Incidence of and risk factors for surgical-site infections in a Peruvian hospital

Plastic Wound Protector vs Surgical Gauze for Surgical Site Infection Reduction in Open GI Surgery: A Randomized Clinical Trial

Importance

Surgical site infections (SSIs) are prevalent hospital-acquired infections with significant patient impacts and global health care burdens. The World Health Organization recommends using wound protector devices in abdominal surgery as a preventive measure to lower the risk of SSIs despite limited evidence.

Objective

To examine the efficacy of a dual-ring, plastic wound protector in lowering the SSI rate in open gastrointestinal (GI) surgery irrespective of intra-abdominal contamination levels.

Design, Setting, and Participants

This multicenter, patient-blinded, parallel-arm randomized clinical trial was conducted from August 2017 to October 2022 at 13 hospitals in an academic setting. Patients undergoing open abdominal bowel surgery (eg, for bowel perforation) were eligible for inclusion.

Intervention

Patients were randomized 1:1 to a dual-ring, plastic wound protector to protect the incision site of the abdominal wall (experimental group) or a conventional surgical gauze (control group).

Main Outcomes and Measures

The primary end point was the rate of SSI within 30 days of open GI surgery.

Results

A total of 458 patients were randomized; after 1 was excluded from the control group, 457 were included in the intention-to-treat analysis (mean [SD] age, 58.4 [12.1] years; 256 [56.0%] male; 341 [74.6%] with a clean-contaminated wound): 229 in the wound protector group and 228 in the surgical gauze group. The overall SSI rate in the intention-to-treat analysis was 15.7% (72 of 458 patients). The SSI rate for the wound protector was 10.9% (25 of 229 patients) compared with 20.5% (47 of 229 patients) with surgical gauze. The wound protector significantly reduced the risk of SSI, with a relative risk reduction (RRR) of 46.81% (95% CI, 16.64%-66.06%). The wound protector significantly decreased the SSI rate for clean-contaminated wounds (RRR, 43.75%; 95% CI, 3.75%-67.13%), particularly for superficial SSIs (RRR, 42.50%; 95% CI, 7.16%-64.39%). Length of hospital stay was similar in both groups (mean [SD], 15.2 [10.5] vs 15.3 [10.2] days), as were the overall postoperative complication rates (20.1% vs 18.8%).

Conclusions and Relevance

This randomized clinical trial found a significant reduction in SSI rates when a plastic wound protector was used during open GI surgery compared with surgical gaze, supporting the World Health Organization recommendation for use of wound protector devices in abdominal surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03170843.

Assessment of risk factors associated with surgical site infection following abdominal surgery: a systematic review

Objective

Surgical site infections (SSIs) are among the most common healthcare-associated infections occurring following 1%-3% of all surgical procedures. Their rates are the highest following abdominal surgery. They are still associated with increased morbidity and healthcare costs despite the advancement in the medical field. Many risk factors for SSIs following abdominal surgery have been identified. The aim of this study is to comprehensively assess these risk factors as published in peer-reviewed journals.

Design

A systematic review was conducted with accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Setting

The databases for search were PubMed and Cochrane Library, in addition to reference lists. Studies were retrieved and assessed for their quality. Data were extracted in a designed form, and a stratified synthesis of data was conducted to report the significant risk factors.

Participants

Patients undergoing general abdominal surgery.

Intervention

The intervention of general abdominal surgery.

Main outcome measures

To identify and assess the risk factors for SSI following abdominal surgery.

Results

Literature search yielded 813 articles, and the final screening process identified 11 eligible studies. The total number of patients is 11 996. The rates of SSI ranged from 4.09% to 26.7%. Nine studies were assessed to be of high quality, the remaining two studies have moderate quality. Stratified synthesis of data was performed for risk factors using summary measures (OR/risk ratio, 95% CI, and p value). Male sex and increased body mass index (BMI) were identified as significant demographic risk factors, and long operative time was among the major significant procedure-related risk factors.

Conclusions

Male sex, increased BMI, diabetes, smoking, American Society of Anesthesiologists classification of >2, low albumin level, low haemoglobin level, preoperative hospital stay, long operative time, emergency procedure, open surgical approach, increased wound class, intraoperative blood loss, perioperative infection, perioperative blood transfusion, and use of drains are potential independent risk factors for SSI following abdominal surgery.

Prevalence and Risk Factors of Surgical Site Infections in a Teaching Medical College in the Trichy District of India

Introduction Surgical site infection (SSI) remains a common and widespread problem, which contributes to significant morbidity and mortality, prolongs hospital stays, and consequently increases healthcare costs. The current study aimed to assess the prevalence of SSI and its associated risk factors among patients who underwent any surgical intervention in a tertiary care center in Trichy, Tamil Nadu, India. Methodology This was a hospital-based, cross-sectional study that was carried out over a period of one year in Trichy, Tamil Nadu, India. All adult patients of both genders older than 16 years who underwent surgery were included. Patients who underwent second surgery at the same site for any reason, patients on immunosuppressant therapy or immunodeficiency disease, patients on antibiotics already, and patients with infection elsewhere were excluded. After 48 hours of surgery, if there was evidence of wound infection, then the patient was considered to have SSI. The data obtained were analyzed using SPSS (Statistical Package for the Social Sciences) version 21 (IBM Corp., Armonk, NY). Results A total of 2076 patients underwent different types of surgeries. The prevalence of SSIs during the study period was 5.6% (n = 2076). SSIs were more common in abdominal surgeries (61.2%). Patients aged 16-24 years have a higher risk of getting SSI than other age groups (p = 0.040). Males have a higher risk of getting SSI than females (p = 0.022). Patients who underwent emergency surgery have a higher risk of getting SSI than those who underwent elective surgery (p = 0.025). Those with diabetes had a higher risk of getting SSI than those who were non-diabetics (p ≤ 0.0001). Conclusion SSIs were more common in abdominal surgeries. Patients who are male, younger in age, had emergency surgery, have diabetes, and have had a long hospital stay are at a higher risk of developing SSIs after any kind of surgery.

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.

Preoperative Surgical Site Hair Removal for Elective Abdominal Surgery: Does It Have Impact on Surgical Site Infection

Introduction  Postoperative surgical site infection (SSI) forms the major burden of nosocomial infections in surgical patients. There is prevalent practice of surgical site hair shaving as a part of preoperative preparation. There is uncertainty regarding the benefit versus harm of shaving for SSIs. Hairs at surgical sites are removed prior to surgery most often by shaving. We performed this study to look for what impact preoperative hair removal by shaving has on postoperative SSI.

Methods  We performed prospective comparative cohort study in patients undergoing elective abdominal surgeries. We included clean and clean-contaminated surgeries in immunocompetent patients of which half were shaved and other half not shaved prior to surgery. Other confounding factors like skin cleaning, aseptic technique of surgery, antibiotic prophylaxis and treatment, and postoperative wound care were as per care. Patients were assessed for presence and grade of SSI postoperatively on day 7, 14, and 30. Results were analyzed statistically using chi-square and Fischer's exact tests for significance in entire sample as well as in demographic subgroups.

Results  Overall SSI rate was 11.42%. There was no statistically significant difference in SSI rates between patients who underwent preoperative surgical site hair removal by shaving (232) and who did not have shaving (232) on all the three different assessment timelines in postoperative period, namely, day 7, 14, and 30. Although the absolute number of patients who had SSI was more in those who underwent preoperative surgical site hair removal by shaving, the difference was not statistically significant ( p  > 0.05). But on subgroup analysis patients with clean-contaminated surgeries ( p  = 0.037) and patients with surgeries lasting for less than 2 hours (Fischer's exact = 0.034) had significantly higher SSI in the shaved group compared with unshaved on day 14.

Conclusion  As per our results, preoperative shaving did not significantly increase overall SSI except in subgroup of clean-contaminated surgeries and in surgeries of less than 2 hours' duration. So especially in these patients avoiding preoperative surgical site hair shaving may be used as one of the infection control measures.

Hospital survey on patient safety culture (HSOPSC): a multi-method approach for target-language instrument translation, adaptation, and validation to improve the equivalence of meaning for cross-cultural research

BACKGROUND

The Hospital Survey on Patient Safety Culture (HSOPSC) is widely utilized in multiple languages across the world. Despite culture and language variations, research studies from Latin America use the Spanish language HSOPSC validated for Spain and the United States. Yet, these studies fail to report the translation method, cultural adaptation process, and the equivalence assessment strategy. As such, the psychometric properties of the HSOPSC are not well demonstrated for cross-cultural research in Latin America, including Peru. The purpose of this study was to develop a target-language HSOPSC for cross-cultural research in Peru that asks the same questions, in the same manner, with the same intended meaning, as the source instrument.

METHODS

This study used a mixed-methods approach adapted from the translation guideline recommended by Agency for Healthcare Research and Quality. The 3-phase, 7-step process incorporated translation techniques, pilot testing, cognitive interviews, clinical participant review, and subject matter expert evaluation.

RESULTS

The instrument was translated and evaluated in 3 rounds of cognitive interview (CI). There were 37 problem items identified in round 1 (14 clarity, 12 cultural, 11 mixed); and resolved to 4 problems by round 3. The pilot-testing language clarity inter-rater reliability was S-CVI/Avg = 0.97 and S-CVI/UA = 0.86; and S-CVI/Avg = 0.96 and S-CVI/UA = 0.83 for cultural relevance. Subject matter expert agreement in matching items to the correct dimensions was substantially equivalent (Kappa = 0.72). Only 1 of 12 dimensions had a low Kappa (0.39), borderline fair to moderate. The remaining dimensions performed well (7 = almost perfect, 2 = substantial, and 2 = moderate).

CONCLUSIONS

The HSOPSC instrument developed for Peru was markedly different from the other Spanish-language versions. The resulting items were equivalent in meaning to the source, despite the new language and different cultural context. The analysis identified negatively worded items were problematic for target-language translation. With the limited literature about negatively worded items in the context of cross-cultural research, further research is necessary to evaluate this finding and the recommendation to include negatively worded items in instruments. This study demonstrates cross-cultural research with translated instruments should adhere to established guidelines, with cognitive interviews, based on evidence-based strategies.

Surgical Antibiotic Prophylaxis Use and Surgical Site Infection Pattern in Dessie Referral Hospital, Dessie, Northeast of Ethiopia

Background

Surgical site infections are the third (14%-16%) most frequent cause of nosocomial infections among hospitalized patients. They still form a large health problem and result in increased antibiotic usage, increased associated costs, and prolonged hospitalization and contribute to increased patient morbidity and mortality. Therefore, studies on surgical site infections and surgical antibiotic prophylaxis contribute to identifying surgical site infection rate and risk factor associated with it as well as for identifying the gap in surgical antibiotic prophylaxis practice.

Objective

To assess surgical antibiotic prophylaxis practice and surgical site infection among surgical patients.

Method

A hospital-based prospective observational study was conducted in 68 patients who underwent major surgery in Dessie Referral Hospital adult surgical wards between March 24 and April 25/2017. Descriptive and logistic regression analyses were performed to determine infection rate and risk factors for surgical site infections.

Result

Assessment of 68 patients who underwent major surgery revealed an overall surgical site infection rate of 23.4%. Prophylactic antibiotics were administered for 59 operations; of these, 33 (48.6%) had inappropriate timing of administration. A combination of ceftriaxone and metronidazole 28 (47.46%) was frequently used. Factors associated with surgical site infection were wound class, patient comorbid condition, duration of the procedure, the timing of administration, and omitting prophylaxis use.

Conclusion

This study indicated a higher rate of surgical site infection and also revealed that wound class, preexisting medical condition, prolonged duration of surgery, omitting of prophylaxis use, and inappropriate timing of administration were highly associated with surgical site infection.

Circular pOlyethylene drape in preVEntion of suRgical site infection (COVER trial): study protocol for a randomised controlled trial

INTRODUCTION

Surgical site infection (SSI) after abdominal surgery remains a significant cause of morbidity and is associated with an increased socioeconomic burden and a reduced quality of life. Circular wound protectors have been expected to reduce the risk of SSI, but previous studies reported conflicting results on their protective effects. The purpose of this study was to evaluate the efficacy of circular wound protectors in reducing SSI in open abdominal surgery.

METHODS AND ANALYSIS

The circular pOlyethylen drape in preVEntion of suRgical site infection (COVER) trial investigates whether the application of a dual-ring circular plastic wound protector reduces the rate of SSI in patients undergoing elective or emergent open abdominal surgery related to the gastrointestinal tract, regardless of the type of wound classified by the Centers for Disease Control. The COVER trial is a multicentre, randomised controlled clinical trial with two parallel arms-one using a dual-ring wound protector with circular polyethylene drape and the other using conventional surgical dressing gauze. The primary outcome will measure the rate of SSI within 30 days after surgery in two groups. Statistical analysis of the primary end point will be based on the intention-to-treat population. The sample size was determined to achieve a study power of 80% with 95% two-sided confidence limits. Considering a dropout rate of up to 5%, a total of 458 patients, 229 patients in each group, will be enrolled in this study.

ETHICS AND DISSEMINATION

The trial protocol and informed consent document have been reviewed and approved by the institutional review board at each participating centre. Written informed consent will be obtained from each study participant. The clinical outcomes of this trial will be submitted to an international peer-reviewed journal and presented at international conferences.

TRIAL REGISTRATION NUMBER

NCT03170843.

Patient safety issues and concerns in Bhutan's healthcare system: a qualitative exploratory descriptive study

OBJECTIVES

To investigate what healthcare professionals perceived and experienced as key patient safety concerns in Bhutan's healthcare system.

DESIGN

Qualitative exploratory descriptive inquiry.

SETTINGS

Three different levels of hospitals, a training institute and the Ministry of Health, Bhutan.

PARTICIPANTS

In total, 140 healthcare professionals and managers.

METHODS

Narrative data were collected via conversational in-depth interviews and Nominal Group Meetings. All data were subsequently analysed using thematic analysis strategies.

RESULTS

The data revealed that medication errors, healthcare-associated infections, diagnostic errors, surgical errors and postoperative complications, laboratory/blood testing errors, falls, patient identification and communication errors were perceived as common patient safety concerns. Human and system factors were identified as contributing to these concerns. Instituting clinical governance, developing and improving the physical infrastructure of hospitals, providing necessary human resources, ensuring staff receive patient safety education and promoting 'good' communication and information systems were, in turn, all identified as processes and strategies critical to improving patient safety in the Bhutanese healthcare system.

CONCLUSION

Patient safety concerns described by participants in this study were commensurate with those identified in other low and middle-income countries. In order to redress these concerns, the findings of this study suggest that in the Bhutanese context patient safety needs to be conceptualised and prioritised.

Prophylactic, Synthetic Intraperitoneal Mesh Versus No Mesh Implantation in Patients with Fascial Dehiscence

BACKGROUND

Primary closure of post-operative facial dehiscence (FD) is associated with a high incidence of recurrence, revisional surgery, and incisional hernia. This retrospective study compares outcomes of implantation of non-absorbable intra-abdominal meshes with primary closure of FD. The outcomes of different mesh materials were assessed in subgroup analysis.

METHODS

A total of 119 consecutive patients with FD were operated (70 mesh group and 49 no mesh group) between 2001 and 2015. Primary outcome parameter was hernia-free survival. Secondary outcome parameters include re-operations of the abdominal wall, intestinal fistula, surgical site infections (SSI), and mortality. Kaplan-Meier analysis for hernia-free survival, adjusted Poisson regression analysis for re-operations and adjusted regression analysis for chronic SSI was performed.

RESULTS

Hernia-free survival was significantly higher in the mesh group compared to the no mesh group (P = 0.005). Fewer re-operations were necessary in the mesh group compared to the no mesh group (adjusted incidence risk ratio 0.44, 95% confidence interval [CI] 0.20-0.93, P = 0.032). No difference in SSI, intestinal fistula, and mortality was observed between groups. Chronic SSI was observed in 7 (10%) patients in the mesh group (n = 3 [6.7%] with polypropylene mesh and 4 [28.6%] with polyester mesh). The risk for chronic SSI was significantly higher if a polyester mesh was used when compared to a polypropylene mesh (adjusted odds ratio 8.69, 95% CI 1.30-58.05, P = 0.026).

CONCLUSION

Implantation of a polypropylene but not polyester-based mesh in patients with FD decreases incisional hernia with a low rate of mesh-related morbidity.

Surgical Site Infections Rates in More Than 13,000 Surgical Procedures in Three Cities in Peru: Findings of the International Nosocomial Infection Control Consortium

BACKGROUND

Surgical site infections (SSIs) are a threat to patient safety. However, there are not available data on SSI rates stratified by surgical procedure (SP) in Peru.

METHODS

From January 2005 to December 2010, a cohort prospective surveillance study on SSIs was conducted by the International Nosocomial Infection Control Consortium (INICC) in four hospitals in three cities of Peru. Data were recorded from hospitalized patients using the U.S. Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) methods and definitions for SSI. Surgical procedures (SPs) were classified into 4 types, according to ICD-9 criteria.

RESULTS

We recorded 352 SSIs, associated to 13,904 SPs (2.5%; CI, 2.3-2.8) SSI rates per type of SP were the following for this study's Peruvian hospitals, compared with rates of the INICC and CDC-NHSN reports, respectively: 2.9% for appendix surgery (vs. 2.9% vs. 1.4%); 2.8% for gallbladder surgery (vs. 2.5% vs. 0.6%); 2.2% for cesarean section (vs. 0.7% vs. 1.8%); 2.8% for vaginal hysterectomy (vs. 2.0% vs. 0.9%).

CONCLUSIONS

Our SSIs rates were higher in all of the four analyzed types of SPs compared with CDC-NHSN, whereas compared with INICC, most rates were similar. This study represents an important advance in the knowledge of SSI epidemiology in Peru that will allow us to introduce targeted interventions.

Surgical site infections after abdominal surgery: incidence and risk factors. A prospective cohort study

BACKGROUND

Abdominal surgeries have high rates of surgical site infections (SSIs), contributing to increased morbidity and mortality and costs for hospitalization. The aim of this study was to determine the SSI incidence rates and risk factors after abdominal surgeries.

METHODS

This prospective cohort study included all patients undergoing abdominal surgeries between 2005 and 2007 in the Western Galilee Medical Center in Nahariya, Israel. SSI incidence rates were calculated per 100 operations. Odds ratios (ORs) were estimated for each risk factor using univariate and multivariate analyses by logistic regression models.

RESULTS

Among 302 patients in the study cohort, the total SSI incidence rate was 22.2%. The univariate analysis defined 13 variables significantly associated with SSI: age > 60 years, lower functional status, diabetes mellitus, congestive heart failure, immunocompromising underlying disease, treatment with chemotherapy and other immunosuppressive medications, impaired immune system open cholecystectomy, laparotomy, an American Society of Anesthesiologists (ASA) score > 2, drain insertion, and 'dirty wound' classification. In multivariate regression analysis, treatment with immunosuppressive medications (OR = 2.5, 95% confidence interval (CI) = 1.099-143.443), open cholecystectomy (OR = 2.25, 95% CI = 2.242-40.109), and dirty wound classification (OR = 2.179, 95% CI = 3.80-20.551) were significantly associated with SSI.

CONCLUSIONS

The significant risk factors defined should be addressed preoperatively to decrease the risk for SSI. Wound surveillance in the post-discharge period is necessary for correct estimation of SSI rates.

Performance of the National Nosocomial Infections Surveillance Risk Index in Predicting Surgical Site Infection in Australia

Background.

The Victorian Hospital Acquired Infection Surveillance System (VICNISS) hospital-acquired infection surveillance system was established in 2002 in Victoria, Australia, and collates surgical site infection (SSI) surveillance data from public hospitals in Australia.

Objective.

To evaluate the association between the US National Nosocomial Infections Surveillance (NNIS) system's risk index and SSI rates for 7 surgical procedures.

Methods.

SSI surveillance was performed with NNIS definitions and methods for surgical procedures performed between November 2002 and September 2004. Correlations were assessed using the Goodman-Kruskal γ statistic.

Results.

Data were submitted for the following numbers of procedures: appendectomy, 545; coronary artery bypass graft (CABG), 4,632; cholecystectomy, 1,001; colon surgery, 623; cesarean section, 4,857; hip arthroplasty, 3,825; and knee arthroplasty, 2,416. NNIS risk index and increasing SSI rate were moderately well correlated for appendectomy (γ = 0.55), colon surgery (γ = 0.48), and cesarean section (γ = 0.42). A fairly positive correlation was found for cholecystectomy (γ = 0.17), hip arthroplasty (γ = 0.2), and knee arthroplasty (γ = 0.16). However, for CABG surgery, a poor association was found (γ = 0.02).

Conclusions.

The NNIS risk index was positively correlated with an increasing SSI rate for all 7 procedures; the strongest correlation was found for appendectomy, cesarean section, and colon surgery, and the poorest correlation was found for CABG surgery. We believe that risk stratification with the NNIS risk index is appropriate for comparison of data for most procedures and superior to use of no risk adjustment. However, for some procedures, particularly CABG, further studies of alternative risk indexes are needed to better stratify patients.

Case studies of patient safety research classics to build research capacity in low- and middle-income countries

BACKGROUND

Strengthening research capacity is a key priority and rate-limiting step for conducting patient safety research, particularly in low- and middle-income countries, but also in other settings where such research is currently limited. Case studies of classic publications in patient safety research were therefore developed as part of a larger strategy aimed at increasing the knowledge base and building the research capacity required for making health care safer and reducing harm to patients.

METHODS

A multistep method was used to develop the case studies, which involved developing a theoretical framework for classifying patient safety research articles; purposively selecting articles to illustrate a range of research methods and study designs; and involving the articles' lead authors to provide context, review the summaries, and offer advice to future patient safety researchers.

RESULTS

The series of patient safety research case studies used 17 examples to illustrate how different research methods and study designs can be used to answer different types of research questions across five stages of the research cycle: (1) measuring harm, (2) understanding causes, (3) identifying solutions, (4) evaluating impact, and (5) translating evidence into safer care. No single study design or research method is better in all circumstances. Choosing the most appropriate method and study design depends on the stage in the research cycle, the objectives, the research question, the subject area, the setting, and the resources available.

CONCLUSIONS

Beyond serving as didactic tools in assisting future leaders in patient safety research to build up their own competencies, the case studies help to illuminate the burgeoning field of patient safety research as a an important vehicle for reducing patient harm and improving health outcomes worldwide.

Risk factors for surgical site infections in abdominal surgery: a study in Nepal

BACKGROUND

Surgical site infection (SSI) remains a major clinical problem for developing countries in terms of morbidity, mortality, and hospital cost. Little is known about the epidemiology of SSI in Nepal. We conducted a study in Nepal to identify the various pre- and intra-operative risk factors for SSIs that are accessible to interventions.

METHODS

The study was a prospective study done on all eligible patients who underwent abdominal surgery in the surgical wards of Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Nepal, from January 2011 to June 2011. We evaluated some patient-related as well as intra-operative variables that could be risk factors for SSIs. We assessed the association between these risk factors and SSI with the Fisher exact test and logistic regression analysis.

RESULTS

Of the 230 patients included in the study, 53 were identified as having a SSI, resulting in an overall rate of SSI of 23%. Multivariable analysis identified the following factors as independent risk factors for SSI: (1) Low hemoglobin concentrations (<12 g/dL) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1-6.1); (2) overweight (OR 7.6; 95% CI 2.1-27.0); and (3) surgery performed by residents (OR 3.4; 95% CI 1.4-8.3).

CONCLUSIONS

Surgical site infection is common among patients undergoing abdominal surgery at TUTH. This study identified some preventable risk factors associated with SSI at TUTH. Identification of such risk factors is expected to help surgeons improve patient care and decrease mortality and morbidity as well as the hospital-care cost of surgical patients.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

BACKGROUND

Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries.

METHODS

We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis.

FINDINGS

Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance.

INTERPRETATION

The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices.

FUNDING

World Health Organization.

Nosocomial bacterial infections in a tertiary hospital in Ethiopia

The aim of this study was to determine the magnitude of nosocomial infection and isolate the bacterial aetiologic agents in a tertiary hospital. A total of 215 patients admitted to surgical wards and intensive care unit were followed prospectively. Specimens from patients were determined using standard techniques. Of the patients observed, 77 (35.8%) had 84 (39.1%) nosocomial infections. The overall incidence of nosocomial infections was 35.8/100 patients. Surgical site, urinary tract and blood stream infections comprised 38 (49.4%), 23 (29.8%) and 16 (20.8%), respectively. Of the bacterial isolates, 58/84 (69.0%) were Gram negative and 26/84 (31.0%) Gram positive. Pseudomonas aeruginosa (22.7%) and Escherichia coli (45.8%) were the major causes of surgical site and urinary tract infections, respectively. Staphylococcus aureus was isolated in 37.5% of the blood stream infections. The incidence of nosocomial infection in the hospital was high. There is a need to reduce the problem with continuous surveillance and the implementation of infection prevention strategies.

Surgical site infections in a tertiary health care center: prospective cohort study

PURPOSE

To investigate the incidence and risk factors associated with the development of surgical site infections (SSIs) using the National Nosocomial Infection Surveillance (NNIS).

METHODS

A prospective cohort study was conducted at a tertiary health care center. Infection control personnel collected general and health care related data about patients. The NNIS risk index was calculated on the basis of data relating to the operation: wound contamination class, duration of surgery, and the American Society of Anesthesiologists (ASA) score.

RESULTS

A total of 5109 surgical procedures were included in the study. The overall cumulative incidence rate was 6.3%. The incidence of SSIs was 2.3% (63.5% of operative procedures), 8.3% (29.7%), 34.6% (6.2%), and 43.3% (0.6%), in patients with 0, 1, 2, and 3 risk index, respectively. The length of hospital stay (OR: 1.0; 95% CI: 1.053-1.075), preoperative length of stay (odds ratio [OR]: 1.9; 95% confidence interval [CI]: 1.953-1.981), antibiotic prophylaxis (OR: 2.5; 95% CI: 1.421-4.628), drainage (OR: 1.7; 95% CI: 1.360-2.353), ASA score (OR: 1.5; 95% CI: 1.235-1.946), class of wound contamination (OR: 2.0; 95% CI: 1.745-2.003), and NNIS risk index (OR: 1.3; 95% CI: 1.063-1.7) were independently associated with an increased risk for SSIs. Staphylococcus aureus was the most frequently isolated microorganism, 64% of them being methicillin-resistant.

CONCLUSION

The aim of this study was to investigate the most important risk factors associated with the development of surgical site infections (SSIs). Therefore, greater attention has been given to adherence to recommendations for the prevention and control of SSIs as well as to antibiotic prophylaxis protocols.

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.

Surgical site infections in orthopedic patients: prospective cohort study

AIM

To estimate the incidence rate and risk factors of surgical site infections in the orthopedic wards in a major teaching hospital in Serbia.

METHODS

A 6-month prospective cohort study, with 30 days of patient follow-up after surgery, was conducted at the teaching hospital in Belgrade. We collected patients' basic demographic data and data on underlying disease status, surgical procedures, preoperative preparation of patients, and antibiotic prophylaxis. The National Nosocomial Infections Surveillance (NNIS) risk index was computed for each patient. Descriptive and logistic regression analyses were performed to determine risk factors for surgical site infections.

RESULTS

Assessment of 277 patients after operation revealed surgical site infection in 63 patients. In 3 (4.8%) of them, surgical site infections were detected after hospital discharge. The overall incidence rate of surgical site infections was 22.7% (95% confidence interval [95% CI], 17.5-29.1). The incidence increased from 13.2% in clean wounds to 70.0% in dirty wounds. The rates of surgical site infection for the NNIS risk index classes 0 to 3 were 8.1% (13 of 161), 36.4% (32 of 88), 63.0% (17 of 27), and 100% (1 of 1) (P<0.001; chi2 test). Multivariate logistic regression analysis identified the following independent risk factors for surgical site infections: greater number of persons in the operating room (odds ratio [OR], 1.28; 95% CI, 1.02-1.60), contaminated or dirty wounds (OR, 12.09; 95% CI, 5.56-26.28), and American Society of Anesthesiologists' (ASA) score >2 (OR, 3.47; 95% CI, 1.51-7.95). In patients who were shaved with a razor, the period of 12 or more hours between shaving and intervention was also an independent risk factor (OR, 2.77; 95% CI, 1.22-6.28).

CONCLUSION

There is a high incidence of surgical site infections in orthopedic patients in Serbia in comparison with developed countries and some developing countries. Points for intervention could be reduction of personnel during surgery, better treatment of wounds, decreasing ASA score, and reduction of the time between surgical site shaving and the intervention.

Current trends in the management of acute appendicitis

BACKGROUND

While laparoscopic appendectomy (LA) has become established in the diagnosis and treatment of acute appendicitis, its utilisation compared to open appendectomy (OA) is variable.

AIM

To compare the utilisation and outcome of laparoscopic (LA) versus OA in an Irish regional hospital setting.

METHOD

Retrospective review of OA and LA performed from 2003 to 2005.

RESULTS

Intention-to-treat analysis of 787 patients in this study revealed that 149 patients (19%) had LA and 638 patients (81%) had OA. Consultants were significantly more likely than trainees to undertake a LA (P < 0.0001). Twenty-two complications (2.8%) were recorded in the post-operative period. The overall negative appendectomy rate by histopathology was 17% with no significant difference between the rate in the LA group (19%) and the OA (17%) group.

CONCLUSION

Mean length of stay and complication rate were comparable between the LA and OA groups.

Lowbury Lecture 2005: infection control from a global perspective

All healthcare settings around the world face the problem of healthcare-associated infections (HCAIs). Rates of infection vary between countries and within the same country depending on resources, interest of caregivers and healthcare staff, and patients' socio-economic situation. According to recent publications, 10-70% of HCAIs are preventable. Failure to comply with guidelines on hand hygiene, glove and gown use, and barrier nursing is a problem and unnecessary infection control measures are costly. National legislations and regional, national and international standards and guidelines associated with infection control also have an impact for countries that are not directly involved. They should be based on the assessment of infection risk, and should not increase costs unnecessarily. The International Federation of Infection Control and national infection control societies play an important role in continuing the education of infection control specialists.

Risk of surgical site infection and efficacy of antibiotic prophylaxis: a cohort study of appendectomy patients in Thailand

Background

No data currently exist about use of antibiotics to prevent surgical site infections (SSI) among patients undergoing appendectomy in Thailand. We therefore examined risk factors, use, and efficacy of prophylactic antibiotics for surgical site infection SSI among patients with uncomplicated open appendectomy.

Methods

From July 1, 2003 to June 30, 2004 we conducted a prospective cohort study in eight hospitals in Thailand. We used the National Nosocomial Infection Surveillance (NNIS) system criteria to identify SSI associated with appendectomy. We used logistic regression analysis to obtain relative risk estimates for predictors of SSI.

Results

Among 2139 appendectomy patients, we identified 26 SSIs, yielding a SSI rate of 1.2 infections/100 operations. Ninety-two percent of all patients (95% CI, 91.0–93.3) received antibiotic prophylaxis. Metronidazole and gentamicin were the two most common antibiotic agents, with a combined single dose administered in 39% of cases. In 54% of cases, antibiotic prophylaxis was administered for one day. We found that a prolonged duration of operation was significantly associated with an increased SSI risk. Antibiotic prophylaxis was significantly associated with a decreased risk of SSI regardless of whether the antibiotic was administered preoperatively or intraoperatively. Compared with no antibiotic prophylaxis, SSI relative risks for combined single-dose of metronidazole and gentamicin, one-day prophylaxis, and multiple-day antibiotic prophylaxis were 0.28 (0.09–0.90), 0.30 (0.11–0.88) and 0.32 (0.10–0.98), respectively.

Conclusion

Single-dose combination of metronidazole and gentamicin seems sufficient to reduce SSIs in uncomplicated appendicitis patients despite whether the antibiotic was administered preoperatively or intraoperatively.