difference in the bacterial concentration in the air when the air purifying units were switched off and switched on (p=0,54). The air movements around and above the surgical wound were disordered and resembled that of dilution mixing air. In conclusion, the three air purifying units installed in the OR did not reduce the airborne bacterial levels in the critical zone during ongoing orthopedic operations in this study.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

Individualized perioperative management in transoral spine surgery: a single-center cohort study evaluating surgical wound complications and wound infections

Background

Transoral spine surgery is specific due to both its surgical approach and the spectrum of diseases it targets. Patients with high age and elevated clinical frailty scores are often involved, and there are reports of increased risks of surgical site infection (SSI) due to extended exposures requiring maxilotomy or mandibulotomy. Our case series describes surgical wound complications under the meticulous application of individualized perioperative multimodal management.

Methods

Our primary outcome was the occurrence of SSI and the secondary outcome was the occurrence of other noninfectious wound complications evaluated in 22 adult patients who consecutively underwent the transoral spine surgery from 2001 to 2018 (trauma – C2, cervical nonunion: 6 patients, 27%; tumor: 4 patients, 18%; osteomyelitis: 6 patients, 27%; other non-traumatic cases: 6 patients, 27%). Structuralized data comprising parameters related to nosocomial infections after spine surgery were continuously processed and put into specialized database of preventive multimodal nosocomial infection control protocol that was used as a main source of analyzed parameters. The mean age of studied cohort was 54.9 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 15.5 years, with 68% males, mean body mass index (BMI) 24.9 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 5.22, and the mean clinical frailty score was 2.59 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\pm$$\end{document}± 1.07. There were 7 patients (32%) who only had the transoral approach and 15 patients (68%) having this approach followed by additional posterior approach. We observed SSI from all wound complications for up to one year after surgery.

Results

There were 4 (18%) superficial wound complications from transoral approach, but none of them were infected. We had 2 patients (13%) with deep wound infections after subsequent posterior approach, but only one (4.5%) was classified as SSI.

Conclusions

We describe the wound complications and the incidence of SSI in a series of 22 patients after the transoral surgery. Considering the average values of the clinical frailty score reaching 2.59, American Society of Anesthesiologists score of 2.73, and the BMI of 26.87, the transoral spine surgery did not seem to be a considerable risk for SSI in the analyzed cohort, provided preventive perioperative multimodal management is properly individualized and followed.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tailoring implementation interventions of different order in infection prevention and control: A cascadic logic model (IPC-CASCADE)

Implementation interventions in infection prevention and control (IPC) differ by recipients. The two target groups are healthcare workers directly involved in patient care ("frontline") and IPC professionals as proxy agents, that is, implementation support practitioners. While both types of implementation interventions aim to promote compliance with clinical interventions to prevent healthcare-associated infections (HAI), their tailoring may be vastly different, for example, due to different behavioural outcomes. Additionally, IPC teams, as recipients of empowering tailored interventions, are under-researched. To overcome this gap and improve conceptual clarity, we proposed a cascadic logic model for tailored IPC interventions (IPC-CASCADE). In the model, we distinguished between interventions by IPC professionals targeting clinicians and those targeting IPC professionals (first- and second-order implementation interventions, respectively). Tailoring implies selecting behaviour change techniques matched to prospectively-assessed determinants of either clinician compliance (in first-order interventions) or interventions by IPC professionals for frontline workers (in second-order interventions). This interventional cascade is embedded in the prevailing healthcare system. IPC-CASCADE is horizontally structured over time and vertically structured by hierarchy or leadership roles. IPC-CASCADE aims to highlight the potential of increasing the impact of tailored interventions by IPC professionals for clinicians (to improve their compliance) via tailored interventions for IPC professionals (to improve their work as proxy agents). It underlines the links that IPC professionals define between macro contexts (healthcare and hospitals) and frontline workers in HAI prevention. It is specific, i.e., "tailored" to IPC, and expected to assist implementation science to better conceptualise tailoring.

Surgical site infection in a Greek general surgery department: who is at most risk?

OBJECTIVE

Surgical site infections (SSIs) are associated with protracted hospitalisation, antibiotics administration, and increased morbidity and mortality. This work investigated the incidence rate of SSIs in the Department of General Surgery at the University Hospital of Ioannina, Greece, the associated risk factors and pathogens responsible.

METHOD

In this prospective cohort study, patients who underwent elective procedures under general anaesthesia were enrolled. Risk factors monitored included age, sex, body mass index, smoking, alcohol consumption, preoperative length of stay, chemoprophylaxis, intensive care unit (ICU) stay, American Society of Anesthesiology (ASA) score, and the National Nosocomial Infections Surveillance System (NNIS) basic SSI risk index.

RESULTS

Of the 1058 enrolled patients, 80 (7.6%) developed SSIs. Of the total cohort, 62.5% of patients received chemoprophylaxis for >24 hours. A total of 20 different pathogens, each with multiple strains (n=108 in total), were identified, 53 (49.5%) Gram-negative rods, 46 (42%) Gram-positive cocci, and nine (8.4%) fungi (Candida spp.). Escherichia coli was the prevalent microorganism (24.3%). SSI-related risk factors, as defined by univariate analysis, included: ICU stay, ASA score >2 (p<0.001), NNIS score >0, and wound classes II, III, and IV. Also, serum albumin levels <3.5g/dl were associated with increased rate of SSIs. The multivariate model identified an NNIS score of >0 and wound classes II, III, and IV as independent SSI-related risk factors.

CONCLUSION

This study showed high SSI rates. Several factors were associated with increased SSI rates, as well as overuse of prophylactic antibiotics. The results of the present study could be a starting point for the introduction of a system for recording and actively monitoring SSIs in Greek hospitals, and implementation of specific guidelines according to risk factors.

Surgeons' mental models of surgical site infection: Insights into adherence with complex prevention bundles

Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than "pay-for-performance" models.

Determinants of orthopedic physicians' self-reported compliance with surgical site infection prevention: results of the WACH-trial's pilot survey on COM-B factors in a German university hospital

BACKGROUND

Prevention of surgical site infections (SSIs), which due to their long-term consequences are especially critical in orthopedic surgery, entails compliance with over 20 individual measures. However, little is known about the psychosocial determinants of such compliance among orthopedic physicians, which impedes efforts to tailor implementation interventions to improve compliance. Thus, for this professional group, this pilot survey examined psychosocial determinants of self-reported compliance, which have been theoretically derived from the COM-B (Capability, Opportunity, Motivation and Behavior) model.

METHODS

In 2019, a cross-sectional survey was conducted in a tertiary care university orthopedic clinic in Hannover, Germany, as a pilot for the WACH-trial ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotics Consumption in Surgery]). Fifty-two physicians participated (38 surgeons, 14 anesthesiologists; response rate: 73.2%). The questionnaire assessed self-reported compliance with 26 SSI preventive measures, and its psychosocial determinants (COM-B). Statistical analyses included descriptive, correlational, and linear multiple regression modeling.

RESULTS

Self-reported compliance rates for individual measures varied from 53.8 to 100%, with overall compliance (defined for every participant as the mean of his or her self-reported rates for each individual measure) averaging at 88.9% (surgeons: 90%, anesthesiologists: 85.9%; p = 0.097). Of the components identified in factor analyses of the COM-B items, planning, i.e., self-formulated conditional plans to comply, was the least pronounced (mean = 4.3 on the 7-point Likert scale), while motivation was reported to be the strongest (mean = 6.3). Bi-variately, the overall compliance index co-varied with all four COM-B-components, i.e., capabilities (r = 0.512, p < 0.001), opportunities (r = 0.421, p = 0.002), planning (r = 0.378, p = 0.007), and motivation (r = 0.272, p = 0.051). After mutual adjustment and adjustment for type of physician and the number of measures respondents felt responsible for, the final backward regression model included capabilities (β = 0.35, p = 0.015) and planning (β = 0.29, p = 0.041) as COM-B-correlates.

CONCLUSION

Though based on a small sample of orthopedic physicians in a single hospital (albeit in conjunction with a high survey response rate), this study found initial evidence for positive correlations between capabilities and planning skills with self-reported SSI preventive compliance in German orthopedic physicians. Analyses of the WACH-trial will further address the role of these factors in promoting SSI preventive compliance in orthopedic surgery.

TRIAL REGISTRATION

This survey was conducted as part of the research project WACH ("Wundinfektionen und Antibiotikaverbrauch in der Chirurgie" [Wound Infections and Antibiotic Consumption in Surgery]), which has been registered in the German Clinical Trial Registry ( https://www.drks.de/ ; ID: DRKS00015502).

Expert commentary on the challenges and opportunities for surgical site infection prevention through implementation of evidence-based guidelines in the Asia-Pacific Region

INTRODUCTION

Surgical site infections (SSIs) are a significant source of morbidity and mortality in the Asia-Pacific region (APAC), adversely impacting patient quality of life, fiscal productivity and placing a major economic burden on the country's healthcare system. This commentary reports the findings of a two-day meeting that was held in Singapore on July 30-31, 2019, where a series of consensus recommendations were developed by an expert panel composed of infection control, surgical and quality experts from APAC nations in an effort to develop an evidence-based pathway to improving surgical patient outcomes in APAC.

METHODS

The expert panel conducted a literature review targeting four sentinel areas within the APAC region: national and societal guidelines, implementation strategies, postoperative surveillance and clinical outcomes. The panel formulated a series of key questions regarding APAC-specific challenges and opportunities for SSI prevention.

RESULTS

The expert panel identified several challenges for mitigating SSIs in APAC; (a) constraints on human resources, (b) lack of adequate policies and procedures, (c) lack of a strong safety culture, (d) limitation in funding resources, (e) environmental and geographic challenges, (f) cultural diversity, (g) poor patient awareness and (h) limitation in self-responsibility. Corrective strategies for guideline implementation in APAC were proposed that included: (a) institutional ownership of infection prevention strategies, (b) perform baseline assessments, (c) review evidence-based practices within the local context, (d) develop a plan for guideline implementation, (e) assess outcome and stakeholder feedback, and (f) ensure long-term sustainability.

CONCLUSIONS

Reducing the risk of SSIs in APAC region will require: (a) ongoing consultation and collaboration among stakeholders with a high level of clinical staff engagement and (b) a strong institutional and national commitment to alleviate the burden of SSIs by embracing a safety culture and accountability.

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications

BACKGROUND

There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.

METHODS

Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.

RESULTS

There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.

CONCLUSION

There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.

Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement

BACKGROUND

Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy.

METHODS

An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included "emergency surgery", "laparotomy", "surgical site infection", "midline incision" and "wound bundle". Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI.

RESULTS

This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39-1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57-1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data.

CONCLUSIONS

This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle's ability to potentially improve outcome after emergency laparotomy.

Implementation of a surgical site infection prevention bundle: Patient adherence and experience

We evaluated barriers and facilitators to patient adherence with a bundled intervention including chlorhexidine gluconate (CHG) bathing and decolonizing Staphylococcus aureus nasal carriers in a real-world setting. Survey data identified 85.5% adherence with home use of CHG as directed and 52.9% adherence with home use of mupirocin as directed.

Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia

Objective:

Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC).

Design:

Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization’s SSI prevention recommendations.

Setting:

A tertiary-care hospital in Jimma, Ethiopia.

Participants:

Surgical nurses, surgeons, and anesthetists at JUMC.

Results:

Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring.

Conclusions:

Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC.

Negative pressure wound therapy in spinal fusion patients

Post-operative wound complications are some of the most common acute complications following spine surgery. These surgical site infections (SSI) contribute to increased healthcare related costs. Negative pressure wound therapy (NPWT) has long been used for treatment of soft tissue injury or defects. NPWT may reduce the incident of SSI following spinal fusion procedures; however, its potential applications need further clarification. Thus, we conducted a retrospective analysis of two cohorts to compare NPWT to traditional sterile dressings following spinal fusions in regards to post-operative outcomes. Following institutional review board approval, 42 patients who had a NPWT were matched by type of surgery to 42 patients who had traditional dressings. A retrospective chart-review was completed. Outcome measures, particularly SSI and need for reoperation, were analyzed using one-way ANOVA for both univariate and multivariate analysis. When controlled for sex and body-mass index, the use of a NPWT was independently correlated with decreased SSI (P = .035). Superficial dehiscence, seroma, need for additional outpatient care, and need for operative revision were all found to occur at higher rates in the traditional dressing cohort. Closed incisional negative pressure wound therapy provides a cost-effective method of decreasing surgical site infection for posterior elective spine surgeries.

Improving sterile processing practices in Cambodian healthcare facilities

Background

Sterile processing practices in low-resource countries contribute to greater post-operative infection rates compared to high-resource countries. Provision of a sterile processing training program in Tanzania and Ethiopia demonstrated statistically significant improvements in sterile processing practice, a key requisite for safe surgical care.

Aim

To determine if a sterile processing program in a South East Asia country would result in improved conditions and practice in urban and rural healthcare facilities.

Methods

In 2019, a mixed-methods study was conducted with two cohorts in Cambodia, involving a total of eight healthcare facilities and 43 healthcare workers. Quantitative data were collected using a sterile processing assessment tool and a multiple-choice test pre- and post-training. Qualitative data in the form of interviews were obtained several months post-training.

Findings

Test results showed statistically significant and sustained effect of training over a four-six month period, as well as a large positive effect on SP knowledge in both cohorts. Analysis of hospital assessment data revealed an aggregate improvement of 36% in sterile processing benchmarks. While all participants reported increased knowledge and confidence (quantitative), rural participants conveyed a lack of support (qualitative) to implement practice changes.

Conclusion

The training course produced improvements in both rural and urban facilities. Findings highlight the importance of informing administrators of the rationale for needed improvements, ensuring funding is available to implement recommendations, and for governments to hold administrators accountable for improvements aligning with universally recommended sterile processing standards.

Qualitative Thematic Analysis of Knowledge and Practices of Surgical Antimicrobial Prophylaxis at a Tertiary Care Teaching Hospital

Background: Surgical antimicrobial prophylaxis (SAP) refers to the utilization of antibiotic agents for the prevention of surgical site infections (SSI), to prevent SSI-associated morbidity and mortality, reduce duration and cost of healthcare, and cause minimal adverse drug effects. The adherence rate among surgeons for the available international and national guidelines and optimal practice remains considerably low in many hospitals, especially in developing countries. The objective of this study was to assess the knowledge and compliance rate for SAP guidelines among various surgical specialties and those involved in providing SAP. Methods: An institution-based exploratory, multi-specialty, collective, mixed method approach (qualitative and quantitative) was used to assess the knowledge and compliance rate for SAP guidelines among the consultants and residents of surgical specialties. Quantitative analysis was performed using a pre-tested questionnaire. For qualitative analysis, focus group discussions were conducted. Thematic analysis was conducted by the Theoretical Domains Framework (TDF) and the Capabilities, Opportunities, Motivation and Behaviour (COM-B) model. Results: Twenty-eight focus groups and 16 paired interviews were undertaken. On thematic analysis six significant themes were noted and mapped to the COM-B model, and subthemes mapped to the relevant TDF domains in a combined framework. Key themes recognized were: (1) solitary focus on surgical skills; (2) following the hierarchy is more important than guideline compliance; (3) doubts and overcautious attitude of surgeons hinders appropriate SAP prescribing; (4) non-availability in-hospital supply of antimicrobial agents; (5) patient characteristics and type of surgery play a role in prescribing SAP; and (6) lack of national and local guidelines. Conclusions: The knowledge and attitudes of surgeons toward appropriate SAP prescribing are crucial factors for execution of guidelines. Including them in policy making decisions can help in strong execution of the same.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis

BACKGROUND

The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work.

METHODS

MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted.

RESULTS

This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis.

CONCLUSIONS

There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases

Surgical site infection (SSI) rates in low- and middle-income countries (LMICs) range from 8 to 30% of procedures, making them the most frequent healthcare-acquired infection (HAI) with substantial morbidity, mortality, and economic impacts. Presented here is an approach to surgical site infection prevention based on surveillance and focused on five critical areas identified by international experts. These five areas include

1. Collecting valid, high-quality data;

2. Linking HAIs to economic incapacity, underscoring the need to prioritize infection prevention activities;

3. Implementing SSI surveillance within infection prevention and control (IPC) programs to enact structural changes, develop procedural skills, and alter healthcare worker behaviors;

4. Prioritizing IPC training for healthcare workers in LMICs to conduct broad-based surveillance and to develop and implement locally applicable IPC programs; and

5. Developing a highly accurate and objective international system for defining SSIs, which can be translated globally in a straightforward manner.

Finally, we present a clear, unambiguous framework for successful SSI guideline implementation that supports developing sustainable IPC programs in LMICs. This entails

1. Identifying index operations for targeted surveillance;

2. Identifying IPC “champions” and empowering healthcare workers;

3. Using multimodal improvement measures;

4. Positioning hand hygiene programs as the basis for IPC initiatives;

5. Use of telecommunication devices for surveillance and healthcare outcome follow-ups.

Additionally, special considerations for pediatric SSIs, antimicrobial resistance development, and antibiotic stewardship programs are addressed.

Effect of perioperative hyperglycemia on surgical site infection in abdominal surgery: A prospective cohort study

BACKGROUND

Surgical site infection (SSI) remains one of the most frequent complications in abdominal surgery, and hyperglycemia prevention is recommended as a measure to reduce this type of infection. The aims of this study were to estimate the incidence of SSI and to identify the effect of perioperative hyperglycemia on the incidence of this type of infection in patients undergoing abdominal surgery.

METHODS

We enrolled 484 abdominal surgery patients ≥ 18 years of age, recruited between July 2016 and May 2017. Data were collected through structured interviews and patient assessments in the perioperative period and at the surgical outpatient clinic (30th day after surgery). Crude and adjusted models were built to identify the effect of hyperglycemia on SSI.

RESULTS

The incidence rate of SSI was 20.25%. The attributable fraction for patients exposed to hyperglycemia was >60%. In the multivariable analysis, patients with hyperglycemia, at the end of the surgery and 12 hours later, were more likely to develop this type of infection (relative risk = 1.89 and 2.17, respectively).

CONCLUSIONS

Perioperative hyperglycemia was identified as an independent risk factor for SSI. The evidence generated reinforces the importance of proper glycemic control management in the perioperative period for the prevention of SSI.

Implementation of World Health Organization Guidelines in the Prevention of Surgical Site Infection in Low- and Middle-Income Countries:What We Know and Do Not Know

Background: In low- and middle-income countries (LMICs), infection is the most frequent complication in surgical procedures, and surgical site infections (SSIs) globally are the most frequent health-care-associated infections (HAIs). Preventing SSI is an important target for overall quality improvement and patient safety as well as supporting the infection prevention and control (IPC) global agenda. Methods: In 2018, the World Heath Organization (WHO) presented the first Global Guidelines for the Prevention of Surgical Site Infections. The WHO also simplified SSI surveillance materials and included process measures, critical to addressing the barriers existing in LMICs. Because surveillance activities alone will not lead to improvements and implementation is more challenging than guideline development, the WHO then outlined a novel, step by step approach for implementation based on its tried and tested improvement approach for IPC measures. These documents have been reviewed and summarized to achieve wider reach in the surgical community. Results: The WHO implementation guidance notes examples of current practice against the WHO SSI prevention guideline recommendations and considers LMIC settings. It identifies the related problem that needs to be addressed if the recommendation is not being applied consistently and reliably. It breaks down the steps required to make an improvement applying key elements known as the multi-modal improvement strategy. Conclusions: Implementation of IPC guidance documents and tools published by global organizations and national governments continues to be a challenge, especially for LMICs. Successful approaches need to include a science-based approach to implementation and improvement, as well as joined up working and learning across IPC and surgical communities. Real improvements can be only achieved, based on WHO workforce recommendations, with IPC programs including the staff to execute these programs and using a proven approach.

Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis

OBJECTIVE

In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction.

METHODS

We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space).

RESULTS

We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48-0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42-0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46-0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50-0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions.

CONCLUSIONS

Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.

Delirium in intensive care: A stepped-wedge cluster randomised controlled trial for a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the intensive care unit (protocol)

BACKGROUND

Delirium is an acute disorder of attention and cognition with the highest rates among adults receiving intensive care. An acute episode of delirium is associated with morbidity and mortality, as well as a significant psychological sequela. Importantly, an increasing body of evidence supports the benefit of nonpharmacological, nurse-led interventions to reduce the incidence and duration of delirium among adults cared for in the intensive care unit (ICU).

OBJECTIVES

This study will evaluate the impact of a nursing-led delirium prevention protocol that is aimed at reducing the incidence and duration of delirium among adults admitted to the ICU. The delirium prevention nursing protocol specifically targets risk factors for delirium.

STUDY PLAN

A stepped-wedge cluster randomised controlled trial approach will be used to assess the effectiveness of the nurse-led intervention, in four adult ICUs across the South Western Sydney Local Health District (SWS-LHD), over a 12-month period. The primary outcomes of interest are (i) the incidence of delirium before and after the implementation of the nurse-led intervention and (ii) the number of delirium-free days during an ICU stay, before and after the implementation of the nurse-led intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): (ACTRN12618000411246p).

Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review

Background

Surgical site infections (SSIs) are highly prevalent in abdominal surgery despite evidence-based prevention measures. Since guidelines are not self-implementing and SSI-preventive compliance is often insufficient, implementation interventions have been developed to promote compliance. This systematic review aims to identify implementation interventions used in abdominal surgery to prevent SSIs and determine associations with SSI reductions.

Methods

Literature was searched in April 2018 (Medline/PubMed and Web of Science Core Collection). Implementation interventions were classified using the implementation subcategories of the EPOC Taxonomy (Cochrane Review Group Effective Practice and Organisation of Care, EPOC). Additionally, an effectiveness analysis was conducted on the association between the number of implementation interventions, specific compositions thereof, and absolute and relative SSI risk reductions.

Results

Forty studies were included. Implementation interventions used most frequently (“top five”) were audit and feedback (80% of studies), organizational culture (70%), monitoring the performance of healthcare delivery (65%), reminders (53%), and educational meetings (45%). Twenty-nine studies (72.5%) used a multimodal strategy (≥3 interventions). An effectiveness analysis revealed significant absolute and relative SSI risk reductions. E.g., numerically, the largest absolute risk reduction of 10.8% pertained to thirteen studies using 3–5 interventions (p < .001); however, this was from a higher baseline rate than those with fewer or more interventions. The largest relative risk reduction was 52.4% for studies employing the top five interventions, compared to 43.1% for those not including these. Furthermore, neither the differences in risk reduction between studies with different numbers of implementation interventions (bundle size) nor between studies including the top five interventions (vs. not) were significant.

Conclusion

In SSI prevention in abdominal surgery, mostly standard bundles of implementation interventions are applied. While an effectiveness analysis of differences in SSI risk reduction by number and type of interventions did not render conclusive results, use of standard interventions such as audit and feedback, organizational culture, monitoring, reminders, and education at least does not seem to represent preventive malpractice. Further research should determine implementation interventions, or bundles thereof, which are most effective in promoting compliance with SSI-preventive measures in abdominal surgery.

Optimizing compliance with surgical antimicrobial prophylaxis guidelines in patients undergoing gastrointestinal surgery at a referral teaching hospital in southern Iran: clinical and economic impact

BACKGROUND

Antibiotic prophylaxis is one of the major approaches to prevent surgical site infection. Despite the availability of international guidelines on it, the practice of antibiotic prophylaxis is still far from optimal. This study aimed to assess the impact of guideline implementation on the rational use of prophylactic antibiotics and its cost-saving effect in gastrointestinal surgery by clinical pharmacist intervention.

METHODS

A pre and post intervention study was carried out between October 2017 and June 2018 on patients who underwent gastrointestinal surgery in a major referral teaching hospital in Shiraz, southern Iran. The intervention phase consisted of revising the institutional guidelines for surgical antimicrobial prophylaxis, assigning a clinical pharmacist to the surgical department, and arranging several meetings with the surgical department regarding the appropriate utilization of antibiotics. Differences in antibiotic utilization in patients before and after the intervention phase were compared. Exposures were surgical antimicrobial prophylaxis timing and agents, and main outcomes were incidence of surgical site infection and length of hospital stay.

RESULTS

A total of 430 patients were included in the post intervention phase, while 445 patients were included in the baseline evaluation. Promoting appropriate antibiotic use in the post intervention group had the potential to decrease medication costs by reducing unnecessary prescriptions and duration of antibiotic usage (P<0.001). In the pre intervention group, the mean cost of antibiotic prescriptions was 11.5 times that of the post intervention group. Mean hospitalization in the pre intervention group was greater than the post intervention group (P<0.001). Furthermore, our data revealed that the rate of postsurgery infection in the post intervention group was 3.03%, while this rate was 6.76% in the preintervention group (P=0.01).

CONCLUSION

This study provides evidence that adherence to surgical antimicrobial prophylaxis guidelines increased the rational use of prophylactic antibiotics, with substantial cost savings in patients who underwent surgery.