Surgical Site Infections in an Italian Surgical Ward: A Prospective Study

Excessive Pregestational Weight and Maternal Obstetric Complications: The Role of Adipokines

There is a high frequency of overweight and obesity in women of reproductive age. Women who start pregnancy with overweight or obesity have an increased risk of developing maternal obstetric complications such as gestational hypertension, pre-eclampsia, gestational diabetes mellitus, postpartum hemorrhage, and requiring C-section to resolve the pregnancy with a higher risk of C-section surgical site infection. Excessive weight in pregnancy is characterized by dysregulation of adipokines, the functions of which partly explain the predisposition of pregnant women with overweight or obesity to these maternal obstetric complications. This review compiles, organizes, and analyzes the most recent studies on adipokines in pregnant women with excess weight and the potential pathophysiological mechanisms favoring the development of maternal pregnancy complications.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The impact of obesity on immune response to infection: Plausible mechanisms and outcomes

Emerging data suggest an association between obesity and infectious diseases. Although the mechanisms underlying this link are not well established, a number of potential factors may be involved. Indeed, the obesity-related vulnerability to infectious diseases could be due to chronic low-grade inflammation, hyperglycemia, hyperinsulinemia, and hyperleptinemia, which lead to a weakening of both the innate and adaptive immune responses. In addition, obesity results in anatomical-functional changes by the mechanical obstacle of excessive adipose tissue that blunt the respiratory mechanisms and predisposing to respiratory infections. Subjects with obesity are also at risk of skin folds and sweat more profusely due to the thick layers of subcutaneous fat, favoring the proliferation of microorganisms and slowing the repair of wounds down. All these factors make subjects with obesity more prone to develop nosocomial infections, surgical site, skin and soft tissue infections, bacteremia, urinary tract infections, and mycosis. Furthermore, infections in subjects with obesity have a worse prognosis, frequently prolonging hospitalization time as demonstrated for several flu viruses and recently for COVID-19. Thus, the aim of this manuscript is to provide an overview of the current clinical evidence on the associations between obesity and infectious diseases highlighting physio pathological insights involved in this link.

Impact of BMI on Complications and Satisfaction in Patients With Papillary Thyroid Cancer and Lateral Neck Metastasis

BACKGROUND

This study investigates the effect of body mass index (BMI) on complications and satisfaction in patients who underwent thyroidectomy and lateral neck dissection.

METHODS

We retrospectively reviewed 386 patients with papillary thyroid cancer who underwent total thyroidectomy and lateral neck dissection between January 2013 and December 2016. We compared variables including population characteristics, subjective satisfaction, and complications in nonobese (BMI < 28.0 kg/m²) and obese (BMI ≥ 28.0 kg/m²) patients.

RESULTS

Obesity was associated with an increased risk of postoperative hemorrhage (POH) (P = .014), accessory nerve injury (P < .001), operative time (P < .001) and infection (P = .013). However, obese patients had higher subjective satisfaction and Vancouver Scar Scale (VSS) scores (P < .05).

CONCLUSIONS

Obesity was associated with increased risk of POH, injury of the SAN, and infection. Interestingly, we found that obese patients had higher subjective satisfaction and VSS scores.

Incidence and Bacterial Etiologies of Surgical Site Infections in a Public Hospital, Addis Ababa, Ethiopia

Background:

Surgical Site Infections (SSIs) are among the frequently reported healthcare-acquired infections worldwide. Successful treatment of SSIs is affected by the continuous evolvement of drug-resistant microbes. This study investigated the incidence of SSIs, identifying the major etiologic agents and their drug resistance patterns in Yekatit 12 Hospital, Ethiopia.

Methods:

A cross-sectional study was conducted on 649 patients who underwent surgery at Yekatit 12 hospital from April 2016 to April 2017. Socio-demographic and clinical data were collected from each patient on admission. After surgery, they were followed for SSI occurrence. SSI was initially diagnosed by a senior surgeon based on standard clinical criteria and then confirmed by culture. Isolates were tested for drug resistance according to the clinical and laboratory standards institute guideline.

Results:

Of the 649 study participants, 56% were females. Their age ranged from 9 months to 88 years with a median age of 37 years. The incidence of culture-confirmed SSI was 10.2% (66/649) where 73 isolates were recovered. About two-third of the isolates were Gram-positive bacteria. Staphylococcus aureus was the most frequently isolated (27/73, 37%) followed by Coagulase-negative staphylococci (18/73, 24.7%), Escherichia coli (11/73, 15.1%) and Klebsiella species (10/73, 13.7%). About 89% and 44% of S. aureus isolates were resistant to penicillin and trimethoprim-sulfamethoxazole, respectively. MRSA constituted 11% of the S. aureus isolates. All the Gram-negative isolates were resistant to ampicillin and trimethoprim-sulfamethoxazole but susceptible to amikacin and meropenem. Klebsiella species showed 70-100% resistance to ceftazidime, cefuroxime, augmentin, chloramphenicol, ciprofloxacin, cefepime and gentamicin. About 82% of E. coli isolates were resistant for chloramphenicol, cefepime, ceftazidime, augmentin, cefuroxime and 64% for gentamicin and ciprofloxacin.

Conclusion:

The incidence of surgical site infection in Yekatit 12 hospital is 10.2%. Most of the SSIs were due to Gram-positive bacteria. Gram-negative isolates showed high resistance to the most commonly prescribed drugs. No resistance was found for meropenem indicating the absence of carbapenem-resistant bacteria. SSI treatments should be guided by culture and drug resistance test. Better infection prevention practices and continuous surveillance of antimicrobial resistance in the hospital are recommended for better patient care.

Sentinel lymph node biopsy in patients with malignant melanoma: analysis of post-operative complications

BACKGROUND

This study investigates the incidence of post-operative complications and risk factors of sentinel lymph node biopsy (SLNB) in melanoma patients.

METHODS

A retrospective cohort study was conducted at a single cancer institution on 408 consecutive SLNBs.

RESULTS

Fifty-five post-operative complications occurred in 39 (9.5%) patients and included: wound infection in 24 (5.9%), seroma and lymphorrhea in 15 (3.7%), wound dehiscence in seven (1.7%), lymphocele in six (1.5%) and others in three (0.7%). Univariate analysis failed to identify possible risk factors (i.e. gender, age, lymph node region, number of excised lymph nodes, Breslow index, pT levels, comorbidities, length of surgery and hospital stay). Metastatic sentinel nodes occurred in four of 135 (3%) patients with thin melanoma (Breslow <1 mm) and in 68 of 262 (25.9%) patients with Breslow >1 mm.

CONCLUSION

For patients with thin melanoma in whom the incidence of lymph node metastasis is low, the reported post-operative morbidity of almost 10% of SLNB highlights the need for careful patient selection.

A New Surgical Site Infection Risk Score: Infection Risk Index in Cardiac Surgery

Various scoring systems attempt to predict the risk of surgical site infection (SSI) after cardiac surgery, but their discrimination is limited. Our aim was to analyze all SSI risk factors in both coronary artery bypass graft (CABG) and valve replacement patients in order to create a new SSI risk score for such individuals. A priori prospective collected data on patients that underwent cardiac surgery (n = 2020) were analyzed following recommendations from the Reporting of studies Conducted using Observational Routinely collected health Data (RECORD) group. Study participants were divided into two periods: the training sample for defining the new tool (2010–2014, n = 1298), and the test sample for its validation (2015–2017, n = 722). In logistic regression, two preoperative variables were significantly associated with SSI (odds ratio (OR) and 95% confidence interval (CI)): diabetes, 3.3/2–5.7; and obesity, 4.5/2.2–9.3. The new score was constructed using a summation system for punctuation using integer numbers, that is, by assigning one point to the presence of either diabetes or obesity. The tool performed better in terms of assessing SSI risk in the test sample (area under the Receiver-Operating Characteristic curve (aROC) and 95% CI, 0.67/055–0.76) compared to the National Nosocomial Infections Surveillance (NNIS) risk index (0.61/0.50–0.71) and the Australian Clinical Risk Index (ACRI) (0.61/0.50–0.72). A new two-variable score to preoperative SSI risk stratification of cardiac surgery patients, named Infection Risk Index in Cardiac surgery (IRIC), which outperforms other classical scores, is now available to surgeons. Personalization of treatment for cardiac surgery patients is needed.

Obesity: impact of infections and response to vaccines

Obesity is a common condition that has rapidly increased in both the industrialised and developing world in recent decades. Obese individuals show increased risk factors for severe infections and significant immune system dysregulation that may impair the immune response to vaccines. The main aim of this paper was to review the current knowledge regarding the association between obesity and the risk and outcome of infections as well as immune response to vaccines. The results showed that obesity is a highly complex clinical condition in which the functions of several organ and body systems, including the immune system, are modified. However, only a small minority of the biological mechanisms that lead to reduced host defences have been elucidated. Relevant efforts for future research should focus on obese children, as the available data on this population are scarce compared with the adult population. Even if most vaccines are given in the first months of life when obesity is rare, some vaccines require booster doses at preschool age, and other vaccines, such as the influenza vaccine, are recommended yearly in the obese population, but it is not known whether response to vaccines of obese patients is impaired. The reduced immune response of obese patients to vaccination can be deleterious not only for the patient but also for the community.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prophylactic antibiotic guidelines in modern interventional radiology practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Obesity and the risk and outcome of infection

The interactions between obesity and infectious diseases have recently received increasing recognition as emerging data have indicated an association between obesity and poor outcome in pandemic H1N1 influenza infection. Obesity is an established risk factor for surgical-site infections, nosocomial infections, periodontitis and skin infections. Several studies indicate that acute pancreatitis is more severe in the obese. Data are controversial and limited as regards the association between obesity and the risk and outcome of community-acquired infections such as pneumonia, bacteremia and sepsis and obesity and the course of HIV infection. As the cause-effect relationship between obesity and infection remains obscure in many infectious diseases, further studies are warranted. The consequences of obesity may have substantial effects on the global burden of infectious diseases.

Performance, revision, and extension of the National Nosocomial Infections Surveillance system's risk index in Brazilian hospitals

OBJECTIVE

To assess the benefit of using procedure-specific alternative cutoff points for National Nosocomial Infections Surveillance (NNIS) risk index variables and of extending surgical site infection (SSI) risk prediction models with a postdischarge surveillance indicator.

DESIGN

Open, retrospective, validation cohort study.

SETTING

Five private, nonuniversity Brazilian hospitals.

PATIENTS

Consecutive inpatients operated on between January 1993 and May 2006 (other operations of the genitourinary system [n = 20,723], integumentary system [n = 12,408], or musculoskeletal system [n = 15,714] and abdominal hysterectomy [n = 11,847]).

METHODS

For each procedure category, development and validation samples were defined nonrandomly. In the development samples, alternative SSI prognostic scores were constructed using logistic regression: (i) alternative NNIS scores used NNIS risk index covariates and cutoff points but locally derived SSI risk strata and rates, (ii) revised scores used procedure-specific alternative cutoff points, and (iii) extended scores expanded revised scores with a postdischarge surveillance indicator. Performances were compared in the validation samples using calibration, discrimination, and overall performance measures.

RESULTS

The NNIS risk index showed low discrimination, inadequate calibration, and predictions with high variability. The most consistent advantage of alternative NNIS scores was regarding calibration (prevalence and dispersion components). Revised scores performed slightly better than the NNIS risk index for most procedures and measures, mainly in calibration. Extended scores clearly performed better than the NNIS risk index, irrespective of the measure or operative procedure.

CONCLUSIONS

Locally derived SSI risk strata and rates improved the NNIS risk index's calibration. Alternative cutoff points further improved the specification of the intrinsic SSI risk component. Controlling for incomplete postdischarge SSI surveillance provided consistently more accurate SSI risk adjustment.

Impact of weight on immune cell counts among HIV-infected persons

Prior studies have shown that weight may impact immune cell counts. However, few data exist about the relationship of weight and immune cell counts among HIV-infected patients. We examined documented HIV seroconverters (mean window, 15.7 months) in a prospective U.S. Military HIV Natural History Study (1 January 1986 to 20 January 2010). We estimated the association of the time-updated body mass index (BMI) category with changes in immune cell counts from HIV diagnosis across time (mean follow-up of 5.1 years) using multiply adjusted longitudinal linear mixed-effects models. Of 1,097 HIV seroconverters, 448 (41%) were overweight and 93 (8%) were obese at HIV diagnosis. Immune cell counts at HIV diagnosis did not significantly differ by BMI category. In the longitudinal models for those diagnosed before the advent of the highly active antiretroviral therapy (HAART) era, mean postdiagnosis decreases in the white cell count, total lymphocyte count, CD4 count, CD4 percentage, and CD4/CD8 ratio were less as the BMI category increased (all with P values of <0.05). Among HIV seroconverters diagnosed in the HAART era, obese compared to normal-weight patients had significantly smaller increases in CD4 counts, CD4 percentages, and the CD4/CD8 ratio (all with P values of <0.05). Similar findings were also noted among underweight versus normal-weight patients. In conclusion, although BMI was not associated with immune cell levels at the time of HIV diagnosis, weight appears to affect immune cells counts over the course of infection. In the HAART era, being either underweight or obese was associated with smaller increases in several important immune cell levels, including the CD4/CD8 ratio.

Systematic review of the incidence of discitis after cervical discography

BACKGROUND CONTEXT

Cervical discography is not uniformly used in part because of the fear of discitis. Studies report widely varying rates of this life-threatening infection.

PURPOSE

The aim of this study was to estimate the incidence of discitis after cervical discography, delineate the consequences of discitis, and identify factors that may influence this complication.

STUDY DESIGN

Meta-analysis.

METHODS

Studies pertaining to cervical discography were identified by a literature review and bibliographic search. These were screened for inclusion into the meta-analysis by two reviewers. Data were collected on a wide range of clinical and demographic variables including age, gender, morbidities, number of patients, number of discograms, use of prophylactic antibiotics, type of surgical prep, number of needles used, and the number of patients and discs infected. Primary data were used to calculate the incidence of discitis per patient and per disc.

RESULTS

Fourteen studies were included in the analysis. Both procedural details and demographic information on patients were missing from eight studies. The mean age of patients ranged from 41 to 47 years, and gender distribution varied greatly. Antibiotics use was reported in three studies. Cervical discography was complicated by postprocedural discitis in 22 of 14,133 disc injections (0.15%) and 21 of 4,804 patients (0.44%). Only one patient suffered from an infection at more than one spinal level.

CONCLUSIONS

The rate of discitis after cervical discography is relatively low. This can perhaps be further decreased by the use of prophylactic intradiscal antibiotics. Should the ability of cervical discography to improve surgical outcomes be proven, the fear of discitis should not preclude performance of disc provocation.