Surgical site infection prevention: how we do it

Small bowel evisceration after abdominal hysterectomy with open vaginal cuff technique: A case report

Key Clinical Message

Vaginal cuff dehiscence post-hysterectomy is rare yet significant. Early recognition and prompt surgical intervention are crucial to prevent complications like bowel infarction. Consider second-look laparotomy in cases of uncertain bowel viability.

Abstract

Vaginal cuff dehiscence (VCD) is a rare but potentially life-threatening complication following a hysterectomy characterized by the separation of the vaginal vault. This condition, which may result in vaginal evisceration (VE), presents a significant risk of pelvic contents, particularly the small bowel, protruding into the vagina. Early diagnosis and prompt surgical intervention are paramount to prevent severe complications, including bowel infarction, obstruction, and peritonitis. Although VCD and VE are rare, they require urgent surgical management to avoid adverse outcomes. We reported a case of small bowel evisceration in a woman with a history of total abdominal hysterectomy 6 months ago. VCD and VE are very rare but life-threatening complications of hysterectomy. Discussing the symptoms with patients who have multiple risk factors is crucial to avoid severe sequels following hysterectomy. Based on our experience, performing a second-look laparotomy is a reliable approach to ensure the viability of the intestinal loop. However, it will likely increase the risk of infection.

Perceived benefit of antibiotics irrigation before pharyngeal repair of severe cut-throat injuries

INTRODUCTION

Wound irrigation has been employed as an important surgical step to remove bacteria, devitalized tissues, and foreign bodies from surgical sites to prevent infection and confer to the wound maximum potential of healing.

METHOD

A prospective study was conducted at Federal Medical Centre, Gusau, between January 2019- August 2023 to assess the benefit of antibiotics as additives in irrigation of dirty wounds. Seven (7) patients in total were presented with severe cut-throat injuries that require laryngopharyngoplasty. A combination of injection ciprofloxacin and metronidazole were used as additives into 1 L of normal saline, low pressure irrigation was done using 20mls syringe fitted to a broken needle or canular. Dysphagia Outcome and Severity Scale (DOSS) was used to assess return of pharyngeal function.

RESULT

The mean time of presentation of the patients was 34 ± 29 h (µ ± standard deviation) and a range of 6-72 h. The mean repair time was 58.3 ± 38.4 h with a range of 24-120 h. Most of the patients (85.7 %) had dysphagia outcome and severity scale of level 5 when per oral feeding was started with steady progress until discharge day.

CONCLUSION

Wound irrigation is one of the most crucial steps in treating severe cut-throat injuries. Based on our experience, adding antibiotics to the irrigant has shown potential in the control of local infection, particularly where patients present late.

Risk Factors for Surgical-site Infections After Liver Transplant: Does Perioperative Antibiotic Regimen Matter?

BACKGROUND

Surgical-site infections (SSIs) are common in liver transplant recipients. The optimal SSI antimicrobial prophylaxis agent and duration are not established. We aimed to explore risk factors for SSIs after transplant, with a particular interest in the impact of perioperative antibiotic regimen on the development of SSIs.

METHODS

Retrospective study of adults undergoing liver transplant across 3 transplant programs between January 1, 2020, and June 01, 2021.

RESULTS

Of 557 patients included in the study, 32 (5.7%) were infected or colonized with a multidrug-resistant organism (MDRO) within 1 y before liver transplant. Narrow-spectrum SSI prophylaxis with ceftriaxone or cefazolin alone was administered in 488 of 577 patients (87.6%); the remaining 69 patients (12.4%) received broad-spectrum prophylaxis with vancomycin and aztreonam (n = 40), piperacillin-tazobactam (n = 11), carbapenems (n = 8), ceftriaxone and another antibiotic (n = 7), and others. Patients with pretransplant MDRO were more likely to receive broad-spectrum coverage than those without pretransplant MDROs (28.1% versus 11.4%, P  = 0.005). SSIs were identified in 40 patients (7.2%); 25 (62.5%) were organ-space infections, 3 (7.5%) were deep incisional infections, and 12 (30.0%) were superficial incisional infections. The median time from liver transplant to SSIs was 14 d (interquartile range, 10-20.2). MDROs were identified in 12 SSIs (30%). Multivariable analysis revealed no significant association between antimicrobial spectrum and risk of SSIs ( P  = 0.5), whereas surgical leak ( P <0.001) and reoperation ( P  = 0.017) were independently associated with increased risk of SSIs. SSIs were not significantly associated with composite risk of death or liver allograft failure.

CONCLUSIONS

The spectrum of antimicrobial prophylaxis did not impact the development of SSIs in liver transplant recipients.

Multifunctional Suture Coating for Combating Surgical Site Infections and Mitigating Associated Complications

Despite advancements in preventive measures and hospital protocols, surgical site infections (SSIs) remain a significant concern following surgeries. Sutures, commonly used for wound closure, can serve as a platform for microbial adherence and contamination, leading to extensive debridement and recurrent antibiotic therapy. The emergence of drug resistance and the formation of biofilms on sutures have further complicated the management of SSIs. Drug-eluting sutures incorporating biocides like triclosan have limitations due to uncontrolled release and associated toxicity. Therefore, there is a need for alternative approaches to impart antimicrobial properties to sutures. In this study, we present a one-step covalent cross-linking method to coat surgical sutures with an antimicrobial small molecule, quaternary benzophenone-based antimicrobial (QSM). Additionally, the sutures are dip-coated with ibuprofen, a nonsteroidal anti-inflammatory drug with analgesic properties. The coated sutures maintained their morphological and tensile properties after in vivo implantation. The antimicrobial coating demonstrated efficacy against a broad-spectrum pathogens, including drug-resistant bacteria and fungi. The optimized formulation retained its biodegradability in vivo. Furthermore, the coated sutures exhibited ∼3 log reduction in methicillin-resistant Staphylococcus aureus (MRSA) burden in a subcutaneous implantation mouse model. Overall, this multifunctional coating provides antimicrobial properties to surgical sutures while preserving their mechanical integrity and biodegradability. These coated sutures have the potential to address the challenge of SSIs and contribute to improved surgical outcomes.

Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention

Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.

Comparative analysis of patients undergoing lower extremity bypass using in-situ and reversed great saphenous vein graft techniques

OBJECTIVE

Autologous great saphenous vein (GSV) is considered the conduit of choice for lower extremity bypass (LEB). However, the optimal configuration remains the source of debate. We compared outcomes of patients undergoing LEB using in-situ and reversed techniques.

METHODS

The Vascular Quality Initiative database was queried for patients undergoing LEB with a single-segment GSV in in-situ (ISGSV) and reversed (RGSV) configurations for symptomatic occlusive disease from 2003 to 2021. Patient demographics, procedural detail, and in-hospital and follow-up outcomes were collected. The primary outcome measures included primary patency at discharge or 30 days and one year. Secondary outcomes were secondary patency, and reinterventions at discharge or 30 days and one year. Cox proportional hazards models were created to determine the association between bypass techniques and outcomes of interest.

RESULTS

Of 8234 patients undergoing LEBs, in-situ and reversed techniques were used in 3546 and 4688 patients, respectively. The indication for LEBs was similar between the two cohorts. ISGSV was performed more frequently from the common femoral artery and to more distal targets. RGSV bypass was associated with higher intraoperative blood loss and longer operative time. Perioperatively, ISGSV cohort had higher rates of reinterventions (13.2 vs 11.1%; p = 0.004), surgical site infection (4.2 vs 3%; p = 0.003), and lower primary patency (93.5 vs 95%; p = 0.004) but a comparable rate of secondary patency (99 vs 99.1%; p = 0.675). At 1 year, in-situ bypasses had a lower rate of reinterventions (19.4% vs 21.6%; p=0.02), with similar rates of primary (82.6 vs 81.8%; p = 0.237) and secondary patency (88.7 vs 88.9%; p = 0.625). After adjusting for significant baseline differences and potential confounders, in-situ bypass was independently associated with decreased risks of primary patency loss (HR 0.9; 95% CI, 0.82-0.98; p = 0.016) and reinterventions (HR 0.88; 95% CI, 0.8-0.97; p = 0.014) but a similar risk of secondary patency loss (HR 0.99; 95% CI, 0.86-1.16; p = 0.985) at follow-up, compared to reversed bypass. A subgroup analysis of bypasses to crural targets showed that in-situ and reversed bypasses had similar rates of primary patency loss and reinterventions at 1 year. Among patients with chronic limb-threatening ischemia, in-situ bypass was associated with a decreased risk of reinterventions but similar rates of primary and secondary patency and major amputations at 1 year.

CONCLUSIONS

In patients undergoing LEBs using the GSV, in-situ configuration was associated with more perioperative reinterventions and lower primary patency rate. However, this was offset by decreased risks of loss of primary patency and reinterventions at 1 year. A thorough intraoperative graft assessment with adjunctive imaging may be performed to detect abnormalities in patients undergoing in-situ bypasses to prevent early failures. Furthermore, closer surveillance of reversed bypass grafts is warranted given the higher rates of reinterventions.

A Prospective Study of Surgical Site Infection with its Risk Factors and Their Correlation with the NNIS Risk Index

Background

Surgical site infection (SSI) is the third most commonly reported nosocomial infection, accounting for 10%-40% of all nosocomial infections and is a major cause of postoperative morbidity. Knowledge of factors related to SSI can help in reducing its incidence and related morbidity, which in many studies is shown to account for 38% of all infections in surgical patients. Lack of extending nosocomial infection surveillance programme and prevention measures in countries like India is viewed as a major challenge for the future.

Objectives

The aims of this work were (1) to study the SSI rate in patients undergoing both elective and emergency abdominal surgery and SSI with CDC, and NNIS risk index; and (2) to assess SSI along with body mass index (BMI), glycaemic status, smoking and duration of pre-operative hospital stay of patients.

Materials and Methods

In total, 300 patients who underwent elective and emergency abdominal surgery were enrolled in the study as per inclusion and exclusion criteria. SSI with CDC's NNIS risk index were analysed considering BMI, glycaemic status, smoking and duration of pre-operative hospital stay of patients.

Results

In total, 300 cases of abdominal surgeries (elective and emergency) were analysed, out of which 60 cases were diagnosed to have SSI as per the criteria.

Conclusion

This study demonstrated that there is a significant increase in SSI with increasing NNIS score that is, the greater the NNIS score, the greater the risk of SSI. With an increase in age, BMI, glycaemic index and preoperative hospital stay, the risk of SSI increases. Smoking and associated comorbidities also increase the risk of SSI.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Development of Biocompatible Ciprofloxacin-Gold Nanoparticle Coated Sutures for Surgical Site Infections

Surgical site infections (SSIs) are mainly observed after surgeries that use biomaterials. The aim of this present work was to develop ciprofloxacin hydrochloride (CPH)-loaded gold nanoparticles. These ciprofloxacin-gold nanoparticles were coated onto a sterile surgical suture using an adsorption technique, followed by rigidization via ionotropic crosslinking using sodium alginate. Furthermore, UV-visible spectroscopy, infrared spectroscopy, and scanning electron microscopy were used to characterize the samples. The particle size of the nanoparticles was 126.2 ± 13.35 nm with a polydispersity index of 0.134 ± 0.03, indicating nanosize formation with a monodispersed system. As per the International Council for Harmonization of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines, stability studies were performed for 30 days under the following conditions: 2-8 °C, 25 ± 2 °C/60 ± 5% RH, and 40 ± 2 °C/75 ± 5% RH. For both Gram-negative and Gram-positive bacteria, the drug-coupled nanoparticle-laden sutures showed a twofold higher zone of inhibition compared with plain drug-coated sutures. In vitro drug release studies showed a prolonged release of up to 180 h. Hemolysis and histopathology studies displayed these sutures' acceptable biocompatibility with the healing of tissue in Albino Swiss mice. The results depict that the use of antibiotic-coated sutures for preventing surgical site infection for a long duration could be a viable clinical option.

Surgical site infections: a scoping review on current intraoperative prevention measures

INTRODUCTION

Surgical site infections (SSIs) remain a significant cause of morbidity for surgical patients worldwide and with growing rates of antibiotic resistance, the development of new nonantimicrobial techniques to target SSI reduction is crucial. This review aimed to explore available nonantibiotic intraoperative interventions to reduce the risk of SSI.

METHODS

A literature search was undertaken using Medline, Web of Science, Embase, and Cochrane Library databases. Any study published from 1 January 1980 to 1 September 2021 that described any nonantibiotic intraoperative physical technique aiming to reduce SSI rates, with a primary or secondary outcome of SSI rates, was included.

FINDINGS

A total of 45 articles were included in the final scoping review. The current nonantibiotic intraoperative interventions advised for use include chlorhexidine skin preparation with alcohol, pressurised wound irrigation, Triclosan-coated sutures for skin closure, and negative pressure wound therapy. Many other widely used surgical practices do not have the supporting evidence to validate their routine use in clinical practice to reduce SSI rates.

CONCLUSIONS

We identified several techniques that can be used in the operating theatre to provide additional opportunities to reduce SSI rates. However, strict adherence to current established SSI prevention guidelines remains the mainstay of ensuring SSI rates remain low.

Safety and performance of surgical adhesives

BACKGROUND

Tissue adhesives are an alternative to conventional surgical sutures to reduce the time and cost of wound closure and to improve patient comfort. The use of tissue adhesives does not require any subsequent intervention and significantly lowers the volume and rate of blood loss, and reduces the need for transfusions during and after surgery. However, based on their formulation, tissue adhesives' safety profile and functional properties may differ. Therefore, this study aimed to evaluate the basic safety and performance of NE'X Glue® Surgical Sealant, BioGlue® Surgical Sealant, and PREVELEAKTM Surgical Sealant in vitro.

METHODS

The basic safety of commercially available tissue adhesives was evaluated using MEM elution assay according to ISO 10993-5 and endotoxin level according to 85. USP. The in vitro performance was evaluated using lap-shear by tension loading test, burst strength test, degradation, and swelling assays.

RESULTS

NE'X Glue®, BioGlue®, and PREVELEAKTM did not cause cytotoxicity in MEM elution assay. All surgical adhesives are below the general limit of endotoxin contamination of 20 EU/device. NE'X Glue® and BioGlue® showed the highest and comparable strength properties in lap shear and burst strength tests compared to PREVELEAKTM. NE'X Glue® and PREVELEAKTM are characterized by lower degradation potential than BioGlue®. PREVELEAKTM is characterized by the highest swelling when compared to NE'X Glue® and BioGlue®.

CONCLUSIONS

NE'X Glue® is most versatile in terms of functional properties while maintaining the same safety profile as BioGlue® and PREVELEAKTM.

Engineering surgical stitches to prevent bacterial infection

Surgical site infections (SSIs) account for a massive economic, physiological, and psychological burden on patients and health care providers. Sutures provide a surface to which bacteria can adhere, proliferate, and promote SSIs. Current methods for fighting SSIs involve the use of sutures coated with common antibiotics (triclosan). Unfortunately, these antibiotics have been rendered ineffective due to the increasing rate of antibiotic resistance. A promising new avenue involves the use of metallic nanoparticles (MNPs). MNPs exhibit low cytotoxicity and a strong propensity for killing bacteria while evading the typical antibiotic resistance mechanisms. In this work, we developed a novel MNPs dip-coating method for PDS-II sutures and explored the capabilities of a variety of MNPs in killing bacteria while retaining the cytocompatibility. Our findings indicated that our technique provided a homogeneous coating for PDS-II sutures, maintaining the strength, structural integrity, and degradability. The MNP coatings possess strong in vitro antibacterial properties against P aeruginosa and S. aureus—varying the %of dead bacteria from ~ 40% (for MgO NPs) to ~ 90% (for Fe₂O₃) compared to ~ 15% for uncoated PDS-II suture, after 7 days. All sutures demonstrated minimal cytotoxicity (cell viability > 70%) reinforcing the movement towards the use MNPs as a viable antibacterial technology.

Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective

Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.

The use of triclosan-coated sutures to prevent surgical site infections: a systematic review and meta-analysis of the literature

INTRODUCTION AND OBJECTIVES

Surgical site infections (SSIs) represent a common and serious complication of all surgical interventions. Microorganisms are able to colonise sutures that are implanted in the skin, which is a causative factor of SSIs. Triclosan-coated sutures are antibacterial sutures aimed at reducing SSIs. Our objective is to update the existing literature by systematically reviewing available evidence to assess the effectiveness of triclosan-coated sutures in the prevention of SSIs.

METHODS

A systematic review of EMBASE, MEDLINE, AMED (Allied and complementary medicine database) and CENTRAL was performed to identify full text randomised controlled trials (RCTs) on 31 May 2019.

INTERVENTION

Triclosan-coated sutures versus non-triclosan-coated sutures.

PRIMARY OUTCOME

Our primary outcome was the development of SSIs at 30 days postoperatively. A meta-analysis was performed using a fixed-effects model.

RESULTS

Twenty-five RCTs were included involving 11 957 participants. Triclosan-coated sutures were used in 6008 participants and non triclosan-coated sutures were used in 5949. Triclosan-coated sutures significantly reduced the risk of SSIs at 30 days (relative risk 0.73, 95% CI 0.65 to 0.82). Further sensitivity analysis demonstrated that triclosan-coated sutures significantly reduced the risk of SSIs in both clean and contaminated surgery.

CONCLUSION

Triclosan-coated sutures have been shown to significantly reduced the risk of SSIs when compared with standard sutures. This is in agreement with previous work in this area. This study represented the largest review to date in this area. This moderate quality evidence recommends the use of triclosan-coated sutures in order to reduce the risk of SSIs particularly in clean and contaminated surgical procedures.

PROSPERO REGISTRATION NUMBER

CRD42014014856.

Meta-analysis Comparing Outcomes of Two Different Negative Pressure Therapy Systems in Closed Incision Management

BACKGROUND

Closed incision negative pressure therapy (ciNPT) is an emerging approach to managing closed incisions of patients at risk of postoperative complications. There are primarily 2 different commercially available ciNPT systems. Both systems consist of a single-use, battery-powered device and foam- or gauze-based peel-and-place dressing designed for closed incisions. These systems vary in design, and there are no data comparing outcomes between the 2 systems.

METHODS

We performed 2 separate meta-analyses to compare surgical site infection (SSI) rates postuse of (1) ciNPT with foam dressing (FOAM) versus conventional dressings and (2) ciNPT with multilayer absorbent dressing (MLA) versus conventional dressings.

RESULTS

Seven articles and 2 abstracts met inclusion criteria in the FOAM group (n = 489) versus the control group (n = 489) in meta-analysis 1; 7 articles and 1 abstract met inclusion criteria in the MLA group (n = 532) versus the control group (n = 540) in meta-analysis 2. Meta-analysis 1 showed that patients in the control group were 3.17 times more likely to develop an SSI compared with patients in the FOAM group [weighted mean odds ratios of FOAM group versus control group was 3.17 (P < 0.0001) with the 95% confidence intervals of 2.17-4.65]. Meta-analysis 2 showed no significant difference in SSI rates between patients in the MLA group and patients in the control group [weighted mean odds ratios of MLA group versus control group was 1.70 (P = 0.08) with the 95% confidence intervals of 0.94-3.08].

CONCLUSIONS

Comparing outcomes of two different ciNPT systems with a common comparator (conventional dressings) may provide an interim basis for comparing ciNPT systems until further comparative evidence is available. More comparative research is required to determine outcomes in clinical practice.

Antibiotic-Free Cationic Dendritic Hydrogels as Surgical-Site-Infection-Inhibiting Coatings

A non-toxic hydrolytically fast-degradable antibacterial hydrogel is herein presented to preemptively treat surgical site infections during the first crucial 24 h period without relying on conventional antibiotics. The approach capitalizes on a two-component system that form antibacterial hydrogels within 1 min and consist of i) an amine functional linear-dendritic hybrid based on linear poly(ethylene glycol) and dendritic 2,2-bis(hydroxymethyl)propionic acid, and ii) a di-N-hydroxysuccinimide functional poly(ethylene glycol) cross-linker. Broad spectrum antibacterial effect is achieved by multivalent representation of catatonically charged β-alanine on the dendritic periphery of the linear dendritic component. The hydrogels can be applied readily in an in vivo setting using a two-component syringe delivery system and the mechanical properties can accurately be tuned in the range equivalent to fat tissue and cartilage (G' = 0.5-8 kPa). The antibacterial effect is demonstrated both in vitro toward a range of relevant bacterial strains and in an in vivo mouse model of surgical site infection.

Infecção de sítio cirúrgico após cirurgia bariátrica: resultados de uma abordagem com pacote de cuidados

RESUMO Objetivo: apresentar uma análise descritiva dos resultados de um pacote de cuidados aplicado em pacientes obesos submetidos à cirurgia bariátrica, no que diz respeito ao controle de infecção. Métodos: um pacote de cuidados foi estruturado, visando a conter as taxas de infecção de sítio cirúrgico (ISC) em pacientes submetidos à cirurgia bariátrica. O pacote incluiu interrupção de tabagismo, banho com clorexidina 4% duas horas antes da cirurgia, cefazolina 2g em bolus na indução anestésica associada à administração da mesma droga com dose de 1g em infusão contínua, tricotomia apropriada, controle glicêmico, oxigênio suplementar, normotermia, controle da dor com morfina intrarraquidiana e remoção do curativo estéril 48 horas após a cirurgia. Todos os pacientes foram seguidos por 30 dias. Resultados: entre os 1.596 pacientes incluídos, 334 (20,9%) foram submetidos à cirurgia aberta e 1.262 (79,1%) à cirurgia videolaparoscópica. As taxas de ISC foram de 0,5% no grupo submetido à cirurgia laparoscópica e de 3% nos submetidos à cirurgia aberta. A incidência geral de ISC foi de 1%. Infecções intra-abdominal, do trato respiratório e do trato urinário ocorreram em 0,9%, 1,1% e 1,5% da amostra, respectivamente. Faixas mais elevadas de índice de massa corporal foram associadas a maiores incidências de ISC (p=0,001). Entre os pacientes com diabetes, 2,2% desenvolveram ISC, enquanto a taxa de infecção entre os não diabéticos foi de apenas 0,6%. Conclusão: o pacote de cuidados instituído, estruturado por estratégias centrais baseadas em evidências, associadas à medidas secundárias, foi capaz de manter baixas taxas de ISC após cirurgia bariátrica.

Effects of the application of vitamin E and silicone dressings vs conventional dressings on incisional surgical site infection in elective laparoscopic colorectal surgery: a prospective randomized clinical trial

AIM

To compare the effect of conventional wound dressings (CD) with vitamin E and silicone (E-Sil) dressings on incisional surgical site infection (SSI) in patients undergoing elective colorectal laparoscopic surgery.

PATIENTS AND METHODS

A prospective, randomized study was performed. Patients were assigned at random into two groups: an E-Sil group and a CD group. Incisional SSI, postoperative pain and acute phase reactants were investigated.

RESULTS

In total, 120 patients were included in this study (60 in each group). The incisional SSI rate was 3.4% in the E-Sil group and 17.2% in the CD group (P = 0.013). Bacteroides fragilis alone grew in the cultures of infected wounds in the E-Sil group, while cultures for infected wounds in the CD group were polymicrobial. Mean postoperative pain 48 h after surgery was 27.1 [standard deviation (SD) 10.7] mm in the E-Sil group and 41.6 (SD 16.9) mm in the CD group (P < 0.001). White blood cell (WBC) count and C-reactive protein (CRP) level were lower in the E-Sil group, even after the exclusion of patients presenting with postoperative complications.

CONCLUSION

Use of an E-sil dressing to cover the Pfannestiel wound after elective laparoscopic colorectal surgery leads to a reduction in the incisional SSI rate, lower postoperative pain, and a decrease in CRP level and WBC count.

Comparison of intraoperative handling and wound healing between (NEOSORB® plus) and coated polyglactin 910 suture (NEOSORB®): a prospective, single-blind, randomized controlled trial

Background

Coated polyglactin 910 suture with chlorhexidine (NEOSORB® Plus) has recently been developed to imbue the parent suture with antibacterial activity against organisms that commonly cause surgical site infections (SSI). This prospective, single-blinded, randomized trial, was performed to compare the intraoperative handling and wound healing characteristics of NEOSORB® Plus with those of the traditional polyglactin 910 suture (NEOSORB®) in urologic surgery patients.

Methods

Patients (aged 19 to 80 years, n = 100) were randomized in a 1:1 ratio for treatment with either NEOSORB® Plus or NEOSORB®, and stratified into an open surgery or a minimally invasive surgery group. The primary endpoint was the assessment of overall intraoperative handling of the sutures. Secondary endpoints included specific intraoperative handling measures and wound healing characteristics. Wound healing was assessed at one and 11 days after surgery. Cumulative skin infection, seroma, and suture sinus events within 30 days after surgery were also evaluated.

Results

A total of 96 patients were included, with 47 patients in the NEOSORB® Plus group and 49 patients in the NEOSORB® group. Scores for intraoperative handling were favorable and were not significantly different between the two suture groups. Wound healing characteristics were also comparable. The incidence of adverse events was 13.6%, although none were deemed attributable to the suture, and no difference was observed between the two groups.

Conclusions

NEOSORB® Plus is not inferior to traditional sutures in terms of intraoperative handling and wound healing, potentially making NEOSORB® Plus a beneficial alternative for patients at increased risk of SSI.

Trial registration

ClinicalTrials.gov: NCT02431039. Trial registration date 14 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s12893-018-0377-4) contains supplementary material, which is available to authorized users.

Viable adhered Staphylococcus aureus highly reduced on novel antimicrobial sutures using chlorhexidine and octenidine to avoid surgical site infection (SSI)

BACKGROUND

Surgical sutures can promote migration of bacteria and thus start infections. Antiseptic coating of sutures may inhibit proliferation of adhered bacteria and avoid such complications.

OBJECTIVES

This study investigated the inhibition of viable adhering bacteria on novel antimicrobially coated surgical sutures using chlorhexidine or octenidine, a critical factor for proliferation at the onset of local infections. The medical need, a rapid eradication of bacteria in wounds, can be fulfilled by a high antimicrobial efficacy during the first days after wound closure.

METHODS

As a pretesting on antibacterial efficacy against relevant bacterial pathogens a zone of inhibition assay was conducted with middle ranged concentrated suture coatings (22 μg/cm). For further investigation of adhering bacteria in detail the most clinically relevant Staphylococcus aureus (ATCC®49230™) was used. Absorbable braided sutures were coated with chlorhexidine-laurate, chlorhexidine-palmitate, octenidine-laurate, and octenidine-palmitate. Each coating type resulted in 11, 22, or 33 μg/cm drug content on sutures. Scanning electron microscopy (SEM) was performed once to inspect the coating quality and twice to investigate if bacteria have colonized on sutures. Adhesion experiments were assessed by exposing coated sutures to S. aureus suspensions for 3 h at 37°C. Subsequently, sutures were sonicated and the number of viable bacteria released from the suture surface was determined. Furthermore, the number of viable planktonic bacteria was measured in suspensions containing antimicrobial sutures. Commercially available sutures without drugs (Vicryl®, PGA Resorba®, and Gunze PGA), as well as triclosan-containing Vicryl® Plus were used as control groups.

RESULTS

Zone of inhibition assay documented a multispecies efficacy of novel coated sutures against tested bacterial strains, comparable to most relevant S. aureus over 48 hours. SEM pictures demonstrated uniform layers on coated sutures with higher roughness for palmitate coatings and sustaining integrity of coated sutures. Adherent S. aureus were found via SEM on all types of investigated sutures. The novel antimicrobial sutures showed significantly less viable adhered S. aureus bacteria (up to 6.1 log) compared to Vicryl® Plus (0.5 log). Within 11 μg/cm drug-containing sutures, octenidine-palmitate (OL11) showed the highest number of viable adhered S. aureus (0.5 log), similar to Vicryl® Plus. Chlorhexidine-laurate (CL11) showed the lowest number of S. aureus on sutures (1.7 log), a 1.2 log greater reduction. In addition, planktonic S. aureus in suspensions were highly inhibited by CL11 (0.9 log) represents a 0.6 log greater reduction compared to Vicryl® Plus (0.3 log).

CONCLUSIONS

Novel antimicrobial sutures can potentially limit surgical site infections caused by multiple pathogenic bacterial species. Therefore, a potential inhibition of multispecies biofilm formation is assumed. In detail tested with S. aureus, the chlorhexidine-laurate coating (CL11) best meets the medical requirements for a fast bacterial eradication. This suture coating shows the lowest survival rate of adhering as well as planktonic bacteria, a high drug release during the first-clinically most relevant- 48 hours, as well as biocompatibility. Thus, CL11 coatings should be recommended for prophylactic antimicrobial sutures as an optimal surgical supplement to reduce wound infections. However, animal and clinical investigations are important to prove safety and efficacy for future applications.

Nanofiber-based sutures induce endogenous antimicrobial peptide

AIM

The aim of this study was to develop nanofiber-based sutures capable of inducing endogenous antimicrobial peptide production.

METHODS

We used co-axial electrospinning deposition and rolling to fabricate sutures containing pam3CSK4 peptide and 25-hydroxyvitamin D₃ (25D₃).

RESULTS

The diameters and mechanical properties of the sutures were adjustable to meet the criteria of United States Pharmacopeia designation. 25D₃ exhibited a sustained release from nanofiber sutures over 4 weeks. Pam3CSK4 peptide also showed an initial burst followed by a sustained release over 4 weeks. The co-delivery of 25D₃ and pam3CSK4 peptide enhanced cathelicidin antimicrobial peptide production from U937 cells and keratinocytes compared with 25D₃ delivery alone. In addition, the 25D₃/pam3CSK4 peptide co-loaded nanofiber sutures did not significantly influence proliferation of keratinocytes, fibroblasts, or the monocytic cell lines U937 and HL-60.

CONCLUSION

The use of 25D₃/pam3CSK4 peptide co-loaded nanofiber sutures could potentially induce endogenous antimicrobial peptide production and reduce surgical site infections.

Twisting electrospun nanofiber fine strips into functional sutures for sustained co-delivery of gentamicin and silver

Surgical site infections (SSIs) represent the most common nosocomial infection among surgical patients. In order to prevent SSIs in a sustained manner and lessen side effects, we developed a twisting method for generation of nanofiber-based sutures capable of simultaneous delivery of silver and gentamicin. The prepared sutures are composed of core-sheath nanofibers with gentamicin/pluronic F127 in the core and silver/PCL in the sheath produced by co-axial electrospinning. The diameters of obtained sutures range from ~80 μm to ~1.2 mm. The in vitro release profiles of silver and gentamicin exhibit an initial burst followed by a sustained release over 5 weeks. The co-encapsulated sutures were able to kill bacteria much more effectively than gentamicin or silver alone loaded nanofiber sutures, without showing obvious impact on proliferation and migration of dermal fibroblasts and keratinocytes. The gentamicin and silver co-loaded PCL nanofiber sutures may hold great potential for prevention of SSIs.

Surgical site infections in the NICU

BACKGROUND

Surgical site infections (SSI) increase morbidity and mortality. In adult and pediatric populations, the incidence ranges from 1.5-12%. Studies in neonates have shown an association between preoperative stay in an intensive care unit and development of SSI. To date, there has only been a single study looking exclusively at SSI in the Neonatal Intensive Care Unit (NICU). Additionally, there has been a suggestion that prematurity may be a risk factor for SSI, but this has come from studies looking at all neonates less than 28days, rather than only neonates hospitalized in a NICU.

OBJECTIVE

Primary outcome variable was to calculate the incidence of SSI in a NICU population. Secondary outcome variables were to determine if SSI is more common in premature infants and to identify additional risk factors for the development of SSI.

METHODS

An IRB-approved retrospective chart review of all patients undergoing surgical procedures in a level IIIC NICU over a 2-year period was used. We utilized the CDC's definitions of surgical procedures and SSI. An epidemiologist reviewed charts if the diagnosis of SSI was questionable. Statistical analysis was done with t test and Fisher's exact test.

RESULTS

We identified 165 patients who underwent 264 surgical procedures. Incidence of SSI was 11.7%. There were 31 SSI that occurred in 29 neonates over the 2-year period, with no mortality in that group. In patients who developed an SSI, 34.5% occurred after the 1st procedure, 41.4% occurred after a 2nd procedure, and 24.1% occurred after the 3rd or later procedure. There was no difference in perioperative antibiotic usage.

CONCLUSIONS

This study describes SSI in a strictly neonatal population in a large academic NICU. Prematurity does not appear to be a risk factor for SSI. SSI is more common in neonates who have undergone an abdominal procedure or multiple procedures. Perioperative antibiotics are not significantly associated with prevention of SSI.

Systematic review and meta-analysis of sutures coated with triclosan for the prevention of surgical site infection after elective colorectal surgery according to the PRISMA statement

BACKGROUND

Several randomized clinical trials (RCTs) conducted to evaluate the effect of triclosan-coated suture on surgical site infection (SSI) yield to controversial results. The primary purpose of this systematic review and meta-analysis was to analyze the available RCTs, comparing the effect of triclosan-coated suture with uncoated suture on the incidence of SSI after elective colorectal operations. As secondary endpoint of the analysis, we considered length of hospital stay after surgery.

METHODS

We performed a systematic literature review through Medline, Embase, Pubmed, Scopus, Ovid, ISI Web of Science, and the Cochrane Controlled Trials Register searching for RCTs published from 1990 to 2015. To conduct these meta-analyses, we followed the guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Study inclusion criteria were as follows: parallel-group RCTs in adult populations reporting the closure of the abdominal wall after elective colorectal operation with triclosan-coated suture or noncoated suture, and reporting the outcomes considered in the meta-analysis.

RESULTS

Six trials including 2168 patients (1102 treated and 1066 controls) provided data on SSIs. The overall rate was 11.7% (129/1102) in the triclosan group and 13.4% (143/1066) in the control group (odds ratio 0.81, 95% confidence interval [CI] 0.58-1.13, P = 0.220). Heterogeneity among studies was moderate (I = 44.9%). No evidence of publication bias was detectable. Five RCTs (1783 patients; 914 treated and 689 controls) described hospital length of stay with no significant effect (mean difference: -0.02, 95% CI -0.11 to -0.07, P = 0.668). The I test for heterogeneity was 0% (P = 0.836). Moderator analyses showed no significant differences were detected in analyses comparing the suture materials (polydioxanone vs polyglactin). In open-label trials, the odds ratio for SSI risk was 0.62 (95% CI 0.20-1.93, P = 0.413), 0.77 in single-blind (95% CI 0.31-1.95, P = 0.583) and 0.85 in double-blind trials (95% CI 0.46-1.54, P = 0.582).

CONCLUSIONS

Our findings failed to demonstrate a significant protective effect of triclosan-coated sutures on the occurrence of SSI after elective colorectal resections. Further large RCTs are needed before introducing this technology into clinical practice.

Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Compliance of Perioperative Antibiotic Dosing and Surgical Site Infection Rate in Office-Based Elective Surgery

BACKGROUND

A best practice goal to reduce surgical site infection includes administration of antibiotics in the ideal preoperative window. This article evaluates an office surgical suite antibiotic administration rate and compares it with the timing of a local hospital treating a similar patient population. The hypothesis was that similar or better compliance and surgical site infection rates can be achieved in the office-based suite.

METHODS

A total of 277 office-based surgeries were analyzed for antibiotic administration time before incision and their corresponding surgical site infection rate.

RESULTS

Our facility administered timely prophylactic antibiotics in 96% of cases with a surgical site infection rate of 0.36%. This rate was significantly lower than a reported rate of 3.7%.

CONCLUSION

Low infection rates with high antibiotic administration rate suggest that compliance with best possible practice protocols is possible in the outpatient setting.

Efficacy of triclosan-coated sutures for reducing risk of surgical site infection in adults: a meta-analysis of randomized clinical trials

BACKGROUND

Surgical site infection (SSI) is the third most frequent type of nosocomial infections. Triclosan-coated sutures are often used to reduce the risk of SSI, but studies examining this have given conflicting results. Therefore, this meta-analysis was performed to assess the efficacy of triclosan-coated sutures for reducing risk of SSI in adults.

METHODS

PubMed, EMBASE, Google Scholar, and ClinicalTrials.gov were searched to identify randomized clinical trials evaluating triclosan-coated sutures for preventing SSI on patients 18 y or older.

RESULTS

Thirteen randomized clinical trials involving 5256 participants were included. Triclosan-coated sutures were associated with lower risk of SSI than uncoated sutures across all surgeries (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.65-0.88, P < 0.001). Similar proportions of patients experienced wound dehiscence with either type of suture (RR 0.97, 95% CI 0.49-1.89, P = 0.92). Subgroup analysis showed lower risk of SSI with triclosan-coated sutures in abdominal surgeries (RR 0.70, 95% CI 0.50-0.99, P = 0.04) and group with prophylactic antibiotic (RR 0.79, 95% CI 0.63-0.99, P = 0.04). However, such risk reduction was not observed in cardiac surgeries, breast surgeries, or group without prophylactic antibiotic.

CONCLUSIONS

Triclosan-coated sutures can decrease the incidence of SSI in abdominal surgeries and might not interfere with wound healing process. Nevertheless, further studies are needed to examine whether triclosan-coated sutures are effective at preventing SSI in non-abdominal surgeries and to further study the interaction of antibiotic prophylaxis with triclosan-coated sutures.

High inspired oxygen versus low inspired oxygen for reducing surgical site infection: a meta-analysis

To perform a meta-analysis of published literature to assess the role of high-concentration inspired oxygen in reducing the incidence of surgical site infections (SSIs) following all types of surgery, a comprehensive search for published randomized controlled trials (RCTs) comparing high- with low-concentration inspired oxygen for SSIs was performed. The related data were extracted by two independent authors. The fixed and random effects methods were used to combine data. Twelve RCTs involving 6750 patients were included. Our pooled result found that no significant difference in the incidence of SSIs was observed between the two groups, but there was high statistic heterogeneity across the studies [risk ratio (RR): 0·91; 95% confidence interval (CI): 0·72-1·14; P = 0·40; I² = 54%]. The sensitivity analysis revealed the superiority of high-concentration oxygen in decreasing the SSI rate (RR: 0·86; 95% CI: 0·75-0·98; P = 0·02). Moreover, a subgroup analysis of studies with intestinal tract surgery showed that patients experienced less SSI when high-concentration inspired oxygen was administrated (RR: 0·53; 95% CI: 0·37-0·74; P = 0·0003). Our study provided no direct support for high-concentration inspired oxygen in reducing the incidence of SSIs in patients undergoing all types of surgery.

In vitro evaluation of novel antimicrobial coatings for surgical sutures using octenidine

BACKGROUND

Sutures colonized by bacteria represent a challenge in surgery due to their potential to cause surgical site infections. In order to reduce these type of infections antimicrobially coated surgical sutures are currently under development. In this study, we investigated the antimicrobial drug octenidine as a coating agent for surgical sutures. To achieve high antimicrobial efficacy and required biocompatibility for medical devices, we focused on optimizing octenidine coatings based on fatty acids. For this purpose, antimicrobial sutures were prepared with either octenidine-laurate or octenidine-palmitate at 11, 22, and 33 μg/cm drug concentration normalized per length of sutures. Octenidine containing sutures were compared to the commercial triclosan-coated suture Vicryl® Plus. The release of octenidine into aqueous solution was analyzed and long-term antimicrobial efficacy was assessed via agar diffusion tests using Staphylococcus aureus. For determining biocompatibility, cytotoxicity assays (WST-1) were performed using L-929 mouse fibroblasts.

RESULTS

In a 7 days elution experiment, octenidine-palmitate coated sutures demonstrated much slower drug release (11 μg/cm: 7%; 22 μg/cm: 5%; 33 μg/cm: 33%) than octenidine-laurate sutures (11 μg/cm: 82%; 22 μg/cm: 88%; 33 μg/cm: 87%). Furthermore sutures at 11 μg/cm drug content were associated with acceptable cytotoxicity according to ISO 10993-5 standard and showed, similar to Vicryl® Plus, relevant efficacy to inhibit surrounding bacterial growth for up to 9 days.

CONCLUSIONS

Octenidine coated sutures with a concentration of 11 μg/cm revealed high antimicrobial efficacy and biocompatibility. Due to their delayed release, palmitate carriers should be preferred. Such coatings are candidates for clinical testing in regard to their safety and efficacy.

Advanced Therapeutic Dressings for Effective Wound Healing--A Review

Advanced therapeutic dressings that take active part in wound healing to achieve rapid and complete healing of chronic wounds is of current research interest. There is a desire for novel strategies to achieve expeditious wound healing because of the enormous financial burden worldwide. This paper reviews the current state of wound healing and wound management products, with emphasis on the demand for more advanced forms of wound therapy and some of the current challenges and driving forces behind this demand. The paper reviews information mainly from peer-reviewed literature and other publicly available sources such as the US FDA. A major focus is the treatment of chronic wounds including amputations, diabetic and leg ulcers, pressure sores, and surgical and traumatic wounds (e.g., accidents and burns) where patient immunity is low and the risk of infections and complications are high. The main dressings include medicated moist dressings, tissue-engineered substitutes, biomaterials-based biological dressings, biological and naturally derived dressings, medicated sutures, and various combinations of the above classes. Finally, the review briefly discusses possible prospects of advanced wound healing including some of the emerging physical approaches such as hyperbaric oxygen, negative pressure wound therapy and laser wound healing, in routine clinical care.

Total Occlusive Ionic Silver-Containing Dressing vs Mupirocin Ointment Application vs Conventional Dressing in Elective Colorectal Surgery: Effect on Incisional Surgical Site Infection

BACKGROUND

Several pre- and intraoperative factors have been associated with incisional surgical site infection (SSI), but little is known about the influence of postoperative wound care and especially, the use of different dressings on incisional SSI. The aim of this study was to compare 3 methods of wound dressings (conventional dressing, silver-containing dressing, and mupirocin ointment dressing) for their ability to prevent SSI, as measured by SSI rates, in patients with colorectal cancer undergoing elective open surgery.

STUDY DESIGN

A prospective, randomized study was performed. Inclusion criteria were diagnosis of colorectal neoplasms and plans to undergo elective surgery with curative aims. Patients were randomized using a 1:1:1 allocation into 3 groups: patients receiving an ionic silver-containing dressing (ISD) (group 1), a mupirocin ointment application (MOA) (group 2), and a conventional dressing (group 3 or standard dressing). The primary outcomes variable was occurrence of incisional SSI. Follow-up was 30 days postoperatively.

RESULTS

A total of 147 patients were included, 49 in each group. Incisional SSI occurred in 9 patients (18.4%) in the ISD group, 2 (4.1%) in the MOA group, and 10 (20.4%) in the standard dressing group (p = 0.028). Adjusting for multiple comparisons, there were no significant differences between ISD and standard dressing groups; a significant difference was observed between ISD and MOA (relative risk [RR] 4.5; 95% CI (1.1 to 19.8); p = 0.046) and between the standard group and the MOA group (RR 5; 95% CI (1.2 to 21.7); p = 0.031).

CONCLUSIONS

Topical application of mupirocin ointment achieves better results for the prevention of SSI than ionic silver-containing dressing or standard dressing in patients undergoing elective open colorectal surgery.

Multi-Center Randomized Controlled Trial on the Effect of Triclosan-Coated Sutures on Surgical Site Infection after Colorectal Surgery

BACKGROUND

Surgical site infection (SSI) remains the most frequent complication after colorectal resection. The role of sutures coated with antimicrobial agents such as triclosan in reducing SSI is controversial.

METHODS

This was a multi-center randomized controlled trial with patients and outcome assessors blinded to treatment. The study was performed in four university referral hospitals. Patient candidates for elective colorectal resection were assigned randomly to abdominal incision closure with polyglactin 910 triclosan-coated sutures (triclosan group) or with polyglactin 910 without triclosan (control group). The primary outcome was the rate of SSI within 30 d after hospital discharge. The secondary outcomes were the overall rate of incision complications and length of hospital stay (LOS).

RESULTS

Two hundred eighty-one patients (triclosan group: 140; control group: 141) were analyzed after randomization. The rate of SSI was 12.9% (18/140) in the triclosan group versus 10.6% (15/141) in the control group (odds ratio: 1.24; 95% confidence interval: 0.60-2.57; p=0.564). Secondary outcome analysis showed an overall incision complication rate of 38.3% in the control group versus 45.7% in the triclosan group (odds ratio: 1.36; 95% confidence interval: 0.84-2.18; p=0.208). Median LOS was 11 d in both groups (p=0.55).

CONCLUSIONS

Surgical sutures coated with triclosan do not appear to be effective in reducing the rate of SSI.

Wound management with vacuum assisted closure in surgical site infection after ankle surgery

OBJECTIVE

The aim of this study was to compare the efficacy of vacuum assisted closure (VAC) with standard moist wound care (SMWC) in surgical site infection after ankle surgery.

METHODS

A prospective cohort was performed among patients with surgical site infection after ankle surgery between 2012 and 2013. The follow-up period was three month, and the efficacy end point was complete wound closure rate.

RESULTS

Ninety-four patients were analyzed, with 61 patients in the VAC group and 33 in the SMWC group. The complete wound closure rate in the VAC group was higher than that in the SMWC group at 3 month follow up (90.2% Vs. 72.7%, p = 0.028). The median time to complete wound closure was 31 days (95% CI 20.2-41.8) for VAC, and 63 days (95% CI 46.9-79.1) for SMWC (χ(2) = 4.023, p = 0.045). In the superficial infection subgroup, the median times to complete wound closure were 20 days (95% CI 14.2-35.1) in the VAC group and 42 days (95% CI 35.4-69.4) in SMWC group (χ(2) = 4.331, p = 0.041). In the deep subgroup, the median times to complete wound closure were 46 days (95% CI 28.2-65.9) in the VAC group and 75 days (95% CI 43.2-79.6) in SMWC group (χ(2) = 6.475, p = 0.026).

CONCLUSION

Our result showed that vacuum assisted closure was more effective than standard moist wound care in surgical site infection after ankle surgery.

Novel high efficient coatings for anti-microbial surgical sutures using chlorhexidine in fatty acid slow-release carrier systems

Sutures can cause challenging surgical site infections, due to capillary effects resulting in bacteria permeating wounds. Anti-microbial sutures may avoid these complications by inhibiting bacterial pathogens. Recently, first triclosan-resistances were reported and therefore alternative substances are becoming clinically relevant. As triclosan alternative chlorhexidine, the “gold standard” in oral antiseptics was used. The aim of the study was to optimize novel slow release chlorhexidine coatings based on fatty acids in surgical sutures, to reach a high anti-microbial efficacy and simultaneously high biocompatibility. Sutures were coated with chlorhexidine laurate and chlorhexidine palmitate solutions leading to 11, 22 or 33 µg/cm drug concentration per length. Drug release profiles were determined in aqueous elutions. Antibacterial efficacy against Staphylococcus aureus was assessed in agar diffusion tests. Biocompatibility was evaluated via established cytotoxicity assay (WST-1). A commercially triclosan-containing suture (Vicryl Plus), was used as anti-microbial reference. All coated sutures fulfilled European Pharmacopoeia required tensile strength and proved continuous slow drug release over 96 hours without complete wash out of the coated drug. High anti-microbial efficacy for up to 5 days was observed. Regarding biocompatibility, sutures using 11 µg/cm drug content displayed acceptable cytotoxic levels according to ISO 10993-5. The highest potential for human application were shown by the 11 µg/cm chlorhexidine coated sutures with palmitic acid. These novel coated sutures might be alternatives to already established anti-microbial sutures such as Vicryl Plus in case of triclosan-resistance. Chlorhexidine is already an established oral antiseptic, safety and efficacy should be proven for clinical applications in anti-microbial sutures.

Strategies to prevent surgical site infections in acute care hospitals: 2014 update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2

[Prevention of surgical site infection in abdominal surgery. A critical review of the evidence]

Surgical site infection (SSI) is associated with prolonged hospital stay, increased morbidity, mortality and sanitary costs, and reduced patients quality of life. Many hospitals have adopted guidelines of scientifically-validated processes for prevention of surgical site and central-line catheter infections and sepsis. Most of these guidelines have resulted in an improvement in postoperative results. A review of the best available evidence on these measures in abdominal surgery is presented. The best measures are: avoidance of hair removal from the surgical field, skin decontamination with alcoholic antiseptic, correct use of antibiotic prophylaxis (administration within 30-60 min before incision, use of 1(st) or 2(nd) generation cephalosporins, single preoperative dosis, dosage adjustments based on body weight and renal function, intraoperative re-dosing if the duration of the procedure exceeds 2 half-lives of the drug or there is excessive blood loss), prevention of hypothermia, control of perioperative glucose levels, avoid blood transfusion and restrict intraoperative liquid infusion.

The effect of laminar air flow and door openings on operating room contamination

We evaluate the association of laminar airflow (LAF) and OR traffic with intraoperative contamination rates. Two sterile basins were placed in each room during 81 cases, one inside and one outside the LAF. One Replicate Organism Detection and Counting (RODAC) plate from each basin was sent for culture at successive 30-minute intervals from incision time until wound closure. At successive 30-minute intervals more plates were contaminated outside than inside the LAF. A negative binomial model showed that the bacteria colony forming units (CFU) depended on whether there were any door openings (P=0.02) and the presence of LAF (P=0.003). LAF decreases CFU by 36.6%. LAF independently reduces the risk of contamination and microbial counts for surgeries lasting 90 minutes or less.

Operating theatre quality and prevention of surgical site infections

Surgical site infections (SSI) account for 14% to 17% of all hospital-acquired infections and 38% of nosocomial infections in surgical patients. SSI remain a substantial cause of morbidity and death, possibly because of the larger numbers of elderly surgical patients or those with a variety of chronic and immunocompromising conditions, and emergence of antibiotic-resistant microorganisms. Factors causing surgical site infection are multifarious. Several studies have identified the main patient-related (endogenous risk factors) and procedure-related (external risk factors) factors that influence the risk of SSI. The rate of surgical wound infections is strongly influenced by operating theatre quality, too. A safe and salubrious operating theatre is an environment in which all sources of pollution and any micro-environmental alterations are kept strictly under control. This can be achieved only through careful planning, maintenance and periodic checks, as well as proper ongoing training for staff Many international scientific societies have produced guidelines regarding the environmental features of operating theatres (positive pressure, exchanges of filtered air per hour, air-conditioning systems with HEPA filters, etc.) and issued recommendations on healthcare-associated infection, including SSI, concerning surveillance methods, intervention to actively prevent SSI and approaches to monitoring the implementation of such strategies. Therefore, the prevention of SSI requires a multidisciplinary approach and the commitment of all concerned, including that of those who are responsible for the design, layout and functioning of operating theatres.

Is there a relationship between preoperative shaving (hair removal) and surgical site infection?

The preoperative preparation of patients for surgery has traditionally included the routine hair removal at the operating site as a part of cleanliness. This literature review will investigate the relationship between preoperative hair removal and surgical site infection. It aims to identify the best method of hair removal to reduce the infection if hair removal is necessary, and to apply the evidence findings into nursing practice.

Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction

We use evidence-based algorithms to treat abnormal scarring, including keloids and hypertrophic scars (HSs). This involves a multimodal approach that employs traditional methods such as surgical removal, postoperative radiotherapy, corticosteroid injection, laser, and silicone gel sheets. As a result, the rate of abnormal scarring recurrence has decreased dramatically over the past 10 years. However, several problems remain to be solved. First, despite the optimization of a radiotherapy protocol, over 10% of cases who are treated with surgery and postoperative radiotherapy still recur in our facility. Second, the treatment options for cases with huge keloids are very limited. To address these problems, we performed basic research on the mechanisms that drive the formation of keloids and HSs. Extrapolation of these research observations to the clinic has led to the development of two treatment strategies that have reduced the rate of abnormal scar recurrence further and provided a means to remove large scars. Our finite element analysis of the mechanical force distribution around keloids revealed high skin tension at the keloid edges and lower tension in the keloid center. Moreover, when a sophisticated servo-controlled device was used to stretch wounded murine dorsal skin, it was observed that the stretched samples exhibited upregulated epidermal proliferation and angiogenesis, which are also observed in keloids and HSs. Real-time RT-PCR also revealed that growth factors and neuropeptides are more strongly expressed in cyclically stretched skin than in statically stretched skin. These findings support the well-established notion that mechanical forces on the skin strongly influence the cellular behavior that leads to scarring. These observations led us to focus on the importance of reducing skin tension when keloids/HSs are surgically removed to prevent their recurrence. Clinical trials revealed that subcutaneous/fascial tensile reduction sutures, which apply minimal tension on the dermis, are more effective in reducing recurrence than the three-layered sutures used by plastic surgeons. Moreover, we have found that by using skin flaps (e.g., perforator flaps and propeller flaps), which release tension on the wound, in combination with postoperative radiotherapy, huge keloids can be successfully treated.

Intraoperative versus extended antimicrobial prophylaxis after gastric cancer surgery: a phase 3, open-label, randomised controlled, non-inferiority trial

BACKGROUND

Although evidence for the efficacy of postoperative antimicrobial prophylaxis is scarce, many patients routinely receive such treatment after major surgeries. We aimed to compare the incidence of surgical-site infections with intraoperative antimicrobial prophylaxis alone versus intraoperative plus postoperative administration.

METHODS

We did a prospective, open-label, phase 3, randomised study at seven hospitals in Japan. Patients with gastric cancer that was potentially curable with a distal gastrectomy were randomly assigned (1:1) to receive either intraoperative antimicrobial prophylaxis alone (cefazolin 1 g before the surgical incision and every 3 h as intraoperative supplements) or extended antimicrobial prophylaxis (intraoperative administration plus cefazolin 1 g once after closure and twice daily for 2 postoperative days). Randomisation was stratified using Pocock and Simon's minimisation method for institution and American Society of Anesthesiologists scores, and Mersenne twister was used for random number generation. The primary endpoint was the incidence of surgical-site infections. We assessed non-inferiority of intraoperative therapy with a margin of 5%. Analysis was by intention-to-treat. During hospital stay, infection-control personnel assessed patients for infection, and the principal surgeons were required to check for surgical-site infections at outpatient clinics until 30 days after surgery. This study is registered with UMIN-CTR, UMIN000000631.

FINDINGS

Between June 2, 2005, and Dec 6, 2007, 355 patients were randomly assigned to receive either intraoperative antimicrobial prophylaxis alone (n=176) or extended antimicrobial prophylaxis (n=179). Eight patients (5%, 95% CI 2-9%) had surgical-site infections in the intraoperative group compared with 16 (9%, 5-14) in the extended group. The relative risk of surgical-site infections with intraoperative antimicrobial prophylaxis was 0·51 (0·22-1·16), which revealed statistically significant non-inferiority (p<0·0001).

INTERPRETATION

Elimination of postoperative antimicrobial prophylaxis did not increase the incidence of surgical-site infections after a gastrectomy. Therefore, this treatment is not recommended after gastric cancer surgery.