Epidemiology of surgical-site infections diagnosed after hospital discharge: a prospective cohort study

Surgical site infections are independently associated with the development of postoperative acute-on-chronic liver failure in liver cirrhosis

Acute-on-chronic liver failure (ACLF) is associated with organ failure and high short-term mortality. Bacterial infections and surgery have been reported as major precipitants for ACLF. However, detailed characterization of postoperative infections after elective surgery in patients with liver cirrhosis and their impact on the development of ACLF have not been investigated yet. A total of 235 patients with cirrhosis without ACLF and proven bacterial infections undergoing elective surgery were included. The primary end point was the development of ACLF within 28 days after surgery, and secondary end points were infection development within 28 days and 3-month ACLF-related mortality. Cox regression analysis was used for identification of risk factors associated with ACLF development, infection development, and mortality. A total of 86 patients (37%) developed ACLF within 28 days after surgery. Patients with new postoperative infections had significantly higher rates of associated ACLF episodes within 28 days (51% vs. 24%, p < 0.001) and higher 3-month mortality ( p < 0.05) than patients without postoperative infections. New infections after surgery [HR: 2.43 (1.59-3.71), p < 0.001] and organ/space surgical site infections [HR: 2.46 (1.26-4.80), p = 0.01] in particular were independent risk factors associated with ACLF development 28 days after surgery. Extensive procedures were associated with the development of new postoperative infection episodes within 28 days. Infections treated with initial appropriate empirical antibiotic strategies showed significantly improved survival. This study characterizes and identifies bacterial infections in general and organ/space surgical site infection in particular as precipitating events for the development of ACLF after elective surgery in patients with cirrhosis. Postoperative ACLF combined with infections leads to higher postoperative short-term mortality than each condition separately, especially in extensive procedures. Interdisciplinary care, early identification of postoperative ACLF and infections, and adequate, broad, and early treatment strategies are needed to improve postoperative outcome.

The Burden of Surgical Site Infection at Hospital Universiti Sains Malaysia and Related Postoperative Outcomes: A Prospective Surveillance Study

Surgical site infections (SSIs) are the most common healthcare-associated infections that occur among surgical patients. Surgical site infections result in longer hospital stays, hospital readmissions, and higher death and morbidity rates. The current study was designed to highlight the importance of such surveillance studies in a Malaysian surgical population with a motive to evaluate and revise concurrent infection control and prevention policies by exploring the burden of surgical site infection and identifying its associated risk factors for future considerations. In this prospective observational cohort study, a total of 216 patients admitted to a surgical ward were identified and studied. Of these 216 patients, 142 elective procedures and 74 emergency procedures were included in the study, of which 13 patients (9.2%) undergoing elective procedures and 15 (20.3%) patients undergoing emergency procedures were SSI positive (OR: 2.5, p = 0.02). Among surgical site infections, 21 were superficial and 7 were deep incisional SSI. No case of organ/space SSI was identified. The time taken for SSIs to develop ranged from 2-17 days with a median of 6 days. Risk factors such as presence of comorbidities (p = 0.011), major co-existing medical diagnosis ≥2 (p = 0.02), and pre-existing infection (p = 0.027) were statistically significant. SSI-positive patients experienced an increase in the post-operative length of hospital stay. In the current population, it was seen that identifying patients who were at high risk of malnutrition via MUST and the NNIS risk index will help clinicians in identifying high risk patients and in managing their patients appropriately. Identifying patients who were at high risk of malnutrition will also improve postoperative outcomes considerably.

Pure abdominal laparoscopic approach versus thoraco-abdominal laparoscopic approach: What is the best technique for liver resection in segment 7 and segment 8? An answer from the Institut Mutualiste Montsouris experience with short- and long-term outcome evaluation

BACKGROUND

Lesions in segments 7 and 8 are a challenge during standard laparoscopic liver resection. The addition of transthoracic trocars could be useful in the standard abdominal approach for laparoscopic liver resection. We report our experience with a thoraco-abdominal laparoscopic combined approach for liver resection with the aim of comparing short- and long-term outcomes.

METHODS

We reviewed 1,003 laparoscopic liver resections in a prospectively maintained, single-institution database. We compared patient outcomes intraoperatively and postoperatively. We analyzed the long-term outcomes of the colorectal liver metastasis subgroup. Propensity score matching 1:1 was performed based on the following variables: age, American Society of Anesthesiologists, body mass index, previous abdominal surgery, multiple or single liver resection, lesion >50 mm or <50 mm, presence of solitary or multiple lesions, T stage, and N stage.

RESULTS

The standard abdominal approach was used in 110 laparoscopic liver resections, and the thoraco-abdominal laparoscopic combined approach was used in 62 laparoscopic liver resections. The thoraco-abdominal laparoscopic combined approach was associated with better intraoperative results (less blood loss and no need for conversion to open surgery). The R1s rate for segmentectomy 7 and 8 was lower in the thoraco-abdominal laparoscopic combined approach in the entire group and in the colorectal liver metastasis subgroup. In the colorectal liver metastasis subgroup, the 3- and 5-year overall survival was 90% and 80% in the thoraco-abdominal laparoscopic combined approach group and 76% and 52% in the standard abdominal approach group, respectively (P = .02). In univariate and multivariate analysis, the thoraco-abdominal laparoscopic combined approach was a significant factor that positively affected disease-free survival and overall survival.

CONCLUSION

The thoraco-abdominal laparoscopic combined approach in laparoscopic liver resection in segments 7 and 8 is safe and feasible, and it has demonstrated better oncologic outcomes than the pure abdominal approach, especially in segmentectomy.

Efficacy of Postoperative Oral Antibiotics in Foot and Ankle Surgery

BACKGROUND

Preoperative oral antibiotic use in patients undergoing foot and ankle surgery is standard practice, but no consensus has been reached regarding the efficacy of postoperative oral antibiotics. The purpose of this study was to determine whether postoperative oral antibiotics reduce the rate of surgical site infections (SSIs) in patients, with and without comorbidities, undergoing foot and ankle surgery.

METHODS

A retrospective chart review was conducted identifying patients who underwent foot and ankle surgery by 4 fellowship-trained, foot and ankle orthopaedic surgeons between January 1, 2015, and January 1, 2019. Patients were divided into 2 groups: those who received postoperative oral antibiotics (group 1) and those who did not (group 2). Two surgeons routinely prescribed postoperative oral antibiotics, and 2 did not. Demographics, comorbidities, and procedure complexity based on surgical site and Current Procedural Terminology code were recorded from the charts. The primary outcome was postoperative infection (superficial or deep) within 6 months after surgery. Patients with antibiotic use prior to surgery, preoperative infection, or lack of follow-up >6 weeks were excluded. Multivariate logistic regression modeling was used to analyze differences in infection rate and severity.

RESULTS

Chart review identified 3631 patients, 1227 of whom did not receive postoperative oral antibiotics whereas 2394 patients did. Routine postoperative oral antibiotic use did not significantly affect postoperative infection rates or severity. However, all covariates studied (diabetes, hypertension, obesity, tobacco use, alcohol use, rheumatoid conditions, and age) influenced postoperative infection rates and severity.

CONCLUSION

The results of this study indicate that postoperative oral antibiotics are not associated with differences in infection rates or severity. We do not recommend routine use in foot and ankle surgery.

The Clinical Impact of Advanced Age on the Postoperative Outcomes of Patients Undergoing Gastrectomy for Gastric Cancer: Analysis Across US Hospitals Between 2011–2017

Purpose

This study systematically evaluated the implications of advanced age on post-surgical outcomes following gastrectomy for gastric cancer using a national database.

Materials and Methods

The 2011–2017 National Inpatient Sample was used to isolate patients who underwent gastrectomy for gastric cancer. From this, the population was stratified into those belonging to the younger age cohort (18–59 years), sexagenarians, septuagenarians, and octogenarians. The younger cohort and each advanced age category were compared in terms of the following endpoints: mortality following surgery, length of hospital stay, charges, and surgical complications.

Results

This study included a total of 5,213 patients: 1,366 sexagenarians, 1,490 septuagenarians, 743 octogenarians, and 1,614 under 60 years of age. Between the younger cohort and sexagenarians, there was no difference in mortality (2.27 vs. 1.67%; P=0.30; odds ratio [OR], 1.36; 95% confidence interval [CI], 0.81–2.30), length of stay (11.0 vs. 11.1 days; P=0.86), or charges ($123,557 vs. $124,425; P=0.79). Compared to the younger cohort, septuagenarians had higher rates of in-hospital mortality (4.30% vs. 1.67%; P<0.01; OR, 2.64; 95% CI, 1.67–4.16), length of stay (12.1 vs. 11.1 days; P<0.01), and charges ($139,200 vs. $124,425; P<0.01). In the multivariate analysis, septuagenarians had higher mortality (P=0.01; adjusted odds ratio [aOR], 2.01; 95% CI, 1.18–3.43). Similarly, compared to the younger cohort, octogenarians had a higher rate of mortality (7.67% vs. 1.67%; P<0.001; OR, 4.88; 95% CI, 3.06–7.79), length of stay (12.3 vs. 11.1 days; P<0.01), and charges ($131,330 vs. $124,425; P<0.01). In the multivariate analysis, octogenarians had higher mortality (P<0.001; aOR, 4.03; 95% CI, 2.28–7.11).

Conclusions

Advanced age (>70 years) is an independent risk factor for postoperative death in patients with gastric cancer undergoing gastrectomy.

Update on the epidemiology of healthcare-acquired bacterial infections: focus on complicated skin and skin structure infections

Healthcare-associated infections (HCAIs) are a threat to patient safety and cause substantial medical and economic burden in acute care and long-term care facilities. Risk factors for HCAIs include patient characteristics, the type of care and the setting. Local surveillance data and microbiological characterization are crucial tools for guiding antimicrobial treatment and informing efforts to reduce the incidence of HCAI. Skin and soft tissue infections, including superficial and deep incisional surgical site infections, are among the most frequent HCAIs. Other skin and soft tissue infections associated with healthcare settings include vascular access site infections, infected burns and traumas, and decubitus ulcer infections.

Management of superficial and deep surgical site infection: an international multidisciplinary consensus

Surgical site infections represent a considerable burden for healthcare systems. To obtain a consensus on the impact and future clinical and economic needs regarding SSI management in an era of multidrug resistance. A modified Delphi method was used to obtain consensus among experts from five European countries. The Delphi questionnaire was assembled by a steering committee, verified by a panel of experts and administered to 90 experts in 8 different surgical specialities (Abdominal, Cancer, Cardiac, General surgery, Orthopaedic, Thoracic, Transplant and Vascular and three other specialities (infectious disease, internal medicine microbiology). Respondents (n = 52) reached consensus on 62/73 items including that resistant pathogens are an increasing matter of concern and increase both treatment complexity and the length of hospital stay. There was strong positive consensus on the cost-effectiveness of early discharge (ED) programs, improvement of quality of life with ED and association between increased length of stay and economic burden to the hospital. However, established ED protocols were not widely available in their hospitals. Respondents expressed a positive consensus on the usefulness of antibiotics that allow ED. Surgeons are aware of their responsibility in an interdisciplinary team for the treatment of SSI, and of the impact of multidrug-resistant bacteria in the context of SSI. Reducing the length of hospital stays by applying ED protocols and implementing new treatment alternatives is crucial to reduce harm to patients and costs for the hospital.

Effect of Postoperative Oral Antibiotics on Infections and Wound Healing Following Foot and Ankle Surgery

BACKGROUND

There is controversy regarding the effectiveness of postoperative antibiotics to prevent wound infection. Some surgeons still use a routine postoperative oral antibiotic regimen. The purpose of this study was to review a series of cases and document statistically any difference in infection rates and whether routine postoperative antibiotics in foot and ankle surgery are justified.

METHODS

A retrospective chart review of 649 patients was performed who underwent elective foot and ankle surgery. Six hundred thirty-one patient charts were included in the final analysis. Evaluated were patients who did and did not receive postoperative oral antibiotics in order to identify whether a difference in infection rate or wound healing occurred. The study also evaluated risk factors for developing infection following foot and ankle surgery.

RESULTS

The number of infections in patients receiving postoperative oral antibiotics was 6 (3%), while the number of infections in those who did not receive postoperative oral antibiotics was 10 (2%) (P = .597). The difference of deep versus superficial infections and delays in wound healing between the 2 groups was not statistically significant. Patients who developed infections were older and had a higher prevalence of hypertension, a history of neoplasm, and a greater American Society of Anesthesiologists Classification of Physical Health.

CONCLUSION

This study suggests that routine use of postoperative antibiotics in foot and ankle surgery does not affect wound complications or infection rates. Additionally, patients who are older and those with multiple medical problems may be at higher risk for developing postoperative infection following foot and ankle surgeries.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Management of Common Postoperative Complications

Postoperative complications are common. Major guidelines have been published on stratifying and managing adverse cardiovascular events and thromboembolic events, but there is often less literature supporting management of other, more common, postoperative complications, including acute kidney injury, gastrointestinal complications, postoperative anemia, fever, and delirium. These common conditions are frequently seen in hospital and can contribute to longer lengths of stay and rising health care costs. These complications are often due to the interplay between both patient-specific and surgery-specific risk factors. Identifying these risk factors, while addressing and optimizing modifiable risks, can mitigate the likelihood of developing these postoperative complications. Often, a multidisciplinary approach, including care team members through all phases of the surgical encounter, is needed. Cardiovascular and thrombotic complications have been addressed in prior articles in this perioperative series. We aim to cover other common postoperative complications, such as acute renal failure, postoperative gastrointestinal complications, anemia, fever, and delirium that often contribute to longer lengths of stay, rising health care costs, and increased morbidity and mortality for patients.

Cost of postoperative complications: How to avoid calculation errors

Postoperative complications (PC) are a basic health outcome, but no surgery service in the world records and/or audits the PC associated with all the surgical procedures it performs. Most studies that have assessed the cost of PC suffer from poor quality and a lack of transparency and consistency. The payment system in place often rewards the volume of services provided rather than the quality of patients’ clinical outcomes. Without a thorough registration of PC, the economic costs involved cannot be determined. An accurate, reliable appraisal would help identify areas for investment in order to reduce the incidence of PC, improve surgical results, and bring down the economic costs. This article describes how to quantify and classify PC using the Clavien-Dindo classification and the comprehensive complication index, discusses the perspectives from which economic evaluations are performed and the minimum postoperative follow-up established, and makes various recommendations. The availability of accurate and impartially audited data on PC will help reduce their incidence and bring down costs. Patients, the health authorities, and society as a whole are sure to benefit.

Optimal timing of surgical antimicrobial prophylaxis in laparoscopic surgery: a before-after study

Background

The optimal timing of preoperative surgical antimicrobial prophylaxis (SAP) remains uncertain. This study aimed to evaluate the impact of changing the timing of SAP on the incidence of surgical site infection (SSI) in laparoscopic surgery.

Methods

We performed a before-after study from August 2014 through June 2017 to assess the impact of changes in the timing of SAP on the incidence of SSI at a 790-bed tertiary care center in Japan. The intervention was the administration of SAP immediately after the study patients entered the operating room for laparoscopic surgery.

Results

In total, 1397 patients who met the inclusion criteria were analyzed. After the intervention, the median time between the time of SAP completion and the time of surgical incision changed from 8 min to 26 min (p <  0.001), and the number of cases without SAP completion prior to surgical incision decreased (16.8% vs. 1.8%; p <  0.001). However, changes in the overall incidence of SSI did not significantly differ between the pre-intervention and the intervention groups (13.8% vs. 13.2%; p = 0.80).

Conclusions

Although the timing of preoperative SAP improved, the intervention did not have a significant impact on reducing the incidence of SSI in the current study. Besides preoperative SAP, multidisciplinary approaches should be incorporated into projects aimed at comprehensively improving surgical quality to reduce SSI.

Risk factors for surgical site infection following cesarean delivery: a retrospective cohort study

BACKGROUND

The rate of cesarean delivery is increasing in North America. Surgical site infection following this operation can make it difficult to recover, care for a baby and return home. We aimed to determine the incidence of surgical site infection to 30 days following cesarean delivery, associated risk factors and whether risk factors differed for predischarge versus postdischarge infection.

METHODS

We identified a retrospective cohort in Nova Scotia by linking the provincial perinatal database to hospital admissions and physician billings databases to follow women for 30 days after they had given birth by cesarean delivery between Jan. 1, 1997 and Dec. 31, 2012. Logistic regression with generalized estimating equations was used to determine risk factors for infection.

RESULTS

A total of 25 123 women had 33 991 cesarean deliveries over the study period. Of the 25 123, 923 had surgical site infections, giving an incidence rate of 2.7% (95% CI 2.54%-2.89%); the incidence decreased over time. Risk factors for infection (adjusted odds ratios ≥ 1.5) were prepregnancy weight 87.0 kg or more, gaining 30.0 kg or more during pregnancy, chorioamnionitis, maternal blood transfusion, anticoagulation therapy, alcohol or drug abuse, second stage of labour before surgery, delivery in 1997-2000 and delivery in a hospital performing 130-1249 cesarean deliveries annually. Women who gave birth earlier in the study period, those who gave birth in a hospital with 130-949 cesarean deliveries per year and those with more than 1 fetus were at a significantly higher risk for surgical site infection before discharge; women who smoked were at significantly higher risk for surgical site infection after discharge.

INTERPRETATION

Most risk factors are known before delivery, and some are potentially modifiable. Although the incidence of surgical site infection decreased over time, targeted clinical and infection prevention and control interventions could further reduce the burden of illness associated with this health-care-related infection.

Early recognition of methicillin-resistant Staphylococcus aureus surgical site infections using risk and protective factors identified by a group of Italian surgeons through Delphi method

BACKGROUND

Surgical site infections (SSIs) constitute a major clinical problem in terms of morbidity, mortality, duration of hospital stay, and overall costs. The bacterial pathogens implicated most frequently are Streptococcus pyogenes (S. pyogenes) and Staphylococcus aureus (S. aureus). The incidence of methicillin-resistant S. aureus (MRSA) SSIs is increasing significantly. Since these infections have a significant impact on hospital budgets and patients' health, their diagnosis must be anticipated and therapy improved. The first step should be to evaluate risk factors for MRSA SSIs.

METHODS

Through a literature review, we identified possible major and minor risk factors for, and protective factors against MRSA SSIs. We then submitted statements on these factors to 228 Italian surgeons to determine, using the Delphi method, the degree of consensus regarding their importance. The consensus was rated as positive if >80% of the voters agreed with a statement and as negative if >80% of the voters disagreed. In other cases, no consensus was reached.

RESULTS

There was positive consensus that sepsis, >2 weeks of hospitalization, age >75 years, colonization by MRSA, and diabetes were major risk factors for MRSA SSIs. Other possible major risk factors, on which a consensus was not reached, e.g., prior antibiotic use, were considered minor risk factors. Other minor risk factors were identified. An adequate antibiotic prophylaxis, laparoscopic technique, and infection committee surveillance were considered protective factors against MRSA SSIs. All these factors might be used to build predictive criteria for identifying SSI due to MRSA.

CONCLUSIONS

In order to help to recognize and thus promptly initiate an adequate antibiotic therapy for MRSA SSIs, we designed a gradation of risk and protective factors. Validation, ideally prospective, of this score is now required. In the case of a SSI, if the risk that the infection is caused by MRSA is high, empiric antibiotic therapy should be started after debriding the wound and collecting material for culture.

Cost and Consequences of Surgical Site Infections: A Call to Arms

Despite decades of attention and advances in medical treatments, surgical site infections (SSI) remain a significant problem to our patients. Surprisingly, the reported incidence of SSI has not changed appreciably in the past five decades, although not surprisingly the timing to diagnosis (inpatient vs. outpatient) has changed. Although the patient consequences have not escaped our notice, until recently the costs associated with SSI have been difficult to ascertain. In this review, we discuss the relevant history of SSI monitoring, the incidence as well as the costs and consequences associated with this complication.

Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures Results From the Nosocomial Surveillance Network in The Netherlands

Objective.

To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important.

Design.

Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record.

Setting.

Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004.

Results.

We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%).

Conclusions.

For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

Postoperative Nonpathologic Fever After Spinal Surgery: Incidence and Risk Factor Analysis

BACKGROUND

Although there are many postoperative febrile causes, surgical-site infection has always been considered as one of the major causes, but it should be excluded; we encountered many patients who showed delayed postoperative fever that was not related to wound infection after spinal surgery. We aimed to determine the incidence of delayed postoperative fever and its characteristics after spinal surgery, and to analyze the causal factors.

METHODS

A total of 250 patients who underwent any type of spinal surgery were analyzed. We determined febrile patients as those who did not show any fever until postoperative day 3, and those who showed a fever with an ear temperature of greater than 37.8°C at 4 days after surgery. We collected patient data including age, sex, coexistence of diabetes mellitus or hypertension, smoking history, location of surgical lesion (e.g., cervical, thoracic, lumbar spine), type of surgery, surgical approach, diagnosis, surgical level, presence of revision surgery, operative time, duration of administration of prophylactic antibiotics, and the presence of transfusion during the perioperative period, with a chart review.

RESULTS

There were 33 febrile patients and 217 afebrile patients. Multivariate logistic regression showed that surgical approach (i.e., posterior approach with anterior body removal and mesh graft insertion), trauma and tumor surgery compared with degenerative disease, and long duration of surgery were statistically significant risk factors for postoperative nonpathologic fever.

CONCLUSIONS

We suggest that most spinal surgeons should be aware that postoperative fever can be common without a wound infection, despite its appearance during the late acute or subacute period.

Randomized Comparison of Subcuticular Sutures Versus Staples for Skin Closure After Open Abdominal Surgery: a Multicenter Open-Label Randomized Controlled Trial

BACKGROUND

The incisional surgical site infection (SSI) is an extremely common complication following open abdominal surgery and imposes a considerable treatment and cost burden.

METHOD

We conducted a multicenter open-label randomized controlled trial at three Tokyo Metropolitan medical institutions. We enrolled adult patients who underwent either an elective or an emergency open laparotomy. Eligible patients were allocated preoperatively to undergo wound closure with either subcuticular sutures or staples. A central Web-based randomization tool was used to assign participants randomly by a permuted block sequence with a 1:1 allocation ratio and a block size of 4 before mass closure to each group. The primary endpoint was the occurrence of a superficial SSI within 30 days after surgery in accordance with the Centers for Disease Control and Prevention criteria. This trial was registered with UMIN-CTR as UMIN 000004836 ( http://www.umin.ac.jp/ctr ).

RESULTS

Between September 1, 2010 and August 31, 2015, 401 patients were enrolled and randomly assigned to either group. One hundred and ninety-nine patients were allocated to the subcuticular suture and 202 patients to the staple groups (hereafter the "suture" and "staple" group, respectively). Three hundred and ninety-nine were eligible for the primary endpoint. Superficial SSIs occurred in 25 of 198 suture patients and in 27 of 201 staple patients. Overall, the rate of superficial SSIs did not differ significantly between the suture and staple groups.

CONCLUSION

Subcuticular sutures did not increase the occurrence of superficial SSIs following open laparotomies mainly consisting of clean-contaminated surgical procedures. The applicability of the wound closure material and method is likely to depend on individual circumstances of the patient and surgical procedure.

Surgical Site Infection During Hospitalization and After Discharge in Patients Who Have Undergone Cardiac Surgery

During a 13-month period, 513 patients who were scheduled to undergo cardiac surgery were prospectively observed for surgical site infection during hospitalization after surgery and for 1 month after hospital discharge. Fifty-three patients showed evidence of surgical site infection (during hospitalization for 31 patients and after discharge for 22). Multivariate analysis identified that risk factors for surgical site infection differed between infections that occurred during hospitalization and those that occurred after discharge.

Surveillance for Surgical Site Infection After Hospital Discharge: A Surgical Procedure–Specific Perspective

Objective.

To estimate the rate of surgical site infection (SSI) occurring after hospital discharge, to evaluate whether limiting surveillance to inpatients underestimates the true rate of SSI, and to select surgical procedures that should be included in a postdischarge surveillance program.

Design.

Prospective surveillance study.

Setting.

A surgical ward at a university teaching hospital in Italy.

Patients.

A total of 264 surgical patients were included in the study.

Results.

The global SSI rate was 10.6% (28 patients); 17 (60.2%) of patients with an SSI developed the infection after hospital discharge. The overall mean length of postoperative stay (±SD) for patients who acquired a postdischarge SSI was 4.9 ± 3.7 days, and SSI was diagnosed a mean duration (±SD) of 11.5 ± 4.5 days after surgery. Among procedures with postdischarge SSIs, those classified by the National Nosocomial Infections Surveillance system (NNIS) as herniorrhaphy, mastectomy, other endocrine system, and other integumentary system were associated with a mean postoperative stay that was less than the mean time between the operation and the onset of SSI. Four (36%) of in-hospital SSIs occurred after procedures with an NNIS risk index of 0, and 7 (64%) occurred after procedures with an NNIS risk index of 1 or higher. Of the 17 SSIs diagnosed after discharge, 14 procedures (82%) had an NNIS risk index of 0, compared with 3 procedures (18%) with an NNIS risk index of 1 or higher.

Conclusions.

Our results revealed an increased risk of postdischarge SSI after some types of surgical procedures and suggest that there is an important need to change from generalized to NNIS operative category-directed postdischarge surveillance, at least for procedures locally considered to be high-risk.

Impact of Postdischarge Surveillance on Surgical Site Infection Rates for Several Surgical Procedures Results From the Nosocomial Surveillance Network in The Netherlands

Objective.

To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important.

Design.

Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record.

Setting.

Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004.

Results.

We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%).

Conclusions.

For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

Focus on the prophylaxis, epidemiology and therapy of methicillin-resistant Staphylococcus aureus surgical site infections and a position paper on associated risk factors: the perspective of an Italian group of surgeons

BACKGROUND

The aim of this research was to study the epidemiology, microbiology, prophylaxis, and antibiotic therapy of surgical site infections (SSIs), especially those caused by methicillin-resistant Staphylococcus aureus (MRSA), and identify the risk factors for these infections. In Italy SSIs occur in about 5 % of all surgical procedures. They are predominantly caused by staphylococci, and 30 % of them are diagnosed after discharge. In every surgical specialty there are specific procedures more associated with SSIs.

METHODS

The authors conducted a systematic review of the literature on SSIs, especially MRSA infections, and used the Delphi method to identify risk factors for these resistant infections.

RESULTS

Risk factors associated with MRSA SSIs identified by the Delphi method were: patients from long-term care facilities, recent hospitalization (within the preceding 30 days), Charlson score > 5 points, chronic obstructive pulmonary disease and thoracic surgery, antibiotic therapy with beta-lactams (especially cephalosporins and carbapenem) and/or quinolones in the preceding 30 days, age 75 years or older, current duration of hospitalization >16 days, and surgery with prothesis implantation. Protective factors were adequate antibiotic prophylaxis, laparoscopic surgery and the presence of an active, in-hospital surveillance program for the control of infections. MRSA therapy, especially with agents that enable the patient's rapid discharge from hospital is described.

CONCLUSION

The prevention, identification and treatment of SSIs, especially those caused by MRSA, should be implemented in surgical units in order to improve clinical and economic outcomes.

A Prognostic Model of Surgical Site Infection Using Daily Clinical Wound Assessment

BACKGROUND

Surgical site infection (SSI) remains a common, costly, and morbid health care-associated infection. Early detection can improve outcomes, yet previous risk models consider only baseline risk factors (BF) not incorporating a proximate and timely data source-the wound itself. We hypothesize that incorporation of daily wound assessment improves the accuracy of SSI identification compared with traditional BF alone.

STUDY DESIGN

A prospective cohort of 1,000 post open abdominal surgery patients at an academic teaching hospital were examined daily for serial features (SF), for example, wound characteristics and vital signs, in addition to standard BF, for example, wound class. Using supervised machine learning, we trained 3 Naïve Bayes classifiers (BF, SF, and BF+SF) using patient data from 1 to 5 days before diagnosis to classify SSI on the following day. For comparison, we also created a simplified SF model that used logistic regression. Control patients without SSI were matched on 5 similar consecutive postoperative days to avoid confounding by length of stay. Accuracy, sensitivity/specificity, and area under the receiver operating characteristic curve were calculated on a training and hold-out testing set.

RESULTS

Of 851 patients, 19.4% had inpatient SSIs. Univariate analysis showed differences in C-reactive protein, surgery duration, and contamination, but no differences in American Society of Anesthesiologists scores, diabetes, or emergency surgery. The BF, SF, and BF+SF classifiers had area under the receiver operating characteristic curves of 0.67, 0.76, and 0.76, respectively. The best-performing classifier (SF) had optimal sensitivity of 0.80, specificity of 0.64, positive predictive value of 0.35, and negative predictive value of 0.93. Features most associated with subsequent SSI diagnosis were granulation degree, exudate amount, nasogastric tube presence, and heart rate.

CONCLUSIONS

Serial features provided moderate positive predictive value and high negative predictive value for early identification of SSI. Addition of baseline risk factors did not improve identification. Features of evolving wound infection are discernable before the day of diagnosis, based primarily on visual inspection.

Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery

OBJECTIVE

Surgical site infection (SSI) is one of the most common postoperative complications after vascular reconstruction, producing significant morbidity and hospital readmission. In contrast to SSI that develops while patients are still hospitalized, little is known about the cohort of patients who develop SSI after discharge. In this study, we explore the factors that lead to postdischarge SSI, investigate the differences between risk factors for in-hospital vs postdischarge SSI, and develop a scoring system to identify patients who might benefit from postdischarge monitoring of their wounds.

METHODS

Patients who underwent major vascular surgery from 2005 to 2012 for aneurysm and lower extremity occlusive disease were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, in-hospital SSI, or SSI after hospital discharge. Predictors of postdischarge SSI were determined by multivariable logistic regression and internally validated by bootstrap resampling. Risk scores were assigned to all significant variables in the model. Summative risk scores were collapsed into quartile-based ordinal categories and defined as low, low/moderate, moderate/high, and high risk. Multivariable logistic regression was used to determine predictors of in-hospital SSI.

RESULTS

Of the 49,817 patients who underwent major vascular surgery, 4449 (8.9%) were diagnosed with SSI (2.1% in-hospital SSI; 6.9% postdischarge SSI). By multivariable analysis, factors significantly associated with increased odds of postdischarge SSI include female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, neurologic disease, prolonged operative time >4 hours, American Society of Anesthesiology class 4 or 5, lower extremity revascularization or aortoiliac procedure, and groin anastomosis. The model exhibited moderate discrimination (bias-corrected C statistic, 0.691) and excellent internal calibration. The postdischarge SSI rate was 2.1% for low-risk patients, 5.1% for low/moderate-risk patients, 7.8% for moderate/high-risk patients, and 14% for high-risk patients. In a comparative analysis, comorbidities were the primary driver of postdischarge SSI, whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI.

CONCLUSIONS

The majority of SSIs after major vascular surgery develop following hospital discharge. We have created a scoring system that can select a cohort of patients at high risk for SSI after discharge. These patients can be targeted for transitional care efforts focused on early detection and treatment with the goal of reducing morbidity and preventing readmission secondary to SSI.

Randomized clinical trial of skin closure by subcuticular suture or skin stapling after elective colorectal cancer surgery

Background

The best suture method to prevent incisional surgical-site infection (SSI) after clean-contaminated surgery has not been clarified.

Methods

Patients undergoing elective colorectal cancer surgery at one of 16 centres were randomized to receive either subcuticular sutures or skin stapling for skin closure. The primary endpoint was the rate of incisional SSI. Secondary endpoints of interest included time required for wound closure, incidence of wound problems, postoperative length of stay, wound aesthetics and patient satisfaction.

Results

A total of 1264 patients were enrolled. The cumulative incidence of incisional SSI by day 30 after surgery was similar after subcuticular sutures and stapled closure (8·7 versus 9·8 per cent respectively; P = 0·576). Comparison of cumulative incidence curves revealed that SSI occurred later in the subcuticular suture group (P = 0·019) (hazard ratio 0·66, 95 per cent c.i. 0·45 to 0·97). Wound problems (P = 0·484), wound aesthetics (P = 0·182) and postoperative duration of hospital stay (P = 0·510) did not differ between the groups; subcuticular sutures took 5 min longer than staples (P &lt; 0·001). Patients in the subcuticular suture group were significantly more satisfied with their wound (52·4 per cent versus 42·7 per cent in the staple group; P = 0·002).

Conclusion

Compared with skin stapling, subcuticular sutures did not reduce the risk of incisional SSI after colorectal surgery. Registration number: UMIN000004001 (http://www.umin.ac.jp/ctr).

Validation of a Modified Version of the National Nosocomial Infections Surveillance System Risk Index for Health Services Research

Objective.

To validate the National Nosocomial Infections Surveillance system risk index through administrative data to predict surgical site infections.

Design.

Retrospective cohort study.

Setting.

Population-based analysis in Ontario, Canada.

Patients.

All elderly patients who underwent elective surgery from April 1, 1992, through March 31, 2006 (n = 469,349).

Methods.

Data on procedural and patient outcomes were gathered from linked population-wide hospital discharge records and physician claims. The 75th percentile of surgical duration was estimated through anesthesiologist billing fees recorded in 15-minute increments; the American Society of Anesthesiology score of at least 3 out of 5 was estimated by diagnostic codes for severe systemic illness; and all surgeries were classified as clean or clean-contaminated because of their elective nature (thus, the maximum score on the modified index was 2).

Results.

A total of 147,216 surgeries (31%) had a score of 0;246,592 (53%) had a score of 1; and 75,541 (16%) had a score of 2 on the modified index. The 30-day risk of surgical site infection increased with each increment in the modified index (score of 0, 5.4%; score of 1, 8.0%; score of 2, 14.3%; P < .001). The association was evident for surgical site infection diagnosed during the index admission (score of 0, 2.0%; score of 1, 3.7%; score of 2, 8.9%; P < .001), as well as that associated with reoperation or death (score of 0, 0.04%; score of 1, 0.23%; score of 2, 0.73%; P < .001). The modified index predicted increases in surgical site infection risk within each of 11 surgical subgroups. In accord with past research, the modified index had modest discrimination (C statistic, 0.59), and the majority of surgical site infections (72%) occurred within lower risk strata.

Conclusions.

The modified index predicts surgical site infection in population-based analyses and is associated with incremental increases in risk.

Incidência de infecção do sítio cirúrgico e fatores de risco associados na clínica cirúrgica de pequenos animais

A infecção do sítio cirúrgico (ISC) apresenta-se como um complicador que possui muitos fatores de risco associados, e a maior parte das informações utilizadas nessa área pela medicina veterinária provém da medicina humana. Objetivou-se com este trabalho determinar a taxa de ISC no HVT-UFV, assim como correlacionar sua incidência com os seguintes fatores de risco: quantidade de pessoas presentes durante a cirurgia, classificação do potencial de contaminação da ferida cirúrgica e utilização de antimicrobiano profilático e ou terapêutico. Para isso, foram colhidas informações sobre a ocorrência de ISC, bem como os fatores de risco citados de 401 prontuários. Esses dados passaram por análise estatística, e foram obtidos os seguintes resultados: 21 pacientes diagnosticados com ISC, o que gerou uma taxa de infecção de 5,24% e associação entre incidência de ISC e cirurgias com risco de contaminação maior que 5%. Os demais fatores de risco avaliados não apresentaram associação, porém, em valores absolutos, foi detectada maior ocorrência de infecção nos procedimentos com maior quantidade de pessoas na sala de cirurgia. Portanto, foi possível observar a importância da obtenção fidedigna de dados e a necessidade do desenvolvimento de um sistema de vigilância epidemiológica voltado para a medicina veterinária.

Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Surgical site infection (SSI) is a costly complication leading to increased resource use and patient morbidity. We hypothesized that postdischarge SSI results in a high rate of preventable readmissions.

METHODS

We used our institutional American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing general surgery procedures from 2006 to 2011.

RESULTS

SSIs developed in 10% of the 3,663 patients who underwent an inpatient general surgical procedure. SSI was diagnosed after discharge in 48% of patients. Patients with a diagnosis of SSI after discharge were less likely to have a history of smoking (15% vs 28%, P = .001), chronic obstructive pulmonary disease (3% vs 9%, P = .015), congestive heart failure (0% vs 3%, P = .03), or sepsis within 48 hours preoperatively (17% vs 32%, P = .001) compared with patients diagnosed before discharge. Over 50% of the patients diagnosed with SSI after discharge required readmission.

CONCLUSIONS

A diagnosis of SSI after discharge is associated with a high readmission rate despite occurring in healthier patients. We propose discharge teaching improvements and a wound surveillance clinic within the first week may result in a decreased readmission rate.

Surgical wound infection rates in Spain: data summary, January 1997 through June 2012

BACKGROUND

The Indicadores Clínicos de Mejora Continua de la Calidad (INCLIMECC) program was established in Spain in 1997.

METHODS

INCLIMECC is a prospective system of health care-associated infection (HAI) surveillance that collects incidence data in surgical and intensive care unit patients. The protocol is based on the National Healthcare Safety Network (NHSN) surveillance system, formerly known as the National Nosocomial Infection Surveillance (NNIS) system, and uses standard infection definitions from the US Centers for Disease Control and Prevention. Each hospital takes part voluntarily and selects the units and surgical procedures to be surveyed.

RESULTS

This report is a summary of the data collected between January 1997 and June 2012. A total of 370,015 patients were included, and the overall incidence of surgical wound infection (SWI) was 4.51%. SWI rates are provided by NHSN operating procedure category and NNIS risk index category. More than 27% of the patients received inadequate antibiotic prophylaxis, the main reason being unsuitable duration (57.05% of cases).

CONCLUSIONS

Today, the INCLIMECC network includes 64 Spanish hospitals. We believe that an HAI surveillance system with trained personnel external to the surveyed unit is a key component not only in infection control and prevention, but also in a quality improvement system.

Assessing surgical site infection risk factors using electronic medical records and text mining

Text mining techniques to detect surgical site infections (SSI) in unstructured clinical notes were used to improve SSI detection. In conjuction with data from an integrated electronic medical record, all of the 22 SSIs detected by traditional hospital-based surveillance were found using text mining, along with an additional 37 SSIs not detected by traditional surveillance.

Cross-sectional study on surveillance of surgical site infections after vascular surgery

Aims: To determine the incidence and risk factors for surgical site infections (SSI) after vascular surgery, to evaluate the Dutch safety bundle to reduce adverse complications and to analyze causative microorganisms of SSIs. Materials & methods: The 3.5-year study was divided into two periods: the control period (before bundle implementation) and intervention period (after implementation). Postdischarge surveillance was performed until 30 days after surgery. Causative microorganisms from in-hospital wound swabs were determined. SSI rates between both periods were compared and a risk analysis was carried out by performing a logistic regression. Results: The study included 1719 operations. The in-hospital SSI rate increased significantly over time. Out of 140 SSIs, 39% were diagnosed postdischarge. Risk factors were diabetes, age >60 years and operations classified as contaminated or dirty. Pseudomonas aeruginosa susceptibility was the highest for gentamicin (97%). All Staphylococcus aureus were methicillin susceptible. Conclusion: As patient demographics are important to determine the effectiveness of infection preventive measures, (postdischarge) surveillance is important for developing SSI interventions.

[Implementation of a post-discharge surgical site infection system in herniorrhaphy and mastectomy procedures]

INTRODUCTION

Monitoring surgical site infection (SSI) performed during hospitalization can underestimate its rates due to the shortening in hospital stay. The aim of this study was to determine the actual rates of SSI using a post-discharge monitoring system.

METHODS

All patients who underwent herniorraphy or mastectomy in the Hospital Universitario Ramón y Cajal from 1 January 2011 to 31 December 2011 were included. SSI data were collected prospectively according to the continuous quality improvement indicators (Indicadores Clinicos de Mejora Continua de la Calidad [INCLIMECC]) monitoring system. Post-discharge follow-up was conducted by telephone survey.

RESULTS

A total of 409patients were included in the study, of whom 299 underwent a herniorraphy procedure, and 110 underwent a mastectomy procedure. For herniorrhaphy, the SSI rate increased from 6.02% to 7.6% (the post-discharge survey detected 21.7% of SSI). For mastectomy, the SSI rate increased from 1.8% to 3.6% (the post-discharge survey detected 50% of SSI).

CONCLUSIONS

Post-discharge monitoring showed an increased detection of SSI incidence. Post-discharge monitoring is useful to analyze the real trend of SSI, and evaluate improvement actions. Post-discharge follow-up methods need to standardised.

[Initial patient assessment of infectious diseases and diagnostic steps with fever]

The initial assessment of patients with infectious diseases is challenging because of the extremely broad differential diagnosis as well as different host pathogen interactions influenced by a different immune status. The formal initial assessment, including the present and past medical history, thorough physical examination, clinical first impressions as well as routine laboratory analyses, is the basis of every preliminary diagnosis. Specific chief complaints have to be recognized in order to narrow down the differential diagnosis. In cases of life-threatening illnesses, such as septicemia, endocarditis, bacterial meningitis and severe pneumonia, the first diagnostic and therapeutic steps should be performed in a rapid sequence: bacterial blood samples, sputum and/or liquor samples are required and the initial antibiotic therapy has to be chosen empirically as the relevant bacterial spectrum related to the suspected illness must be covered. In less urgent cases it is recommended that a multi-step diagnostic approach be carried out which takes the differential diagnosis into account and prioritizes the probabilities. In the latter situation antibiotic treatment should be delayed to diagnose the infection correctly. Importantly, atypical courses must necessitate careful and critical reassessment of the diagnosis.

Prospective Analysis Methicillin-resistant Staphylococcus aureus and its Risk Factors

Background:

Since the early nineties, a new methicillin-resistant Staphylococcus aureus (MRSA) has existed in a form correlating with community health personnel. Community-acquired MRSA (CA-MRSA) could be differentiated from healthcare-associated MRSA (HA-MRSA) microbiologically, epidemiologically, and molecularly.

Aims:

To determine the prevalence, risk factors of MRSA infections in community and hospital.

Settings:

The incidence and risk factors for CA-MRSA and HA-MRSA among patients of medical, surgical, and pediatrics wards and ICU at a Kuwaiti teaching hospital between 1 March 2011 and 30 November 2011 were studied.

Materials and Methods:

Cultures for MRSA were taken from nasal (nostril), groin, axilla, wound, sputum, or throat, and the inguinal area in all enrolled patients upon admission. All preserved isolates were examined for their susceptibility to different types of antibiotics.

Results and Conclusion:

A total of 71 MRSA patients admitted to different hospital wards were examined. Among these patients, 52 (73.2%) were carriers of MRSA before they were admitted to the hospital. Nineteen patients (26.8%) were found to have acquired MRSA during their stay in the hospital. Twenty-nine patients (40.8%) were given mupirocin local skin antibiotic. Binomial and the t-test (paired) were used to compare the prevalence of CA-MRSA and HA-MRSA; significant correlation (P < 0.05) between the type of MRSA and different wards, sites, and lengths of hospital stay was found. The level of serum albumin that is routinely measured at hospital admission is a predictor to MRSA infection. This study suggests that S. aureus and MRSA should become a national priority for disease control to avoid outbreaks.

Surgical site infection rate is lower in laparoscopic than open colorectal surgery

OBJECTIVE

Few studies have investigated whether surgical site infection (SSI) incidence differs between laparoscopic colorectal surgery (LCS) and open colorectal surgery (OCS). This study investigated the SSI incidence using the validated UK SSI Surveillance Service (SSISS) criteria for diagnosing wound infections.

METHOD

Prospective data collection recorded patients' demographics, operative details, antibiotic use, wound evaluation and microbiological wound culture results, for consecutive patients undergoing elective resectional LCS and OCS. Postdischarge surveillance consisted of patient questionnaires sent out at 30 days and the primary care communication.

RESULTS

A total of 122 patients underwent colorectal resections over 1 year (LCS 43; OCS 79). Patients' demographics and operative case-mix were similar for both groups, including body mass index (BMI), diabetic and smoking status. Operative duration was longer in the LCS group compared with OCS group (P = 0.012, Mann-Whitney U-test), but hospital stay was shorter for LCS (P = 0.0001, Mann-Whitney U-test). The SSI rate was significantly lower in the LCS than OCS group (7%vs 25% respectively; P = 0.015, two-tailed Fisher's exact test). BMI > 30 and operation length > 4 h influenced the risk of SSI formation (P < 0.05, chi-squared test). One LCS patient required conversion to a limited laparotomy.

CONCLUSIONS

Surgical site infection incidence is significantly lower following LCS when compared with OCS. Confounding factors in this study include patient selection for LCS and nonrandomization.

Discharge after discharge: predicting surgical site infections after patients leave hospital

In this population-based retrospective cohort study, we examined the frequency, severity, and prediction of post-discharge surgical site infections (SSIs). We evaluated all patients admitted for their first elective surgical procedure in Ontario, Canada, between 1 April 2002 and 31 March 2008. Procedure and patient characteristics were derived from linked hospital, emergency room and physician claims databases within Canada's universal healthcare system. The 30 day risk of SSI was derived from the initial hospital admission, outpatient consultations, return emergency room visits and readmissions. The cohort included 622 683 patients, of whom 84 081 (13.5%) were diagnosed with SSI, and more than half (48 725) were diagnosed post-discharge. Post-discharge infections were associated with an increased risk of reoperation (odds ratio: 2.28; 95% confidence interval: 2.11-2.48), return emergency room visit (9.08; 8.89-9.27), and readmission (6.16; 5.98-6.35). The most common risk index predicted incremental increases in the risk of in-hospital SSI, but did not predict increases in the risk of post-discharge infection. Patients with post-discharge infections had baseline characteristics more akin to uninfected patients than patients with in-hospital infections. Predictors of post-discharge infection included shorter procedure duration, shorter length of stay, rural residence, alcoholism, diabetes and obesity. Post-discharge SSIs are frequent, severe, scattered over time and location, and hard to predict using common risk indices. They represent an important hidden burden in our healthcare system.

Rates of surgical site infection as a performance measure: Are we ready?

With the introduction of quality assurance in health care delivery, there has been a proliferation of research studies that compare patient outcomes for similar conditions among many health care delivery facilities. Since the 1990s, increasing interest has been placed in the incorporation of clinical adverse events as quality indicators in hospital quality assurance programs. Adverse post-operative events, and very especially surgical site infection (SSI) rates after specific procedures, gained popularity as hospital quality indicators in the 1980s. For a SSI rate to be considered a valid indicator of the quality of care, it is essential that a proper adjustment for patient case mix be performed, so that meaningful comparisons of SSI rates can be made among surgeons, institutions, or over time. So far, a significant impediment to developing meaningful hospital-acquired infection rates that can be used for intra- and inter-hospital comparisons has been the lack of an adequate means of adjusting for case mix. This paper discusses what we have learned in the last years regarding risk adjustment of SSI rates for provider performance assessment, and identifies areas in which significant improvement is still needed.

Surveillance, control, and prevention of surgical site infections in breast cancer surgery: a 5-year experience

BACKGROUND

We analyzed variations in surgical site infections (SSIs) during 5 years of a prospective surveillance program and investigated possible contributors to SSIs in a cohort of patients who underwent surgery for breast cancer.

METHODS

All breast surgeries performed between January 2001 and December 2005 were registered. Patients were followed-up by direct observation for at least 30 days under standardized conditions. The main outcome studied was SSI. A case-control analysis was conducted to identify SSI-associated risk factors and to evaluate SSI variations by means of a control chart.

RESULTS

During the study period, a total of 2338 breast cancer surgeries were recorded, and 441 SSIs (18.9%) were diagnosed. SSI frequency varied across the 5-year period, with a sharp decline seen after the introduction of preventive policies. After 2002, 3 out-of-confidence limits of SSIs were observed, 2 related to the use of evacuation systems and 1 associated with a group of rotating residents. Concomitant preoperative chemoradiation (odds ratio [OR]=3.47; 95% confidence interval [CI]=2.51 to 4.80), hematoma (OR=3.05; 95% CI=1.70 to 5.52), age > or = 58 years (OR=1.83; 95% CI=1.27 to 2.65), body mass index > or = 30.8 (OR=1.58; 95% CI=1.14 to 2.18), and duration of surgery > or = 160 minutes (OR=1.73; 95% CI=1.20 to 2.50) were found to be SSI-associated risk factors.

CONCLUSIONS

After 5 years of a continuous prospective surveillance program, we were able to decrease the rate of SSIs in patients undergoing breast cancer surgery (from 33.3% in 2000 to 18.9% in 2005), identify SSI-associated risk factors, and improve the quality of care delivered to these patients.

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

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

Vigilância pós-alta das infecções de sítio cirúrgico em crianças e adolescentes em um hospital universitário de Belo Horizonte, Minas Gerais, Brasil

As infecções hospitalares são as principais complicações na prática cirúrgica e, dentre estas, as infecções de sítio cirúrgico são as mais freqüentes. Apesar dessas infecções poderem se manifestar após a alta, no Brasil, a maioria dos serviços não faz vigilância pós-alta. Para avaliar a importância dessa vigilância e o perfil das infecções em crianças e adolescentes, acompanhou-se uma coorte de 730 pacientes cirúrgicos de um hospital universitário de Belo Horizonte, Minas Gerais, Brasil, de 1999 a 2001. Calculou-se a incidência acumulada, aplicou-se o teste t de Student na comparação de médias e o método de Kaplan-Meier na análise do tempo de ocorrência das infecções; considerou-se significativo o valor p < 0,05. Foram diagnosticadas 87 infecções de sítio cirúrgico na coorte estudada, sendo 37% após a alta hospitalar. A taxa de incidência de infecções de sítio cirúrgico foi de 11,9%; mas seria apenas de 7,5% sem o controle pós-alta. Verificou-se no grupo dos pacientes com infecções identificadas após a alta uma média de aparecimento das infecções de 11,3 ± 6,4 dias; que os tempos de permanência pré e pós-operatórios foram significativamente menores em relação aos pacientes com infecções intra-hospitalares. O estudo indica que a vigilância pós-alta é importante para se conhecer a real incidência das infecções de sítio cirúrgico.

Surgical site infections in Italian Hospitals: a prospective multicenter study

BACKGROUND

Surgical site infections (SSI) remain a major clinical problem in terms of morbidity, mortality, and hospital costs. Nearly 60% of SSI diagnosis occur in the postdischarge period. However, literature provides little information on risk factors associated to in-hospital and postdischarge SSI occurrence. A national prospective multicenter study was conducted with the aim of assessing the incidence of both in-hospital and postdisharge SSI, and the associated risk factors.

METHODS

In 2002, a one-month, prospective national multicenter surveillance study was conducted in General and Gynecological units of 48 Italian hospitals. Case ascertainment of SSI was carried out using standardized surveillance methodology. To assess potential risk factors for SSI we used a conditional logistic regression model. We also reported the odds ratios of in-hospital and postdischarge SSI.

RESULTS

SSI occurred in 241 (5.2%) of 4,665 patients, of which 148 (61.4%) during in-hospital, and 93 (38.6%) during postdischarge period. Of 93 postdischarge SSI, sixty-two (66.7%) and 31 (33.3%) were detected through telephone interview and questionnaire survey, respectively. Higher SSI incidence rates were observed in colon surgery (18.9%), gastric surgery (13.6%), and appendectomy (8.6%). If considering risk factors for SSI, at multivariate analysis we found that emergency interventions, NNIS risk score, pre-operative hospital stay, and use of drains were significantly associated with SSI occurrence. Moreover, risk factors for total SSI were also associated to in-hospital SSI. Additionally, only NNIS, pre-operative hospital stay, use of drains, and antibiotic prophylaxis were associated with postdischarge SSI.

CONCLUSION

Our study provided information on risk factors for SSI in a large population in general surgery setting in Italy. Standardized postdischarge surveillance detected 38.6% of all SSI. We also compared risk factors for in-hospital and postdischarge SSI, thus providing additional information to that of the current available literature. Finally, a large amount of postdischarge SSI were detected through telephone interview. The evaluation of the cost-effectiveness of the telephone interview as a postdischarge surveillance method could be an issue for further research.