Incidence and Risk Factors of Wound Infection in Women Who Underwent Cesarean Section in 2014 at King Abdulaziz Medical City, Jeddah

Introduction

Cesarean section (C/S) is considered one of the most commonly performed procedures among women. The maternal morbidity due to infection post-C/S reaches eight-fold higher than that of vaginal delivery. Our aim is to identify the incidence and risk factors of surgical site infection (SSI) among patients at King Abdul Aziz Medical City (KAMC), Jeddah, Saudi Arabia, in order to develop a strong strategy to reduce its occurrence.

Methods

This retrospective cohort study was conducted at KAMC, Jeddah. The study included a total of 387 women who underwent cesarean sections from January 2014 to December 2014. The data were collected consecutively by reviewing medical records of pregnant patients who underwent elective or emergency C/S. The risk factors studied included age, presence of underlying diseases, BMI, hemoglobin level, prophylactic antibiotics, pre-labor rupture of membrane, duration of induction of labor, type of C/S, type of uterine incision, duration of operation, type of anesthesia, estimated blood loss, type of organism, and the duration of hospital stay postoperatively. 

Results

The incidence rate of wound infections (WI) was 3.4% (13/387). The mean age score was 31.1±5.6 years, and the mean score of BMI was 32.7±6.2, where the majority were obese (255, 65.9%). More than half of the participants (205, 53.0%) had elective C/S, with mean hospitalization duration 2.5±1.3 days, and operation duration mean score 59.5±22.0 minutes. The majority (378, 97.7%) received antibiotics before the operation, where cefazolin was the main antibiotic (376, 97.2%). Only 38 (10%) cases had intra-operative complications, where the main complication was postpartum hemorrhage (18, 44.0%). The majority of WI were superficial (11 cases), the main organism was E. coli in four (36.4%) cases, followed by Staphylococcus aureus in three (27.3%) cases. There was a significant association between WI post-C/S and BMI, type of uterine incision, and induction of labor (P=006, P=0.003, respectively). 

Conclusions

This study showed that WI post-C/S is associated with high BMI, prolonged induction of labor, and Pfannenstiel incision. Reducing the rate of SSI will help to reduce its morbidity by identifying the risk factors pre-pregnancy and encouraging the implementation of preconception counseling clinics and antenatal classes to educate and increase awareness among patients.

Infections after pediatric ambulatory surgery: Incidence and risk factors

OBJECTIVE

To describe the epidemiology of surgical site infections (SSIs) after pediatric ambulatory surgery.

DESIGN

Observational cohort study with 60 days follow-up after surgery.

SETTING

The study took place in 3 ambulatory surgical facilities (ASFs) and 1 hospital-based facility in a single pediatric healthcare network.ParticipantsChildren <18 years undergoing ambulatory surgery were included in the study. Of 19,777 eligible surgical encounters, 8,502 patients were enrolled.

METHODS

Data were collected through parental interviews and from chart reviews. We assessed 2 outcomes: (1) National Healthcare Safety Network (NHSN)-defined SSI and (2) evidence of possible infection using a definition developed for this study.

RESULTS

We identified 21 NSHN SSIs for a rate of 2.5 SSIs per 1,000 surgical encounters: 2.9 per 1,000 at the hospital-based facility and 1.6 per 1,000 at the ASFs. After restricting the search to procedures completed at both facilities and adjustment for patient demographics, there was no difference in the risk of NHSN SSI between the 2 types of facilities (odds ratio, 0.7; 95% confidence interval, 0.2-2.3). Within 60 days after surgery, 404 surgical patients had some or strong evidence of possible infection obtained from parental interview and/or chart review (rate, 48 SSIs per 1,000 surgical encounters). Of 306 cases identified through parental interviews, 176 cases (57%) did not have chart documentation. In our multivariable analysis, older age and black race were associated with a reduced risk of possible infection.

CONCLUSIONS

The rate of NHSN-defined SSI after pediatric ambulatory surgery was low, although a substantial additional burden of infectious morbidity related to surgery might not have been captured by standard surveillance strategies and definitions.

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.

Abdominoperineal Resection, Pelvic Exenteration, and Additional Organ Resection Increase the Risk of Surgical Site Infection after Elective Colorectal Surgery: An American College of Surgeons National Surgical Quality Improvement Program Analysis

BACKGROUND

Determining predictors of surgical site infection (SSI) in a large cohort is important for the design of accurate SSI surveillance programs. We hypothesized that additional organ resection and pelvic exenterative procedures are associated independently with a higher risk of SSI.

METHODS

Patients in the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®; American College of Surgeons, Chicago, IL) database (2005-2012) were identified (n=112,282). Surgical site infection (superficial or deep SSI) at 30 d was the primary outcome. Using primary and secondary CPT® codes (American Medical Association, Chicago, IL) pelvic exenteration was defined and additional organ resection was defined as: bladder resection/repair, hysterectomy, partial vaginectomy, additional segmental colectomy, small bowel, gastric, or diaphragm resection. Univariable analysis of patient and procedure factors identified significant (p<0.05) predictors, which were modeled using stepwise logistic regression.

RESULTS

The rate of SSI was 9.2%. After adjusting for operative duration, predictors of SSI were body mass index (BMI) 25-29.9 (odds ratio [OR]: 1.3), BMI 30-34.9 (OR: 1.59), BMI 35-39.9 (OR: 2.11), BMI>40 (OR: 2.51), pulmonary comorbidities (OR: 1.22), smoking (OR: 1.24), bowel obstruction (OR: 1.40), wound classification 3 or 4 (OR: 1.18), and abdominoperineal resection (OR: 1.58). Laparoscopic or laparoscopically assisted procedures offered a protective effect against incision infection (OR: 0.55). Additional organ resection (OR: 1.08) was also associated independently with SSI, but the magnitude of the effect was decreased after accounting for operative duration. In the analysis that excludes operative duration, pelvic exenteration is associated with SSI (OR: 1.38), but incorporating operative duration into the model results in this variable becoming non-significant.

CONCLUSIONS

In addition to other factors, obesity, surgery for bowel obstruction, abdominoperineal resection, and additional organ resection are independently associated with a higher risk of SSI. Surgical site infection risk in pelvic exenteration and multiple organ resection cases appears to be mediated by prolonged operative duration. In these established high-risk sub-groups of patients, aggressive interventions to prevent SSI should be implemented.

Bacteria in hernia sac: an important risk fact for surgical site infection after incarcerated hernia repair

BACKGROUND

Although some recent reports have proven that incarcerated and/or strangulated hernia is not contraindication to mesh repair, there is still a common concern owing to increased rate of postoperative surgical site infection (SSI). The aim of this clinical study was to evaluate factors that increase the risk of SSI after incarcerated hernia repair, and to identify the pathogens related to SSI.

METHODS

A retrospective analysis was performed on data collected prospectively over a 4-year interval from January 2007 to December 2011. A total of 121 patients who underwent emergency surgery for incarcerated hernias were analyzed.

RESULTS

107 hernias were repaired using mesh versus 14 primary suture repairs. SSIs were observed in 9 of the 121 patients. Of 15 preoperative and intraoperative variables studied, duration of symptoms, diabetes mellitus, present of ileus, bowel resection or mesh repair performed, bacteria present in hernia sac and cloudy fluid in hernia sac were found to be significant factors predicting SSI. On multivariate analysis only bowel resection, duration of symptoms and bacteria present in hernia sac were independent variables. The most common pathogen found in hernia sac and cultured from wound drainage or swab was Escherichia coli. The strains of bacteria cultured from wound drainage or swab were same as those cultured from fluid in hernia sac in six of nine patients.

CONCLUSION

Gut-sourced E. coli is an important common organisms associated with SSI after incarcerated hernia repair. Prosthetic mesh could be used when no bowel resection is performed, duration of symptoms less than 24 h and fluid hernia sac is clear.

Incidence and risk factors for surgical site infection after gastric surgery: a multicenter prospective cohort study

Background

Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. While gastrointestinal surgery is relatively common in Korea, few studies have evaluated SSI in the context of gastric surgery. Thus, we performed a prospective cohort study to determine the incidence and risk factors of SSI in Korean patients undergoing gastric surgery.

Materials and Methods

A prospective cohort study of 2,091 patients who underwent gastric surgery was performed in 10 hospitals with more than 500 beds (nine tertiary hospitals and one secondary hospital). Patients were recruited from an SSI surveillance program between June 1, 2010, and August 31, 2011 and followed up for 1 month after the operation. The criteria used to define SSI and a patient's risk index category were established according to the Centers for Disease Control and Prevention and the National Nosocomial Infection Surveillance System. We collected demographic data and potential perioperative risk factors including type and duration of the operation and physical status score in patients who developed SSIs based on a previous study protocol.

Results

A total of 71 SSIs (3.3%) were identified, with hospital rates varying from 0.0 - 15.7%. The results of multivariate analyses indicated that prolonged operation time (P = 0.002), use of a razor for preoperative hair removal (P = 0.010), and absence of laminar flow in the operating room (P = 0.024) were independent risk factors for SSI after gastric surgery.

Conclusions

Longer operation times, razor use, and absence of laminar flow in operating rooms were independently associated with significant increased SSI risk after gastric surgery.

Single dose of gentamicin in combination with metronidazole versus multiple doses for prevention of post-caesarean infection at Bugando Medical Centre in Mwanza, Tanzania: a randomized, equivalence, controlled trial

Background

Caesarean section(C/S) has been found to increase rates of maternal infectious morbidities five times more than vaginal delivery. The provision of intravenous prophylactic antibiotics 30 to 60 minutes prior to C/S has been found to substantially reduce post-caesarean infection. At Bugando Medical Centre, there is no consistent protocol for the administration of antibiotic prophylaxis to patients who are undergoing emergency C/S. Providing repeated dosages of antibiotic prophylaxis after C/S is the common practice. This study aimed to determine the comparative efficacy of a single dose of gentamicin in combination with metronidazole versus multiple doses for prevention of post-caesarean infection.

Methods

From October 2011 to May 2012, a randomized, equivalence, non-blinding clinical trial was conducted at Bugando Medical Centre in Mwanza, Tanzania. A total of 500 eligible participants were enrolled in the study and were randomly allocated into two study arms -- “A” and “B”. Participants in “A” received a single dose of gentamicin in combination with metronidazole 30 to 60 minutes prior to the operation, and participants in “B” received the same drugs prior to the operation but continued with for 24 hours. Both groups had 30 days of follow-up and were assessed for signs and symptoms of surgical-site infection as the primary outcome. The equivalence margin was set at 5%. The two-tailed equivalence was analyzed based on intention- to-treat analysis.

Results

The randomization was proper, as the distribution of various demographic and other baseline characteristics had a p-value of > 0.05. All 500 participants were included in our analysis; of these, no participants were lost to follow-up. Surgical-site infection occurred in 12 out of the 250 (4.8%) receiving single dose compared to 16 out of the 250 (6.4%) receiving multiple doses. There is an absolute proportion difference of 1.6% (95% Confidence interval: -2.4 – 5.6%) which lies outside the pre-specified 5% equivalence margin.

Conclusion

We recommend the administration of pre-operative single dose antibiotic prophylaxis for emergency caesarean as this intervention proved to be not equivalent to multiple doses antibiotic prophylaxis in reducing surgical site infection. Single dose therapy also reduces staff workload along with medication costs.

Trial registration

Current Controlled Trials ISRCTN44462542

Outcome of cefazolin prophylaxis for total knee arthroplasty at an institution with high prevalence of methicillin-resistant Staphylococcus aureus infection

OBJECTIVES

The aim of this study was to evaluate the outcome of cefazolin prophylaxis for total knee arthroplasty (TKA) in a hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection.

METHODS

Since July 1, 2006, we have applied a 'care bundle' to TKA to prevent surgical site infection (SSI) without using vancomycin as antimicrobial prophylaxis, in accordance with the 1999 Hospital Infection Control Practices Advisory Committee guidelines. All patients undergoing TKA from July 1, 2006 to September 30, 2009 were enrolled. We reviewed data on SSI collected prospectively as part of routine infection control surveillance.

RESULTS

Of 1323 TKAs, an SSI developed in 14 (1.06%) cases, which is comparable to the percentage obtained in other previous reports. When stratified by the National Nosocomial Infection Surveillance risk index, SSI rates were 0.86% (8/926), 1.30% (5/384), and 7.69% (1/13) in risk categories 0, 1, and 2, respectively. Of 14 SSIs, four (29%) were classified as superficial incisional, two (14%) as deep incisional, and eight (57%) as organ-space SSI.

CONCLUSIONS

Our data suggest that antimicrobial prophylaxis using only cefazolin can maintain low SSI rates if other important infection management measures are employed, even where there is a high prevalence of MRSA infection.

Association of surgeon with surgical site infection after liver transplantation

Surgical site infection (SSI) after liver transplantation has been associated with increased risk of allograft loss and death. Identification of modifiable risk factors for these infections is imperative. To our knowledge, intraoperative practices associated with transplant surgeons have not been assessed as a risk factor. A retrospective cohort study of risk factors for SSI after 1036 first liver transplantations completed by seven surgeons at a single center between 2003 and 2008 was undertaken. Cox proportional hazards models were used to evaluate the association between surgeons and SSIs. SSIs were identified in 166 of 1036 patients (16%). Single variable analysis showed strong evidence of an association between surgeon and SSI (p = 0.0007); the estimated cumulative incidence of SSI ranged from 7% to 24%. This result was consistent in multivariable analysis adjusting for potentially confounding variables (p = 0.002). The occurrence of organ-space or deep SSI varied significantly among surgeons in both single variable analysis (p = 0.005) and multivariable analysis (p = 0.006). These findings provide evidence that differences in the surgical practices of individual surgeons are associated with risk for SSI after liver transplantation. Identification of specific surgical practices associated with risk of SSI is warranted.

[Incidence of nosocomial infection in open prostate surgery]

OBJECTIVES

To know the rate of nosocomial infections in open prostate surgery and to assess the application of pre-surgery preparation and preoperative antibiotic prophylaxis protocols at three public hospitals in the Autonomous Community of Madrid.

MATERIALS AND METHODS

Prospective observational and multicentre study, including all the patients operated on at the services monitored and admitted for more than 48 hours between 1 January and 31 December 2009. They were monitored from admittance until their discharge.

RESULTS

The rate of hospital infection observed was 3.38%. The most frequent infection was surgical localization, with an incidence rate of 2.77% (superficial=1.23%; deep=0.31%; organ-space=1.23%). The percentage of appropriate surgical prophylaxis, both in the indication and in the selection of antibiotics, initiation and duration, with respect to all those patients that received it, was 47.42%. According to the data obtained from their clinical records, the percentage of patients in which the pre-surgery preparation protocol was correctly complied with, was 92%.

CONCLUSIONS

The results obtained in this multicentre study can serve not only as a reference to other public hospitals, but they are also comparable to other international monitoring systems. Monitoring and controlling infections associated with healthcare must be a key aspect in Patient Care and Safety programmes.

Standardized incidence rates of surgical site infection: a multicenter study in Thailand

BACKGROUND

No previous multicenter data regarding the incidence of surgical site infection (SSI) are available in Thailand. The magnitude of the problem resulting from SSI at the national level could not be assessed. The purpose of this study was to estimate the incidence of SSI in 9 hospitals, together with patterns of surgical antibiotic prophylaxis, risk factors for SSI, and common causative pathogens.

METHODS

A prospective data collection among patients undergoing surgery in 9 hospitals in Thailand was conducted. The National Nosocomial Infection Surveillance (NNIS) system criteria and method were used for identifying and diagnosing SSI. The SSI rates were benchmarked with the NNIS report by means of indirect standardization and reported in terms of standardized infection ratio (SIR). Antibiotic prophylaxis was categorized into preoperative, intraoperative, and postoperative. Risk factors for SSI were evaluated using multiple logistic regression models.

RESULTS

From July 1, 2003, to February 29, 2004, the study included 8764 patients with 8854 major operations and identified 127 SSIs, yielding an SSI rate of 1.4 infections/100 operations and a corresponding SIR of 0.6 (95% CI: 0.5-0.8). Of these, 35 SSIs (27.6%) were detected postdischarge. The 3 most common operative procedures were cesarean section, appendectomy, and hysterectomy. The 3 most common pathogens isolated were Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa, which accounted for 15.3%, 8.5%, and 6.8% of infections, respectively. The 3 most common antibiotics used for prophylaxis were ampicillin/amoxicillin, cefazolin, and gentamicin. The proportion of types of antibiotic prophylaxis administered were 51.6% preoperative, 24.3% intraoperative, and 24.1% postoperative. Factors significantly associated with SSI were high degree of wound contamination, prolonged preoperative hospital stay, emergency operation, and prolonged duration of operation.

CONCLUSION

Overall SSI rates were less than the average NNIS rates. The causative pathogens of SSI were different from those of other reports. There was a crucial proportion of operations that did not comply with the antibiotic guidelines. The risk factors for SSI identified in this study were consistent with most other reports.

Superficial incisional infection in arthroplasty of the lower limb

The Department of Health and the Public Health Laboratory Service established the Nosocomial Infection National Surveillance Scheme in order to standardise the collection of information about infections acquired in hospital in the United Kingdom and provide national data with which hospitals could measure their own performance. The definition of superficial incisional infection (skin and subcutaneous tissue), set by the Center for Disease Control (CDC), should meet at least one of the defined criteria which would confirm the diagnosis and determine the need for specific treatment.

We have assessed the interobserver reliability of the criteria for superficial incisional infection set by the CDC in our current practice. The incisional site of 50 patients who had an elective primary arthroplasty of the hip or knee was evaluated independently by two orthopaedic clinical research fellows and two orthopaedic ward sisters for the presence or absence of surgical-site infection. Interobserver reliability was assessed by comparison of the criteria for wound infection used by the four observers using kappa reliability coefficients. Our study demonstrated that some of the components of the current CDC criteria were unreliable and we recommend their revision.

Methicillin-resistant Staphylococcus aureus infections in ICU patients

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections in patients admitted to the intensive care unit has dramatically increased in recent years, with an associated increase in morbidity and mortality and the costs of caring for patients with MRSA infections. Although indiscriminate and inappropriate use of antibiotics has contributed to this phenomenon, horizontal transmission of MRSA between patients and health care providers is the principal cause of this observed increase. This article discusses the pathogenesis, epidemiology, treatment, and prevention of MRSA infections in critically ill patients.

Intraoperative antibiotic prophylaxis in clean spinal surgery: a retrospective analysis in a consecutive series of 973 cases

BACKGROUND

Antibiotic prophylaxis in spine surgery is still a debated question, involving medical, ethical, economic, and legal issues. The aim of our retrospective study was to evaluate the safety and effectiveness of an intraoperative protocol of antibiotic prophylaxis.

METHODS

During a 3-year period, 973 patients were consecutively operated on for clean spinal operations. Twenty-three percent of the cases involved the cervical spine and 77% the thoraco-lumbar spine; about 90% of patients were operated on for degenerative diseases and the remaining for traumatic lesions or tumors. Patients undergoing operations shorter than 120 minutes received a single-dose of IV ampicillin 1000 mg and sulbactam 500 mg (AS) at induction of anesthesia. In procedures longer than 120 minutes and/or requiring prosthetic materials, an IV single-dose of teicoplanin 400 mg was also administered at the same time. A second intraoperative dose of AS and teicoplanin was administered in operations longer than 4 hours (240 minutes after the first one) and in procedures in which blood loss exceeded 1500 mL. Postoperative prophylaxis has never been performed.

RESULTS

The only side effect was a cutaneous rash in 7 cases (0.7%), without any consequence. A wound infection was detected in 9 cases (<1%), all successfully treated with surgical toilette and specific antibiotic treatment. A lumbar discitis was detected in 4 out of 657 microdiscectomies (0.6%).

CONCLUSIONS

Even if this study has the weakness of the retrospective character, our intraoperative antibiotic prophylaxis protocol proved to be safe and efficacious. We hope that these preliminary results will be confirmed by larger prospectic trials.

A prospective study of surgical site infections in a pediatric hospital in Mexico City

BACKGROUND

Pediatric surgical site infection (SSI) rates in the United States range from 2.5% to 4.4%. There is little data regarding their risk factors among children. We quantified SSI rates and identified risk factors of SSI in a tertiary care pediatric teaching hospital in Mexico City.

METHODS

All neurosurgical, cardiovascular, and general surgical patients who underwent operation between Aug 1, 1998, and Jan 31, 1999, were followed-up daily during hospitalization. On postoperative day 30, a full review of microbiology reports and medical records was performed. Univariate and multivariate analyses were done to identify risk factors.

RESULTS

Four hundred twenty-eight of 530 children completed follow-up. The overall SSI rate was 18.7%. Forty percent of SSI were superficial incisional, 21% were deep incisional, and 39% were organ/space infections. For clean, clean-contaminated, contaminated, and dirty procedures, SSI infection rates were 12.4%, 24.4%, 14.3%, and 32.4%, respectively. Open drains (OR = 2.3; 95% CI = 1.3-4.2; P <.005) and surgery that lasted 90 or more minutes (OR = 2.9; 95% CI = 1.6-5.1; P <.001) were associated with infection.

CONCLUSIONS

Our rates are greater than comparable reported data among children. Duration of surgery and use of open drains were associated with SSI.

Nosocomial infections in intensive care patients

Facilities must manage core system processes to minimize medication errors and other adverse outcomes, such as nosocomial infections. Characterization of specific risk factors for the development of nosocomial infections and efficacious evidence-based care interventions are expanding. Health care providers need to evaluate their patient populations and systems of care to minimize lack of knowledge, slips. and lapses in care and other system issues to assure that successful care practices are consistently used to minimize nosocomial infections.

Infection surveillance scheme: collaborative working practices

This article describes the development of the Nosocomial infection National Surveillance Scheme. Doctors and nurses are expected to collaborate and work together in order to improve patient care. Guidelines on infection control in hospitals include the need for infection control teams to carry out surveillance and feed back the results to doctors so that they can make the necessary changes. The relationship between doctors and nurses has long been debated, and this could hinder the success of doctors cooperating and sharing ownership of the scheme. Interpersonal skills, group dynamics, organizational controls and professional standards are discussed.

Surgical site infections at the National Cancer Institute in Mexico: a case-control study

OBJECTIVES

To quantify the surgical infection rate and to identify risk factors associated with surgical site infection.

METHODS

We conducted a case-control study of all surgical patients between January 1, 1993, and June 30, 1994. The frequency of surgical site infection per 100 surgeries was calculated. The odds ratio (OR) was estimated by using logistic regression analysis.

SETTING

A 130-bed tertiary-care teaching hospital for adult patients with cancer.

RESULTS

The study followed 3372 surgeries. Three hundred thirteen patients had a surgical site infection (rate per 100 surgeries: 9. 30). The risk factors associated with surgical site infection were diabetes mellitus (OR = 2.5, 95% confidence interval [CI] = 1.27-4. 91), obesity (OR = 1.76, 95% CI = 1.14-2.7), presence of surgical drains for >5 and <16 days (OR = 1.84, 95% CI = 1.02-3.31), and presence of surgical drains for >/=16 days (OR = 2.14, 95% CI = 1. 0-4.6). The bacteria most frequently isolated were Escherichia coli 38 (21.8% of the total of microorganisms found), Pseudomonas sp 22 (12.6%), Staphylococcus aureus 16 (9.2%), and coagulase-negative Staphylococcus 25 (13.6%). The coexistence of other nosocomial infections was greater among the cases (OR = 1.8, 95% CI = 1.1-3.1) than in the control group.

CONCLUSIONS

The surgical site infection rate in our hospital is slightly higher than the rates reported for general hospitals. The risk factors associated with surgical site infection are similar to those previously reported. Diabetes mellitus, obesity, and prolonged presence of a surgical drain increased the risk of infection.

Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee

EXECUTIVE SUMMARY The "Guideline for Prevention of Surgical Site Infection, 1999" presents the Centers for Disease Control and Prevention (CDC)'s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1,2 Part I, "Surgical Site Infection: An Overview," describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, "Recommendations for Prevention of Surgical Site Infection," represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge.It has been estimated that approximately 75% of all operations in the United States will be performed in "ambulatory," "same-day," or "outpatient" operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not: Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care. Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures. Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6-11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy). Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activitie

Surgical wound infection surveillance: the importance of infections that develop after hospital discharge

BACKGROUND

The aim of this study was to evaluate two methods of post-discharge surgical wound surveillance and to compare the incidence and outcomes of wound infections that develop prior to patients' discharge with those that develop after hospital discharge.

METHODS

One thousand, three hundred and sixty inpatients who underwent major elective surgery in an 800-bed teaching hospital in western Sydney between February 1996 and July 1997 were followed prospectively. Pre-discharge wound surveillance was performed by clinical assessment by an independent researcher on the fifth (or later) postoperative day. Post-discharge wound surveillance was performed by a mail out of questionnaires completed independently by patients and surgeons.

RESULTS

Overall, 138 wound infections were diagnosed (incidence 10.1%), of which fewer than one-third (n = 44) were diagnosed before discharge (average 10.4 days postoperatively) and the remainder (n = 94) after discharge (average 20.6 days postoperatively). Seven hundred and eighty-two (57.5%) post-discharge survey forms were returned by patients and 680 (50.0%) by surgeons. When forms were returned by both surgeons and patients for the same wound (641 cases), there was substantial agreement in diagnosing infection or no infection (kappa = 0.73).

CONCLUSIONS

The majority of nosocomial surgical wound infections develop after the patients' discharge from hospital. A post-discharge surveillance programme including self-reporting of infections by patients and return of questionnaires by patients and surgeons is feasible in an Australian hospital setting. However, such a programme is labour and resource intensive and strategies to increase return of questionnaires are required.

Infection registration underestimates the risk of surgical wound infections

Two consecutive bedside prevalence studies of 455 surgical patients were made by the same infection control nurse in 15 surgical and gynaecological departments in eight Danish hospitals. There was a high degree of diagnostic agreement between the prevalence survey and the clinical data. Four point six percent had a deep, and another 4.6%, a superficial surgical wound infection (SWI). Two months after the second survey only one third of these patients had their infection correctly recorded by the routine hospital surveillance of SWI. Better routines need to be developed to secure a valid, reliable and simple registration of relevant infectious wound complications. A follow-up was carried out with self-administered questionnaires in 2976 patients, of whom 1447 (48.6%) responded. This post-discharge survey showed that 15.7% had been treated with antibiotics, because of pus in the wound, 12.4% had to have the wound reopened and 6.6% experienced both these treatments.

Should antibiotic prophylaxis be used routinely in clean surgical procedures: a tentative yes

BACKGROUND

The incidence of surgical site infection (SSI) after clean surgical procedure has traditionally been regarded as too low for routine antibiotic prophylaxis. But we now know that host factors may increase the risk of SSI to as high as 20%. We assessed the value of prophylactic cefotaxime in patients stratified for risk of SSI in a randomized double-blind trial.

METHODS

Patients admitted for clean elective operations were enrolled, stratified for risk by National Nosocomial Infection Survey criteria, and randomized to receive intravenous cefotaxime 2 gm or placebo on call for operation. They were followed for 4 to 6 weeks for SSI diagnosed by Centers for Disease Control and Prevention criteria.

RESULTS

Analysis of 775 patients showed that the 378 evaluable patients who received cefotaxime had 70% fewer SSI than those who did not--Mantel-Haenszel risk ratio (MH-RR) 0.31; 95% confidence intervals (CI) 0.11 to 0.83. Benefit was clear in the 616 low risk patients--0.97% versus 3.9% SSI (MH-RR 0.25, CI 0.07 to 0.87, p = 0.018), but only a trend was seen in 136 high risk patients--2.8% versus 6.1% SSI (MH-RR 0.48, CI 0.09 to 2.5).

CONCLUSIONS

The results indicate clear benefit for routine antibiotic prophylaxis in clean surgical procedures. High risk patients need more study.

Underestimation of surgical site infection rates in obstetrics and gynecology

BACKGROUND

With the increasing volume of same-day operations and shortened hospital stays, it becomes more likely that a significant percentage of surgical site infections will occur after these patients' discharges.

METHODS

To document the true incidence of postdischarge surgical site infection, surveillance was undertaken in a group of obstetric and gynecologic patients. The study consisted of two parts. (1) A questionnaire was mailed to each surgeon, inquiring about clinical evidence of infection. The infection control service continued to do surveillance of wound infection in the usual manner, and the results of the two methods were compared. (2) A questionnaire was provided to patients undergoing operation, inquiring about signs and symptoms of wound infection.

RESULTS

A total of 469 surgical procedures were included, with a total of 24 infections detected (5.2%). Of these, 14 infections (58.3%) were detected by the usual surveillance method. An additional 10 infections (41.7%) were detected after patient discharge by the physician questionnaire. Only two of the 24 infections were detected by the patient questionnaire.

CONCLUSIONS

Failure to include postdischarge surgical site surveillance results in a substantial underestimation of the true surgical site infection rate. Physician input and strong support have prompted a regular biannual postdischarge surgical site surveillance program in this patient population.