Strategies to prevent surgical site infections in acute care hospitals

Systematic review and meta-analysis comparing surgical site infection in abdominal surgery between triclosan-coated and uncoated sutures

PURPOSE

Surgical site infection (SSI) is a frequent complication after abdominal surgery and impacts morbidity, mortality and medical costs. This systematic review evaluates whether the use of triclosan-coated sutures for closing the fascia during abdominal surgery reduces the rate of SSI compared to uncoated sutures.

METHODS

A systematic review and meta-analysis were conducted using the PRISMA guidelines. On February 17, 2024, a literature search was performed in Medline ALL, Web of Science Core Collection, Cochrane Central Register of Controlled Trials and Embase. Randomized controlled trials (RCTs) on abdominal fascial closure in human adults, comparing triclosan-coated and uncoated sutures, were included. The risk of bias was assessed using the Cochrane RoB 2 tool. Pooled meta-analysis was performed using RevMan.

RESULTS

Out of 1523 records, eleven RCTs were included, with a total of 10,234 patients: 5159 in the triclosan-coated group and 5075 in the uncoated group. The incidence of SSI was statistically significantly lower in the triclosan-coated group (14.8% vs. 17.3%) with an odds ratio (OR) of 0.84 (95% CI [0.75, 0.93], p = 0.001). When polydioxanone was evaluated separately (coated N = 3999, uncoated N = 3900), triclosan-coating reduced SSI; 17.5% vs. 20.1%, OR 0.86 (95% CI [0.77; 0.96], p = 0.008). When polyglactin 910 was evaluated (coated N = 1160, uncoated N = 1175), triclosan-coating reduced the incidence of SSI; 5.4% vs. 7.8%, OR 0.67 (95% CI [0.48; 0.94], p = 0.02).

CONCLUSION

According to the results of this meta-analysis the use of triclosan-coated sutures for fascial closure statistically significantly reduces the incidence of SSI after abdominal surgery with a risk difference of about 2%.

Effect of participation in a surgical site infection surveillance programme on hospital performance in Japan: a retrospective study

BACKGROUND

The effect of hospital participation in the Japan Nosocomial Infection Surveillance (JANIS) programme on surgical site infection (SSI) prevention is unknown.

AIM

To determine if participation in the JANIS programme improved hospital performance in SSI prevention.

METHODS

This retrospective before-after study analysed Japanese acute care hospitals that joined the SSI component of the JANIS programme in 2013 or 2014. The study participants comprised patients who had undergone surgeries targeted for SSI surveillance at JANIS hospitals between 2012 and 2017. Exposure was defined as the receipt of an annual feedback report 1 year after participation in the JANIS programme. The changes in standardized infection ratio (SIR) from 1 year before to 3 years after exposure were calculated for 12 operative procedures: appendectomy, liver resection, cardiac surgery, cholecystectomy, colon surgery, caesarean section, spinal fusion, open reduction of long bone fracture, distal gastrectomy, total gastrectomy, rectal surgery, and small bowel surgery. Logistic regression models were used to analyse the association of each post-exposure year with the occurrence of SSI.

FINDINGS

In total, 157,343 surgeries at 319 hospitals were analysed. SIR values declined after participation in the JANIS programme for procedures such as liver resection and cardiac surgery. Participation in the JANIS programme was significantly associated with reduced SIR for several procedures, especially after 3 years. The odds ratios in the third post-exposure year (reference: pre-exposure year) were 0.86 [95% confidence interval (CI) 0.79-0.84] for colon surgery, 0.72 (95% CI 0.56-0.92) for distal gastrectomy, and 0.77 (95% CI 0.59-0.99) for total gastrectomy.

CONCLUSION

Participation in the JANIS programme was associated with improved SSI prevention performance in several procedures in Japanese hospitals after 3 years.

Sprint Team Approach Yields Rapid Improvement in Leapfrog Quality Indicators

GOAL

Patient safety and quality care are two critical areas that every healthcare organization strives to grow and improve upon. At Scripps Health, specific efforts reviewed for this article were implemented to reduce hospital-acquired conditions and hospital readmissions that are components of Centers for Medicare & Medicaid Services programs and Leapfrog Hospital Survey scores.

METHODS

Sprint teams, a novel approach to rapidly develop a checklist for lower-performing care improvement areas, were implemented after an internal review of existing tools and an evidence-based literature review. These areas included catheter-associated urinary tract infections (CAUTIs), central-line associated bloodstream infections (CLABSIs), Clostridioides difficile (C. diff.) and methicillin-resistant Staphylococcus aureus (MRSA) infections, chronic obstructive pulmonary disease (COPD) and heart failure readmissions, surgical site infections and handwashing, bar coding, and the computerized physician order entry components of Leapfrog scoring. The checklist for each area served as a teaching tool for staff and a guideline for case review to ensure that standard work was routinely performed.

PRINCIPAL FINDINGS

The sprint teams showed dramatic results in the initial focus areas. From a baseline standardized infection ratio (SIR) of 1.141 for CLABSIs, the sprint team reduced the SIR to 0.885 in Year 1 of the program and to 0.687 in Year 2. For CAUTIs, the SIR decreased from a baseline of 1.391 in Year 1 to 0.720 in Year 2. C. diff. infections fell from 0.422 to 0.315 in Year 1 and to 0.260 in Year 2. While the MRSA SIR did not improve during the first year, the MRSA reduction sprint team showed success in Year 2 with a decrease in the SIR from 0.537 to 0.245. Readmission reduction sprint teams focused on heart failure, COPD, and total hip and knee complications. The teams also achieved positive results in reducing readmissions by following checklists and reviewing each readmission case for justification.

PRACTICAL APPLICATIONS

Rapid change can be safely and effectively implemented with multidisciplinary sprint teams. Developed with an evidence-based, case review approach, sprint team checklists can help to standardize processes for the review of any infections or readmissions that occur in the inpatient arena.

Rapid Visual Detection of Methicillin-Resistant Staphylococcus aureus in Human Clinical Samples via Closed LAMP Assay Targeting mecA and spa Genes

The emergence of antimicrobial resistance (AMR), particularly methicillin-resistant Staphylococcus aureus (MRSA), poses a significant global health threat as these bacteria increasingly become resistant to the most available therapeutic options. Thus, developing an efficient approach to rapidly screen MRSA directly from clinical specimens has become vital. In this study, we establish a closed-tube loop-mediated isothermal amplification (LAMP) method incorporating hydroxy-naphthol blue (HNB) colorimetric dye assay to directly detect MRSA from clinical samples based on the presence of mecA and spa genes. In total, 125 preidentified S. aureus isolates and 93 clinical samples containing S. aureus were sourced from the microbiology laboratory at Hamad General Hospital (HGH). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed based on conventional PCR. The assay demonstrated 100% specificity, 91.23% sensitivity, 0.90 Cohen Kappa (CK), 100% PPV, and 87.8% NPV for the clinical samples, while clinical isolates exhibited 100% specificity, 97% sensitivity, 0.926 CK, 100% PPV, and 88.89% NPV. Compared to cefoxitin disk diffusion, LAMP provided 100% specificity and sensitivity, 1.00 CK, and 100% for PPV and NPV. The study revealed that the closed-tube LAMP incorporating (HNB) dye is a rapid technique with a turnaround time of less than 1 h and high specificity and sensitivity.

Association between the introduction of a national targeted intervention program and the incidence of surgical site infections in Swiss acute care hospitals

BACKGROUND

In Switzerland, the national surgical site infection (SSI) surveillance program showed a modest decrease in SSI rates for different procedures over the last decade. The study aimed to determine whether a multimodal, targeted intervention program in addition to existing SSI surveillance is associated with decreased SSI rates in the participating hospitals.

METHODS

Prospective multicenter pre- and postintervention study conducted in eight Swiss acute care hospitals between 2013 and 2020. All consecutive patients > 18 years undergoing cardiac, colon, or hip/knee replacement surgery were included. The follow-up period was 30 days and one year for implant-related surgery. Patients with at least one follow-up were included. The intervention was to optimize three elements of preoperative management: (i) hair removal; (ii) skin disinfection; and (iii) perioperative antimicrobial prophylaxis. We compared SSI incidence rates (main outcome measure) pre- and postintervention (three years each) adjusted for potential confounders. Poisson generalized linear mixed models fitted to quarter-yearly confirmed SSIs and adjusted for baseline differences between hospitals and procedures. Adherence was routinely monitored through on-site visits.

RESULTS

A total of 10 151 patients were included, with a similar median age pre- and postintervention (69.6 and IQR 60.9, 76.8 years, vs 69.5 and IQR 60.4, 76.8 years, respectively; P = 0.55) and similar proportions of females (44.8% vs. 46.1%, respectively; P = 0.227). Preintervention, 309 SSIs occurred in 5 489 patients (5.6%), compared to 226 infections in 4 662 cases (4.8%, P = 0.09) postintervention. The adjusted incidence rate ratio (aIRR) for overall SSI after intervention implementation was 0.81 (95% CI, 0.68 to 0.96, P = 0.02). For cardiac surgery (n = 2 927), the aIRR of SSI was 0.48 (95% CI, 0.32 to 0.72, P < 0.001). For hip/knee replacement surgery (n = 4 522), the aIRR was 0.88 (95% CI, 0.52 to 1.48, P = 0.63), and for colon surgery (n = 2 702), the aIRR was 0.92 (95% CI, 0.75 to 1.14, P = 0.49).

CONCLUSIONS

The SSI intervention bundle was associated with a statistically significant decrease in SSI cases. A significant association was observed for cardiac surgery. Adding a specific intervention program can add value compared to routine surveillance only. Further prevention modules might be necessary for colon and orthopedic surgery.

Risk of disease transmission to patients from "contaminated" surgical instruments and immediate use steam sterilization

BACKGROUND

There are several sources of pathogens that cause surgical site infections (SSI) to include the patients endogenous microflora and exogenous sources (e.g., air, surfaces, staff, surgical equipment).

METHODS

We searched the published English literature (Google, Google Scholar, PubMed) for articles on reprocessing surgical instruments, effectiveness of sterilization methods, microbial load on surgical instruments, frequency of "contaminated" instruments, and the infection risk associated with "contaminated" surgical instruments and immediate use steam sterilization.

RESULTS

There is substantial redundancy in instrument reprocessing to include: even if a patient was exposed to a "contaminated" instrument, the decontamination and sterilization process would have removed and/or inactivated the contaminating pathogens due to the exceptional effectiveness of the manual and mechanical cleaning (i.e., washer-disinfector) and the remarkable robustness of sterilization technology; and the low-level of microorganisms on surgical instruments after use and before cleaning.

CONCLUSIONS

A critical review of the literature suggests that the risk of acquiring an SSI from instruments used in surgery is essentially zero if the sterilization cycle is validated.

A meta-analysis examined the effect of stoma on surgical site wound infection in colorectal cancer

To assess the impact of a stoma on surgical site wound infection in colorectal cancer, we conducted a meta-analysis. A thorough review of the literature up to September 2022 revealed that 3223 participants had colorectal cancer at the start of the investigations; 258 of them had a stoma, while 2965 did not have a stoma. Using dichotomous or contentious methods and a random or fixed-effect model, odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CIs) were estimated to evaluate the impact of a stoma on surgical site wound infection in colorectal cancer. The stoma present had significantly higher surgical site wound infections (OR, 4.37; 95% CI, 3.08-6.21; P < 0.001) with no heterogeneity (I2 = 12%) compared to stoma absent in colorectal cancer. The stoma present had significantly higher surgical site wound infections compared to the stoma absent in colorectal cancer. The low number of selected studies in the meta-analysis calls for care when analysing the results.

Surgical Site Infections in Gastroenterological Surgery

Surgical site infections (SSIs) remain one of the most common serious surgical complications and are the second most frequent healthcare-associated infection. Patients with SSIs have a significantly increased postoperative length of hospital stay, hospital expenses, and mortality risk compared with patients without SSIs. The prevention of SSI requires the integration of a range of perioperative measures, and approximately 50% of SSIs are preventable through the implementation of evidence-based preventative strategies. Several international guidelines for SSI prevention are currently available worldwide. However, there is an urgent need for SSI prevention guidelines specific to Japan because of the differences in the healthcare systems of Japan versus western countries. In 2018, the Japan Society for Surgical Infection published SSI prevention guidelines for gastroenterological surgery. Although evidence-based SSI prevention guidelines are now available, it is important to consider the appropriateness of these guidelines depending on the actual conditions in each facility. A systemic inflammatory host response is a hallmark of bacterial infection, including SSI. Therefore, blood inflammatory markers are potentially useful in SSI diagnosis, outcome prediction, and termination of therapeutic intervention. In this review, we describe the current guideline-based perioperative management strategies for SSI prevention, focusing on gastroenterological surgery and the supplemental utility of blood inflammatory markers.

Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study

BACKGROUND

Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA).

METHODS

We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19-years-old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists.

RESULTS

Of the 11,878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (p<0.01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no BLA procedures with beta-lactam AMP (1.6%) .

CONCLUSIONS

Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association of non-beta-lactam AMP and SSI in children.

Do postoperative infectious complications really affect long-term survival in colorectal cancer surgery? A multicenter retrospective cohort study

Aim

To investigate the impact of postoperative infection (PI), surgical site infection, and remote infection (RI), on long-term outcomes in patients with colorectal cancer (CRC).

Methods

The Japan Society for Surgical Infection conducted a multicenter retrospective cohort study involving 1817 curative stage I/II/III CRC patients from April 2013 to March 2015. Patients were divided into the No-PI group and the PI group. We examined the association between PI and oncological outcomes for cancer-specific survival (CSS) and overall survival (OS) using Cox proportional hazards models and propensity score matching.

Results

Two hundred and ninety-nine patients (16.5%) had PIs. The 5-year CSS and OS rates in the No-PI and PI groups were 92.8% and 87.6%, and 87.4% and 83.8%, respectively. Both the Cox proportional hazards models and propensity score matching demonstrated a significantly worse prognosis in the PI group than that in the No-PI group for CSS (hazard ratio: 1.60; 95% confidence interval: 1.10-2.34; P = .015 and P = .031, respectively) but not for OS. RI and the PI severity were not associated with oncological outcomes. The presence of PI abolished the survival benefit of adjuvant chemotherapy.

Conclusions

These results suggest that PI after curative CRC surgery is associated with impaired oncological outcomes. This survival disadvantage of PI was primarily derived from surgical site infection, not RI, and PI induced lower efficacy of adjuvant chemotherapy. Strategies to prevent PI and implement appropriate postoperative treatment may improve the quality of care and oncological outcomes in patients undergoing curative CRC surgery.

Impact of large amount of intra-abdominal lavage on surveillance of surgical site infection after hepato-pancreato-biliary surgery: A prospective cohort study

BACKGROUND/PURPOSE

In hepatobiliary and pancreatic (HBP) surgery, the role and significance of intra-abdominal lavage (IAL) for surgical site infection (SSI) is controversial.

METHODS

This prospective study was performed between July 2020 and July 2022. A total of 150 patients, 10-L IAL was performed. The lavage fluid at 1-L, 5-L, and 10-L was subjected to bacterial culture examination. Risk factors for SSI were evaluated.

RESULTS

Bacterial positivity rate significantly decreased as follows: 1-L, 36% (n = 54); 5-L, 27% (n = 41); 10-L, 23% (n = 35) (36% vs 23%, p = .001). Patients with positive lavage fluid culture at 10-L had significantly higher incidence of both incisional (37% vs 6%, p < .01) and organ/space (54% vs 3%, p < .01) SSI. Multivariate analysis revealed positivity for bacterial culture at 10-L as the strongest independent risk factor for incisional SSI (OR 13.0, 95% CI: 3.86-43.6, p < .01), followed by postoperative pancreatic fistula (OR 11.7, 95% CI: 3.03-45.6, p < .01). Likewise, in organ/space SSI, positivity for bacterial culture at 10-L was the strongest independent risk factor (OR 48.9, 95% CI:12.1-197.7, p < .01), followed by digestive reconstruction (OR 5.20, 95% CI: 1.45-18.6, p = .01).

CONCLUSION

IAL decreased the intraperitoneal contamination rate in a volume-dependent manner and can be useful in the surveillance of SSI development in HBP surgery.

Safety and efficacy of negative pressure wound therapy in treating deep surgical site infection after lumbar surgery

PURPOSE

To evaluate the efficacy and safety of negative pressure wound therapy (NPWT) for post-operative deep surgical site infection (SSI) after posterior instrumented spinal surgery.

METHODS

We retrospectively compared the clinical outcomes of NPWT with standard debridement for deep SSI after posterior instrumented spinal surgery from 2012 to 2020 in our department. The primary outcomes were peri-operative characteristics including positive organism results, duration of fever, and visual analogue scale (VAS) pain scores three days after re-operation. The secondary outcomes were post-operative characteristics including implant infection recurrence, implant retention rate, duration of hospitalization, and VAS at discharge. Pearson's chi-squared analysis (categorical) and Student's t test (continuous) were used to determine the differences.

RESULTS

Thirty-four patients were included, of which 19 underwent NPWT, and 15 underwent standard debridement. Patients in the NPWT group all significantly improved primary outcomes including duration of fever after re-operation (0.95 ± 1.13 vs 4.07 ± 5.35, P = 0.001), positive organism results (14 of 19 vs 2 of 15, P < 0.01), and VAS at 3 days after re-operation (2.58 ± 0.69 vs 3.40 ± 1.06, P < 0.05). Patients in NPWT group exhibited significant decrease in implant infection recurrence (0 of 19 vs 5 of 15, P < 0.01), implant retention rate (19 of 19 vs 10 of 15, P < 0.01), duration of hospitalization (27.74 ± 10.95 vs 37.67 ± 13.67, P < 0.01).

CONCLUSIONS

NPWT is a feasible and safe treatment option for deep SSI after posterior instrumented spinal surgery.

Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ² = 0.246; χ² = 69.75; p < 0.001; I² = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India

Background

Caesarian section is one of the most commonly performed surgeries in India. Determination of the incidence as well as the clinical and financial burden of post caesarian surgical site infection (SSI), is of critical importance for all the stakeholders for rational and fair allocation of resources.

Methods

This study was a prospective observational case-control study. The mean direct and indirect cost of treatment for the cases were compared with the control patients. An unpaired t-test was used to compare the mean between the two groups.

Results

Out of 2024 patients, who underwent caesarian section during the study period, 114 had acquired incisional surgical site infection (ISSI), with the infection incidence being 5.63%. The total cost of illness due to post caesarian ISSI was almost three times higher compared to the non-infected matched control group. (P<0.0001). An average length of hospital stay in the ISSI patient group was 10 days longer than that in the control group (P<0.0001) and importantly total length of antimicrobial therapy(LOT) in patients with ISSI was also almost three times higher than the control group (P<0.0001).

Conclusion

The development of post caesarian SSI imposes a significant clinical as well as a financial burden. The study highlights the necessity of taking effective preventive measures to decrease the incidence of SSI.

Surgical Wound Complications after Colorectal Surgery with Single-Use Negative-Pressure Wound Therapy Versus Surgical Dressing over Closed Incisions: A Randomized Controlled Trial

BACKGROUND

Global studies indicate that surgical site infections (SSIs) are a major healthcare challenge within hospitals and can have a profound impact on patient quality of life and healthcare costs. Closed-incision negative-pressure therapy (ciNPT) has been reported to provide positive clinical benefits for patients with various incisions, including those following colorectal surgeries.

METHODS

Investigators performed a prospective, randomized, multicenter trial to evaluate complications of surgical incisions in patients who received a ciNPT dressing versus a conventional surgical dressing (control) over their closed incision following colorectal surgery. The incidence of SSI was determined at 7, 15, and 30 days postsurgery.

RESULTS

A total of 148 patients participated in the study. Results showed that the SSI rate on day 7 was lower in the ciNPT group versus the control group (10/75 [13.3%] vs 17/73 [23.3%]), but this difference was not statistically significant. On day 15, the SSI rate was 12/75 (16.0%) in the ciNPT group versus 21/73 (28.8%) in the control group; however, this difference was only marginally statistically significant (P = .0621). At 1 month, the SSI rate remained lower in the ciNPT group (13/75 [17.3%] vs 21/73 [28.8%], P = .0983) compared with the control group.

CONCLUSIONS

Future studies with larger population sizes are necessary to determine the impact of ciNPT on patients' incisions after colorectal surgery.

Meta-analysis of the efficacy of preoperative skin preparation with alcoholic chlorhexidine compared to povidone iodine in orthopedic surgery

Preoperative skin preparation is an effective method to prevent surgical site infections (SSI). Alcoholic chlorhexidine (CHG) and povidone iodine (PV-I) are the most widely used antiseptic agents. This meta-analysis aims to determine their efficacy in reducing natural bacterial skin flora in clean orthopedic surgery. A systematic search was conducted through current literature up to June 2021 to identify clinical randomized trials that compared the efficacy of alcoholic chlorhexidine and povidone iodine in reducing bacterial skin colonization after preoperative skin preparation. A meta-analysis was conducted. Of 235 screened articles, 8 randomized controlled trials were included. The results of the meta-analysis demonstrate a significantly lower positive culture rate in the chlorhexidine group than in the povidone iodine group (RR = 0.53, 95% Cl: 0.32-0.88). The present data show the superiority of chlorhexidine in reducing the normal bacterial flora compared to povidone iodine in clean orthopedic surgery.

Chlorhexidine-alcohol versus povidone-iodine as preoperative skin antisepsis for prevention of surgical site infection in cesarean delivery-a pilot randomized control trial

Objectives

To compare the efficacy of chlorhexidine–alcohol and povidone–iodine as preoperative antiseptic skin preparation for prevention of surgical site infection (SSI) after cesarean delivery (CD).

Materials and methods

A total of 311 eligible women who underwent CS were recruited in the study after fulfilling all the eligibility and exclusion criteria. Patients were randomized into two groups (153 in chlorhexidine–alcohol group and 158 in povidone–iodine group) by a computer-generated randomization table. Patients were followed for a period of 30 days in postoperative period to monitor for SSI.

Results

The rate of SSI in the chlorhexidine–alcohol group is 5.4% and that of the povidone–iodine group is 8.6%. E. coli, K. pneumoniae, and Acinetobacter baumannii were the most common organisms isolated. E. coli was found in 9.5% of the total SSI cases.

Conclusions

The study found that the patients who received chlorhexidine–alcohol as skin antiseptic had less chance of developing SSI than those who received povidone–iodine; however, it did not reach a statistical significance.

Trial registration

Clinical Trials Registry of India CTRI/2018/05/014294. Registered on May 31, 2018

Pediatric surgical site infection (SSI) following ambulatory surgery: Incidence, risk factors and patient outcomes

BACKGROUND

Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes.

METHODS

We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case-control methodology using multivariate backward logistical regression to assess risk-factor association with SSI.

RESULTS

In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37-3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32-12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0-48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6-9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9-315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage.

CONCLUSIONS

Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

Risk factors of vaginal cuff infection in women undergoing laparoscopic hysterectomy for benign gynecological diseases

AIM

This study aimed to identify the risk factors for vaginal cuff infection after laparoscopic hysterectomy for benign gynecological diseases.

METHODS

We conducted a retrospective cohort study among 1559 Japanese women who underwent total laparoscopic hysterectomy (TLH) for benign indications between 2014 and 2018 at Teine Keijinkai Hospital in Sapporo, Japan. All patients received preoperative antibiotics based on appropriate timing, choice, and weight-based dosing. We assessed the risk factors of vaginal cuff infection after TLH, including demographic and clinical variables, and patient- and surgery-related factors, using univariable and multivariable logistic regression analyses.

RESULTS

Among all the patients who underwent TLH, 71 cases of vaginal cuff infections (4.6%) were recorded. Univariate analyses showed that current smoking, pathological result of adenomyosis, use of Seprafilm as an antiadhesive material, white blood cell counts on postoperative day (POD) 2, C-reactive protein (CRP) level on POD2 and postoperative vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. In multivariate analysis, current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection.

CONCLUSION

Current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were identified as significant risk factors of vaginal cuff infection in the 30 days after surgery in Japanese women who underwent TLH for benign indications.

Preoperative Intranasal Decolonization with Topical Povidone-Iodine Antiseptic and the Incidence of Surgical Site Infection: A Review

Surgical site infection (SSI) occurs at the incisional site of a surgical procedure and usually involves the skin. The use of antibacterial courses to manage SSIs is still very challenging in clinical settings. When not used appropriately, antibacterial agents can lead to increased rates of adverse events. However, various antibacterial agents that can destroy the growth of bacteria are now available. This article aims to discuss the role of preoperative intranasal decolonization with topical povidone-iodine antiseptic in the incidence of SSI based on a review of the literature.

Topical bactericidal agents can be administered intranasally before surgery to eliminate potentially harmful bacteria, including antibiotic-resistant strains of bacteria. Therefore, a few studies have recommended the use of intranasal povidone-iodine solution in the clinical setting; however, it also appears to be a promising antiseptic regimen for preoperative decontamination in patients planned to undergo surgery. Povidone-iodine is a commonly used medical antiseptic agent that is used by surgeons to promote wound healing and prevent postoperative bacterial infections. Chlorhexidine gluconate is both an antiseptic and a disinfectant, which is used to clean the skin and surgical instruments. Our review of the literature on studies on the effectiveness of intranasal povidone-iodine in the reduction of intranasal bacterial colonization and the prevention of SSI identified only 5 controlled clinical studies. One study, however, showed increased effectiveness in preventing SSI when topical intranasal povidone-iodine was combined with the use of chlorhexidine gluconate washcloths. Further large-scale controlled clinical studies are needed before proper guidelines can be made.

Antimicrobial Prophylaxis in Clean Pediatric Surgical Procedures: A Necessity or Redundancy?

Background

The clinical utility of antimicrobial prophylaxis in clean pediatric surgical cases remains enigmatic. The present study aims to evaluate the prevalence of surgical site infections in instances where antibiotic prophylaxis is not employed prior to clean pediatric surgical procedures.

Methods

A retrospective cross-sectional study that included data of all pediatric clean surgical procedures from January 2018 till January 2020 was conducted. All children undergoing clean surgical procedures who did not receive antibiotics at least two weeks prior to the procedure were included in the study. The exclusion criteria included patients with congenital heart disease, ventriculoperitoneal shunt, nephrotic syndrome, immunodeficiency, and prior administration of antimicrobial prophylaxis. All patients were followed for two to four weeks for any signs of surgical site infections.

Results

Of the 178 patients included, 119 were male and 59 were female, with the mean age hovering at 8.19 ± 2.87 years. Orchidopexy and herniotomy were the most commonly performed surgical procedures, and were performed in 56 (31.46%) and 54 (30.33%) patients, respectively. Only one case of postoperative surgical site wound infection was reported, accounting for a prevalence rate of 0.56%.

Conclusion

In clean pediatric surgical procedures, the risk of surgical site infections is exceedingly low. The unnecessary use of antibiotics in children can cause deleterious adverse effects and promote antimicrobial resistance. In a carefully selected pediatric population, administration of antibiotic prophylaxis might confer no added benefit.

Dual antibiotic prevention bundle is associated with decreased surgical site infections

BACKGROUND

Gynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain.

STUDY DESIGN

A retrospective cohort study was performed to compare surgical site infection rates for patients undergoing hysterectomy over a 1-year period surrounding the implementation of an institutional infection prevention bundle. The bundle comprised pre-operative, intra-operative, and post-operative interventions including a dual-agent antibiotic surgical prophylaxis with cefazolin and metronidazole. Cohorts consisted of patients undergoing surgery during the 6 months prior to this intervention (pre-bundle) versus those undergoing surgery during the 6 months following the intervention (post-bundle). Secondary outcomes included length of stay, readmission rates, compliance measures, and infection microbiology. Data were compared with pre-specified one-sided exact test, Chi-square test, Fisher's exact test, or Kruskal-Wallis test as appropriate.

RESULTS

A total of 358 patients were included (178 PRE, 180 POST). Median age was 58 (range 23-90) years. The post-bundle cohort had a 58% reduction in surgical site infection rate, 3.3% POST vs 7.9% PRE (-4.5%, 95% CI -9.3% to -0.2%, p=0.049) as well as reductions in organ space infection, 0.6% POST vs 4.5% PRE (-3.9%, 95% CI -7.2% to -0.7%, p=0.019), and readmission rates, 2.2% POST vs 6.7% PRE (-4.5%, 95% CI -8.7% to -0.2%, p=0.04). Gram-positive, Gram-negative, and anaerobic bacteria were all prevalent in surgical site infection cultures. There were no monomicrobial infections in post-cohort cultures (0% POST vs 58% PRE, p=0.04). No infections contained methicillin-resistant Staphylococcus aureus.

CONCLUSION

Implementation of a dual antibiotic infection prevention bundle was associated with a 58% reduction in surgical site infection rate after hysterectomy in a surgically diverse gynecologic oncology practice.

Detailed standardized protocol to prevent cerebrospinal fluid shunt infection

OBJECTIVE

While cerebrospinal fluid (CSF) shunt surgery plays an essential role in the treatment of hydrocephalus, postoperative infection due to the implantation of foreign materials is still one of the most common and potentially serious complications of this procedure. Because no previously reported protocol has been proven to prevent postoperative infection after CSF shunt surgeries in adults, the authors investigated the effectiveness of a protocol introduced in their institution.

METHODS

A detailed standardized surgical protocol to prevent infection in patients undergoing CSF shunt surgeries was introduced in the authors' institution in December 2011. The protocol included a series of detailed rules regarding the surgical procedure, the surgical environment to minimize contamination from air, double gloving, local injection of antibiotics, and postoperative management. The rate of CSF shunt infection during the 3 years after surgery before and after implementation of the protocol was compared in patients undergoing their first CSF shunt surgeries. The inclusion periods were from January 2006 to November 2011 for the preprotocol group and from December 2011 to December 2014 for the postprotocol group.

RESULTS

The study included 124 preprotocol patients and 52 postprotocol patients. The mean patient age was 59 years in both groups, ranging from 40 days to 88 years. Comparison of patient background factors, including known risk factors for surgical site infections, showed no significant difference between the patient groups before and after implementation of the protocol. While 9 patients (7.3%) developed shunt infections before protocol implementation, no shunt infections (0%) were observed in patients who underwent surgery after protocol implementation. The difference was statistically significant (p = 0.047).

CONCLUSIONS

The authors' detailed protocol for CSF shunt surgeries was effective in preventing postoperative infection regardless of patient age.

A Scoping Review on the Use of Antibiotic-Impregnated Beads and Applications to Vascular Surgery

INTRODUCTION

Surgical site infection (SSI) presents a ubiquitous concern to surgical specialties, especially in the presence of prosthetic material. Antibiotic-impregnated beads present a novel and evolving means to combat this condition. This review aims to analyze the quality of evidence and methods of antibiotic bead use, particularly for application within vascular surgery.

METHODS

A systematic scoping review was conducted within Embase, MEDLINE, and the Cochrane Registry of Randomized Controlled Trials. Articles were evaluated by 2 independent reviewers. Level of evidence was evaluated using the Oxford Center for Evidence-Based Medicine Criteria and the Cochrane Risk of Bias Tool for Randomized Controlled Trials.

RESULTS

The search yielded 6951 papers, with 275 included for final analysis. Publications increased in frequency from 1978 to the present. The most common formulation was polymethyl methacrylate; however publications on biodegradable formulations, including calcium sulfate beads, have been published with increasing frequency. Most publications had positive conclusions (94.2%); however, the data was mainly subjective and may be prone to publication bias. Only 11 randomized controlled trials were identified and all but one was evaluated to be at a high risk of bias. The most common indication was for osteomyelitis (52%), orthopedic prosthetic infections (20%), and trauma (9%). Within vascular surgery, beads have been used primarily for the treatment of graft infection, with freedom from recurrence rates being reported from 41% to 87.5%.

CONCLUSIONS

Antibiotic-impregnated beads provide a means to deliver high doses of antibiotic directly to a surgical site, without the risks of parenteral therapy. There has yet to be significant high-level quality data published on their use. There is a large body of evidence that suggests antibiotic beads may be used in SSIs in high-risk patients, prosthetic infections, and other complex surgical infections. Important potential areas of application in vascular surgery include graft infection, prevention of wound infection in high-risk patients, and diabetic foot infection.

Multicentre randomised double-blind placebo controlled trial of combination vancomycin and cefazolin surgical antibiotic prophylaxis: the Australian surgical antibiotic prophylaxis (ASAP) trial

INTRODUCTION

Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established.

METHODS AND ANALYSIS

This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums.

TRIAL REGISTRATION NUMBER

ACTRN12618000642280.

Prevalence and root causes of surgical site infection among women undergoing caesarean section in Ethiopia: a systematic review and meta-analysis

Background

Surgical site infection is a common complication in women undergoing Caesarean section and the second most common cause of maternal mortality in obstetrics. In Ethiopia, prevalence and root causes of surgical site infection post-Caesarean section are highly variable. This systematic review and meta-analysis estimate the overall prevalence of surgical site infection and its root causes among women undergoing Caesarean section in Ethiopia.

Method

Systematic review and meta-analysis were conducted to assess the prevalence and root causes of surgical site infection in Ethiopia. The articles were searched from the databases such as Medline, Google Scholar and Science Direct. A total of 13 studies from different regions of Ethiopia reporting the prevalence and root causes of surgical site infection among women undergoing Caesarean section were included. A random effect meta-analysis model was computed to estimate the overall prevalence. In addition, the association between risk factor variables and surgical site infection related to Caesarean section were examined.

Results

Thirteen studies in Ethiopia showed that the overall prevalence of surgical site infection among women undergoing Caesarean section was 8.81% (95% CI: 6.34–11.28). Prolonged labor, prolonged rupture of membrane, presence of anemia, presence of chorioamnionitis, presence of meconium, vertical skin incision, greater than 2 cm thickness of subcutaneous tissue, and general anesthesia were significantly associated with surgical site infection post-Caesarean section.

Conclusion

Prevalence of surgical site infection among women undergoing Caesarean section was relatively higher in Ethiopians compared with the report of center of disease control guideline. Prolonged labor, prolonged rupture of membrane, presence of anemia, chorioamnionitis, presence of meconium, vertical skin incision, greater than 2 cm thickness of subcutaneous tissue and/or general anesthesia were significantly associated with surgical site infection post-Caesarean section.

Incidence of surgical site infection in dogs undergoing soft tissue surgery: risk factors and economic impact

Objectives

To determine (1) the incidence of surgical site infection (SSI) in patients undergoing soft tissue surgery at a veterinary teaching hospital and to study (2) and describe the main risk factors associated with SSI and (3) assess the economic impact of SSI.

Design

Prospective cohort study.

Setting

Veterinary teaching hospital.

Participants

184 dogs undergoing soft tissue surgery during a 12-month period (October 2013 to September 2014).

Primary outcome measure

Surgical site infection.

Results

Out of the 184 patients analysed, SSI was diagnosed in 16 (8.7 per cent) patients, 13 (81.3 per cent) were classified as superficial incisional infection, 2 (12.5 per cent) as deep incisional infection and 1 (6.3 per cent) as organ/space infection. The administration of steroidal anti-inflammatory drugs (P=0.028), preoperative hyperglycaemia (P=0.015), surgical times longer than 60 minutes (P=0.013), urinary catheterisation (P=0.037) and wrong use of the Elizabethan collar (P=0.025) were identified as risk factors. Total costs increased 74.4 per cent, with an increase in postsurgical costs of 142.2 per cent.

Conclusions

The incidence of SSI was higher than the incidence reported in other published studies, although they were within expected ranges when a surveillance system was implemented. This incidence correlated with an increase in costs. Additionally new important risk factors for its development were detected.

Quality Improvement Project in Congenital Cardiothoracic Surgery Patients: Reducing Surgical Site Infections

Background:

Healthcare-associated infections are a major focus for quality improvement in hospitals today. Surgical site infections (SSIs), a postoperative complication in cardiac surgery, are associated with increased morbidity, mortality, hospital length of stay, and financial burden.

Methods:

A recent increase in cardiothoracic surgery SSIs (CT-SSIs) at our institution instigated a multidisciplinary team to explore infection prevention, bundle element compliance, and to identify interventions to reduce the CT-SSI rate. Key interventions included preoperative screening and decolonization of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus with repeated intranasal applications of mupirocin, universal skin prep with chlorhexidine for all patients, and additional antibiotic dosing upon initiating cardiopulmonary bypass.

Results:

In 2014, the CT-SSI rate at our institution was 1.9/100 cases, which increased during the “intervention period” to 3.6 infections/100 cases in 2015 (16 total infections). Postinterventions, the CT-SSI rate decreased to 0.3 infections/100 cases (2 total infections), which was significantly lower than our baseline before the spike in infection rate.

Conclusions:

A comprehensive interdisciplinary approach with multiple interventions was successful in significantly reducing the CT-SSI rate in cardiothoracic surgery at a tertiary care pediatric hospital.

Prevention of Arrhythmia Device Infection Trial: The PADIT Trial

BACKGROUND

Infection of implanted medical devices has catastrophic consequences. For cardiac rhythm devices, pre-procedural cefazolin is standard prophylaxis but does not protect against methicillin-resistant gram-positive organisms, which are common pathogens in device infections.

OBJECTIVE

This study tested the clinical effectiveness of incremental perioperative antibiotics to reduce device infection.

METHODS

The authors performed a cluster randomized crossover trial with 4 randomly assigned 6-month periods, during which centers used either conventional or incremental periprocedural antibiotics for all cardiac implantable electronic device procedures as standard procedure. Conventional treatment was pre-procedural cefazolin infusion. Incremental treatment was pre-procedural cefazolin plus vancomycin, intraprocedural bacitracin pocket wash, and 2-day post-procedural oral cephalexin. The primary outcome was 1-year hospitalization for device infection in the high-risk group, analyzed by hierarchical logistic regression modeling, adjusting for random cluster and cluster-period effects.

RESULTS

Device procedures were performed in 28 centers in 19,603 patients, of whom 12,842 were high risk. Infection occurred in 99 patients (1.03%) receiving conventional treatment, and in 78 (0.78%) receiving incremental treatment (odds ratio: 0.77; 95% confidence interval: 0.56 to 1.05; p = 0.10). In high-risk patients, hospitalization for infection occurred in 77 patients (1.23%) receiving conventional antibiotics and in 66 (1.01%) receiving incremental antibiotics (odds ratio: 0.82; 95% confidence interval: 0.59 to 1.15; p = 0.26). Subgroup analysis did not identify relevant patient or site characteristics with significant benefit from incremental therapy.

CONCLUSIONS

The cluster crossover design efficiently tested clinical effectiveness of incremental antibiotics to reduce device infection. Device infection rates were low. The observed difference in infection rates was not statistically significant. (Prevention of Arrhythmia Device Infection Trial [PADIT Pilot] [PADIT]; NCT01002911).

Efficacy of Antibiotic Prophylaxis for Hysteroscopy: A Meta-Analysis of Randomized Trials

OBJECTIVE

To assess the efficacy and side effects of antibiotic prophylaxis compared with placebo or no treatment in women undergoing hysteroscopy.

DATA SOURCES

A structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through December 31, 2018.

METHODS OF STUDY SELECTION

The search included a combination of the following terms: "hysteroscopy," "endoscopic surgery," "antibiotic prophylaxis." The following outcomes were selected: postoperative fever, infection rate, pelvic inflammatory disease (PID) and abscess occurrence, postoperative antibiotic requirement, and side effects occurrence (lower abdominal pain, vomiting, diarrhea, anaphylactic reaction). A random-effects model was used at meta-analysis. Study quality and bias risk were assessed with the Cochrane tool.

TABULATION, INTEGRATION, AND RESULTS

Five randomized controlled trials comparing efficacy of antibiotic prophylaxis with placebo or no treatment were included in the meta-analysis. Overall, pooled incidence of events was very low in both groups (fever, 3.79% vs 1.8%; overall infection, .52% vs .58%; postoperative antibiotic therapy, 1.18% vs 1.32%; and lower abdominal pain, 12.46% vs 9.31%). Moreover, the incidence of serious infections requiring further actions (PID or abscess) appeared to be extremely low (.2% in pretreated women and none in control groups). No one trial individually or the pooled analysis showed a statistically significant benefit of antibiotics prophylaxis over placebo for the outcome considered.

CONCLUSION

The use of antibiotics appears not to be beneficial to prevent infection after hysteroscopy; however, the lack of high-quality studies makes it difficult to draw firm conclusions. Considering the very low infection rate highlighted after hysteroscopic procedures, a difference will probably never be proven in a randomized trial. A larger population and program data to confirm these results are therefore warranted.

Quality appraisal of clinical guidelines for surgical site infection prevention: A systematic review

Background

Surgical site infections (SSI) occur in up to 10% of surgeries. Wound care practices to prevent infections are guided by Clinical Practice Guidelines (CPGs), yet their contribution to improving patient outcomes relies on their quality and adoption in practice. We critically evaluated the quality of CPGs for SSI prevention during pre-, intra- and post-operative phases of care.

Methods

We systematically reviewed the literature from 1990–2018 using the Cochrane Library, CINAHL, EMBASE, MEDLINE, ProQuest databases and five guidelines repositories. We extracted characteristics of each guideline using purposely-developed data collection tools. We assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

Results

Combined searches of databases and repositories yielded 5,910 citations. Of these, we reviewed 215 full text documents. The final sample included 15 documents: 6 complete CPGs, 3 CPG updates, and 6 supplementary documents. The overall %mean scores across AGREE II domains for CPGs were: 1) scope and purpose (%mean ± SD = 86.3±23.5); 2) stakeholder involvement (%mean ± SD = 64±31.0); 3) rigour of development (%mean ± SD = 68.7±30.6); 4) clarity and presentation (%mean ± SD = 88.5±16.7); 5) applicability (%mean ± SD = 44±30.2); and, 5) editorial independence (%mean ± SD = 61±37.6). Based on individual AGREE II domains and overall scores, we appraised 4 out of 6 CPGs (inclusive of updates) as “recommended” for use in practice. Overall agreement among appraisers was excellent (ICC 0.86 [95%CI 0.73–0.94] - 0.98 [95%CI 0.96–0.99]; p <0.001).

Discussion

International interest in CPG development has resulted in refinements to methodologies, which has led to improvements in the overall quality of the product.

Implications for translation

Given the domains that received the lowest scores, it is clear that we need more consumer involvement and better consideration of the implementation challenges with CPG uptake and sustainability.

Surgical Site Infections in Emergency Abdominal Surgery at Tamale Teaching Hospital, Ghana

BACKGROUND

Surgical site infections (SSIs) result in delayed wound healing, increased use of antibiotics and increased length of hospital stay, putting remarkable physical and financial burden on patients, their relatives and the healthcare facilities. Patient-related factors, such as pre-existing colonization with antibiotic-resistant bacteria, and clinical-related factors, such as adherence to sterile techniques, contribute to the development of SSIs. The objective of this study, therefore, was to determine the SSI rate and risk factors for emergency abdominal surgeries at Tamale Teaching Hospital, Ghana.

METHODS

The study population was composed of patients undergoing emergency abdominal surgery at the Tamale Teaching Hospital between June 2010 and June 2015. Demographic and clinical data were collected and included, but was not limited to, patient age and sex, type of procedure performed, wound class (dirty or contaminated), receipt of perioperative blood transfusion, American Society of Anesthesiologists (ASA) score, presence of SSI, length of hospital stay and outcome of surgery. Standard multiple regression was used to statistically assess the independent variables for their association with SSI, and Pearson correlation coefficient was used to determine the strength of association. The beta (β) values, which had the greatest influence on the overall SSI, indicated the relative influence of the entered variable(s).

RESULTS

A total of 1011 patients underwent various emergency abdominal surgical procedures during the period of study. The β values were 0.008 for perioperative blood transfusion, 0.050 for sex, - 0.048 for ASA risk, - 0.001 for having health insurance, 0.037 for being referred from another health facility and 0.034 for age. Sex was the most distinctive contributor to SSI, while perioperative blood transfusion showed the least influence. Sex and ASA score were the best predictors of SSI occurrence. The coefficients of the P values for wound class and serum haemoglobin level (g/dL) were 0.000 and 0.032, respectively. The outcome of surgery was significantly and strongly associated with overall SSI and vice versa (r = 0.088, P < 0.01 two-tailed).

CONCLUSION

Sex, ASA score, perioperative blood transfusion, wound class and haemoglobin level can predispose to SSI.

Risk of Surgical Site Infection (SSI) following Colorectal Resection Is Higher in Patients With Disseminated Cancer: An NCCN Member Cohort Study

BACKGROUNDSurgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.OBJECTIVETo examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRSDESIGNAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011-2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.SETTINGMulticenter studyPARTICIPANTSOf 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.MAIN OUTCOMEThe primary outcome of interest was 30-day SSI rate.RESULTSA total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23-2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09-1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06-2.53; P=.02), and longer duration of procedure were associated with development of SSI.CONCLUSIONSPatients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.Infect Control Hosp Epidemiol 2018;39:555-562.

Impact of the Antibiotic Stewardship Program on Prevention and Control of Surgical Site Infection during Peri-Operative Clean Surgery

BACKGROUND

Surgical site infections (SSIs) are the leading cause of hospital-acquired infections and are associated with substantial healthcare costs, with increased morbidity and mortality. To investigate the effects of the antibiotic stewardship program on prevention and control of SSI during clean surgery, we investigated this situation in our institution.

PATIENTS AND METHODS

We performed a quasi-experimental study to compare the effect before and after the antibiotic stewardship program intervention. During the pre-intervention stage (January 1, 2010 through December 31, 2011), comprehensive surveillance was performed to determine the SSI baseline data. In the second stage (January 1, 2012 through December 31, 2016), an infectious diseases physician and an infection control practitioner identified the surgical patients daily and followed up on the duration of antimicrobial prophylaxis.

RESULTS

From January 1, 2010 to December 31, 2016, 41,426 patients underwent clean surgeries in a grade III, class A hospital. The rate of prophylactic antibiotic use in the 41,426 clean surgeries was reduced from 82.9% to 28.0% after the interventions. The rate of antibiotic agents administered within 120 minutes of the first incision increased from 20.8% to 85.1%. The rate at which prophylactic antimicrobial agents were discontinued in the first 24 hours after surgery increased from 22.1% to 60.4%. Appropriate antibiotic selection increased from 37.0% to 93.6%. Prophylactic antibiotic re-dosing increased from 3.8% to 64.8%. The SSI rate decreased from 0.7% to 0.5% (p < 0.05). The pathogen detection rate increased from 16.7% up to 41.8% after intervention. The intensity of antibiotic consumption reduced from 74.9 defined daily doses (DDDs) per 100 bed-days to 34.2 DDDs per 100 bed-days after the interventions.

CONCLUSION

Long-term and continuous antibiotic stewardship programs have important effects on the prevention and control of SSI during clean surgery.

Patient Self-Assessment of Surgical Site Infection is Inaccurate

BACKGROUND

Availability of surgical site infection (SSI) surveillance rates challenges clinicians, healthcare administrators and leaders and the public. The purpose of this report is to demonstrate the consequences patient self-assessment strategies have on SSI reporting rates.

METHODS

We performed SSI surveillance among patients undergoing general surgery procedures, including telephone follow-up 30 days after surgery. Additionally we undertook a separate validation study in which we compared patient self-assessments of SSI with surgeon assessment. Finally, we performed a meta-analysis of similar validation studies of patient self-assessment strategies.

RESULTS

There were 22/266 in-hospital SSIs diagnosed (8.3%), and additional 16 cases were detected through the 30-day follow-up. In total, the SSI rate was 16.8% (95% CI 10.1-18.5). In the validation survey, we found patient telephone surveillance to have a sensitivity of 66% (95% CI 40-93%) and a specificity of 90% (95% CI 86-94%). The meta-analysis included five additional studies. The overall sensitivity was 83.3% (95% CI 79-88%), and the overall specificity was 97.4% (95% CI 97-98%). Simulation of the meta-analysis results divulged that when the true infection rate is 1%, reported rates would be 4%; a true rate of 50%, the reported rates would be 43%.

CONCLUSION

Patient self-assessment strategies in order to fulfill 30-day SSI surveillance misestimate SSI rates and lead to an erroneous overall appreciation of inter-institutional variation. Self-assessment strategies overestimate SSIs rate of institutions with high-quality performance and underestimate rates of poor performance. We propose such strategies be abandoned. Alternative strategies of patient follow-up strategies should be evaluated in order to provide valid and reliable information regarding institutional performance in preventing patient harm.

An observational study of perioperative antibiotic-prophylaxis use at a major quaternary care and referral hospital in Saudi Arabia

Context

The use of perioperative antimicrobial prophylaxis has been consistently considered an effective means of reducing the risk of surgical site infections. However, inappropriate use of surgical antibiotic prophylaxis is associated with complications such as reduced treatment efficacy, development of antibiotic resistance, and increased health-care costs.

Aims

The aim of this study is to investigate the adherence to international/national guidelines regarding the use of surgical antibiotic prophylaxis in the perioperative period.

Settings and Design

King Faisal Specialist Hospital and Research Centre (KFSH&RC) a 1589-bed tertiary/quaternary care and referral hospital based in Riyadh, Saudi Arabia.

Subjects and Methods

A retrospective observational study, in which antibiotic prophylaxis parameters were assessed against recommendations provided by international/national guidelines in elective/emergency procedures performed at the general operating suite. Data was obtained from the medical records starting of 174 cases over a period of 2 weeks in May 2016.

Results

Preoperative antibiotic prophylaxis (PAP) was prescribed for 118 (78.7%) patients, 72 (61%) of which were "recommended," whereas 46 (39%) were "not recommended." Of the 72 patients for whom the antibiotics were "recommended" and given, 19 (26.4%) received "inadequate" choice of antibiotics, 50 (69.4%) received a sub-therapeutic dose, 14 (19.4%) had "improper" timing of the first dose, 11 (15.3%) were given an "inappropriate" second intraoperative dose, and 43 (59.7%) had an unnecessarily extended duration of prophylaxis. The overall compliance to guidelines was achieved in only 23 (15.3%) patients.

Conclusions

A significant gap between current KFSH & RC practice and international/national guidelines regarding surgical antibiotic prophylaxis usage has been demonstrated which calls for immediate action to ensure effective guideline adoption and implementation.

Randomized Controlled Trial of Two Alcohol-based Preparations for Surgical Site Antisepsis in Colorectal Surgery

OBJECTIVE

To compare 2 alcohol-based, dual-action skin preparations for surgical site infection (SSI) prevention in elective colorectal surgery.

BACKGROUND

Colorectal surgery is associated with the highest SSI rate among elective surgical procedures. Although evidence indicates that alcohol-based skin preparations are superior in SSI prevention, it is not clear if different alcohol-based preparations are equivalent in clean-contaminated colorectal procedures.

METHODS

We performed a blinded, randomized, noninferiority trial comparing iodine povacrylex-alcohol (IPA) and chlorhexidine-alcohol for elective, clean-contaminated colorectal surgery. The primary outcome was the presence or absence of SSI, defined as superficial or deep SSI, within 30 days postdischarge. A 6.6% noninferiority margin was chosen.

RESULTS

Between January 2011 and January 2015, 802 patients were randomized with 788 patients included in the intent to treat analysis (396 IPA and 392 chlorhexidine-alcohol). The difference in overall SSI rate between IPA (18.7%) and chlorhexidine-alcohol (15.9%) was 2.8% (P = 0.30). The upper bound of the 2.5% confidence interval of this difference was 8.9%, which is greater than the prespecified noninferiority margin of 6.6%. Other endpoints, including individual SSI types, time to SSI diagnosis, and length of stay were not different between the 2 arms.

CONCLUSIONS

In patients undergoing elective, clean contaminated colorectal surgery, the use of IPA failed to meet criterion for noninferiority for overall SSI prevention compared with chlorhexidine-alcohol. Photodocumentation of wounds and rigorous tracking of outcomes up to 30 days postdischarge contributed to high fidelity to current standard SSI descriptions and wound classifications.

The Association Between Operating Room Personnel and Turnover With Surgical Site Infection in More Than 12 000 Neurosurgical Cases

BACKGROUND

Surgical site infection (SSI) contributes significantly to postoperative morbidity and mortality and greatly increases the cost of care.

OBJECTIVE

To identify the impact of workflow and personnel-related risk factors contributing to the incidence of SSIs in a large sample of neurological surgeries.

METHODS

Data were obtained using an enterprisewide electronic health record system, operating room, and anesthesia records for neurological procedures conducted between January 1, 2009, and November 30, 2012. SSI data were obtained from prospective surveillance by infection preventionists using Centers for Disease Control and Prevention definitions. A multivariate model was constructed and refined using backward elimination logistic regression methods.

RESULTS

The analysis included 12 528 procedures. Most cases were elective (94.5%), and the average procedure length was 4.8 hours. The average number of people present in the operating room at any time during the procedure was 10.0. The overall infection rate was 2.3%. Patient body mass index (odds ratio, 1.03; 95% confidence interval [CI], 1.01-1.04) and sex (odds ratio, 1.36; 95% CI, 1.07-1.72) as well as procedure length (odds ratio, 1.19 per additional hour; 95% CI, 1.15-1.23) and nursing staff turnovers (odds ratio, 1.095 per additional turnover; 95% CI, 1.02-1.21) were significantly correlated with the risk of SSI.

CONCLUSION

This study found that patient body mass index and male sex were associated with an increased risk of SSI. Operating room personnel turnover, a modifiable, work flow-related factor, was an independent variable positively correlated with SSI. This study suggests that efforts to reduce operating room turnover may be effective in preventing SSI.

ABBREVIATIONS

OR, operating roomSSI, surgical site infection.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures

BACKGROUND

Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries.

METHODS

From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability.

RESULTS

Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses.

CONCLUSIONS

Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

The use of negative pressure wound therapy to prevent post-operative surgical site infections following pancreaticoduodenectomy

BACKGROUND

Rates of superficial surgical site infection (SSI) following pancreaticoduodenectomy remain high. Following resection for cancer, complications such as SSI impact adjuvant therapy delivery and portend worse survival. An incisional negative pressure dressing (iVAC) has been demonstrated to reduce SSI in other high-risk cohorts.

METHODS

Following a comprehensive effort to identify patients at high risk for SSI, the practice patterns at a single academic center shifted and iVAC use increased. SSI rates were tracked in a prospectively maintained database and are reported.

RESULTS

394 patients underwent pancreaticoduodenectomy over 21 months. 120 patients (30.5%) had an iVAC applied. The overall rate of SSI was 19.8%. On multivariate analysis, increased risk for SSI was associated with neoadjuvant therapy, preoperative biliary interventions and prior abdominal surgery. iVAC use decreased the rate of SSI (OR 0.45, p = 0.015). In the highest-risk patients, SSI rate declined from 50% in patients without an iVAC to 19.1% with iVAC use (p = 0.015).

CONCLUSION

The use of an iVAC following pancreaticoduodenectomy is associated with decreased SSI rates. This is particularly true for patients at highest risk as defined by a previously established risk scoring system in patients undergoing open pancreaticoduodenectomy.

Surgical Site Infections: An Update

Surgical site infections (SSIs) lead to adverse patient outcomes, including prolonged hospitalization and death. Wound contamination occurs with each incision, but proven strategies exist to decrease the risk of SSI. In particular, improved adherence to evidence-based preventative measures related to appropriate antimicrobial prophylaxis can decrease the rate of SSI. Aggressive surgical debridement and effective antimicrobial therapy are needed to optimize the treatment of SSI.

Surgical-site infection in gynecologic surgery: pathophysiology and prevention

Surgical-site infections (SSIs) represent a well-known cause of patient morbidity as well as added health care costs. In gynecologic surgery, particularly hysterectomy, SSIs are often the result of a number of risk factors that may or may not be modifiable. As both the Centers for Medicaid and Medicare Services and the Joint Commission on the Accreditation of Healthcare Organizations have identified SSIs as a patient safety priority, gynecologic surgeons continue to seek out the most effective interventions for SSI prevention. This review studies the epidemiology and pathophysiology of SSIs in gynecologic surgery and evaluates the current literature regarding possible interventions for SSI prevention, both as individual measures and as bundles. Data from the obstetrical and general surgery literature will be reviewed when gynecological data are either unclear or unavailable. Practitioners and hospitals may use this information as they develop strategies for SSI prevention in their own practice.

Surgical Site Infections at a Saudi Hospital: The Need for a National Surveillance Program

Surgical site infection (SSI) continues to be a global health problem that causes increased morbidity and mortality, especially in developing countries. This study aimed to determine the prevalence of SSI, the microbial pathogens, and their resistance patterns, as well as to identify risk factors associated with this infection at a Saudi tertiary care hospital. This cross-sectional observational study involved all patients who had undergone surgery and who stayed in the hospital for at least 48 hours during a 1-year period. SSI was diagnosed using the guidelines of the US Centers for Disease Control and Prevention. A total of 2160 patients were included, and the overall SSI rate was 10.2%. Malignancy [odds ratio (OR) = 1.63], duration of operation (OR = 1.41), high American Society of Anesthesiologists score (OR = 1.8), and clean-contaminated (OR = 1.5) and contaminated (OR = 3.2) operations were found to be statistically significant risk factors for SSI. The most frequently isolated microorganisms were Acinetobacter spp (31.5%), Escherichia coli (25.5%), and Pseudomonas spp (17.9%). This study further illustrates the burden of SSI in a typical hospital situation in developing countries. Our findings highlight the urgent need to develop a consistent national surveillance program for SSI, with accurate feedback of appropriate data to help surgeons control and reduce the SSI rates in developing countries.

A Practice Improvement Project to Reduce Cesarean Surgical Site Infection Rates

We implemented an evidence-based practice improvement project at a health care facility in the Midwestern United States to address the increasing rate of cesarean surgical site infections. Women who experienced cesarean birth were cared for using a standardized evidence-based protocol including preoperative and postoperative care and education. In addition, a team-created educational video was used by both women and their families during the postoperative period and at home after discharge. This new protocol resulted in a decrease in the rate of cesarean surgical site infections from 1.35% in 2013 to 0.7% in 2014 and 0.36% in 2015. Our interdisciplinary approach to integrate best-practice strategies resulted in decreased infection rates and improved patient satisfaction scores.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Transumbilical abdominal incision for laparoscopic colorectal surgery does not increase the risk of postoperative surgical site infection

PURPOSE

Besides antibiotic prophylaxis, antiseptic skin preparation is an important measure to prevent surgical site infection (SSI). No reports have detailed the relationship between SSI and umbilical microflora following laparoscopic colorectal cancer with a transumbilical longitudinal incision.

METHODS

Risk factors and the rate of SSI were investigated in 453 patients who underwent laparoscopic colorectal resection over a 3-year period. Microbiological samples were collected from the umbilicus and SSI areas.

RESULTS

After laparoscopic procedure, we observed SSIs in approximately 5% of cases, with superficial SSI in 15 (3.3%) patients and organ/space SSIs 7 (1.5%). In univariate analysis, preoperative albumin (Alb) value and anastomosis of enterocolostomy were significantly associated with superficial SSI development. Also, age, blood loss, stoma, tumor site (rectum), and Hartmann/abdominal perineal resection (APR) were significant risk factors for organ/space SSI. In multivariate analysis, the preoperative Alb value was the most significant factor associated with a predisposition to superficial SSI. The bacteria detected in SSI were mostly different from those at wound closure. Antibiotic-resistant bacteria were included in organ/space SSI all cases.

CONCLUSIONS

SSI development with laparoscopic surgery reportedly occurs in about 3-15% cases. The SSI rate in this study and other reports was comparable. Using small transumbilical longitudinal incision in laparoscopic colorectal surgery is less likely to cause SSI when sufficient control measures are enacted, even though the umbilicus contains resident bacteria in abundance.