Adherence to surgical care improvement project measures and post-operative surgical site infections

The efficacy of an alcohol-based nasal antiseptic versus mupirocin or iodophor for preventing surgical site infections: A meta-analysis

BACKGROUND

Nasal decolonization of Staphylococcus aureus is a proven strategy to reduce surgical site infections (SSI). Recently updated guidelines expanded nasal decolonization beyond traditionally high-risk populations to include the option for alcohol-based antiseptics (ABAs). We assessed the efficacy of a novel ABA for reducing SSI compared to mupirocin and iodophor.

METHODS

A literature search in Google Scholar, PubMed, MEDLINE, and Cochrane databases was completed of studies reporting SSI outcomes in hospitals using an ABA. Primary meta-analyses were conducted to analyze ABA clinical efficacy versus no intervention (7 studies); subanalyses compared the ABA to mupirocin (3 studies) or iodophor (2 studies).

RESULTS

One hundred forty-seven nasal decolonization titles for SSI prevention were identified, of which 7 were accepted. In the studies selected, 16,212 patients were included: 7,983 (49.24%) control group, and 8,129 (50.14%) intervention group. Significant effect sizes (measured as odds ratios [ORs]) and z-scores were found in all 3 meta-analyses: (OR = 3.178, z = 4.743, P < .001) in ABA clinical efficacy, (OR = 4.110, z = 3.167, P < .01) in ABA versus mupirocin, and (OR = 3.043, z = 3.155, P < .01) in ABA versus iodophor. Funnel plots for each demonstrated a lack of bias.

CONCLUSIONS

Statistically significant positive effects were identified in all 3 meta-analyses. An ABA appears to be a viable alternative to mupirocin or iodophors to reduce SSIs.

Does Intrawound Vancomycin Decrease Postoperative Surgical Site Infection in Spine Surgery: A Retrospective Case-control Study

STUDY DESIGN

Retrospective Case-Control series.

OBJECTIVE

The objective of this study is to define the overall postoperative rate of surgical site infection (SSI) in patients undergoing spine surgery and examine the effects of intrawound Vancomycin on postoperative infection rates.

SUMMARY OF BACKGROUND DATA

Surgical site infections (SSI) account for 22% of all health care-associated infections. The use of intrawound Vancomycin in an attempt to reduce the incidence of postoperative SSI has not been sufficiently evaluated in the existing literature.

METHODS

All spine surgeries (n=19,081) from our institution were reviewed from 2003 to 2013. All cases of verified SSI were identified from the database. Cases were then matched to controls in a 1:1 fashion based on age, gender, and date of surgery (+/-30 d). Patient demographics, comorbidities, estimated blood loss, duration of surgery, intrawound administration of Vancomycin, and smoking status were evaluated.

RESULTS

At total of 316 cases of SSI after spine surgery were identified, representing an infection rate of 1.7%. The mean follow-up for cases and controls was 31.5 and 41.6 months, respectively. OR for intrawound Vancomycin was 0.44 (95% CI 0.23-0.88, P =0.019). OR for BMI greater than 30 was 1.63 (95% CI 1.04-2.56, P =0.03).

CONCLUSIONS

In this large cohort of spine surgery patients, administration of intrawound Vancomycin was associated with a significant reduction in postoperative surgical site infections. Further studies are needed to determine appropriate dosing and application as well as long-term safety in spine surgery.

Study of the Practice of Surgical Antibiotic Prophylaxis Use for Elective Neurosurgical Cases in a Tertiary Hospital and Understanding the Rationale

BACKGROUND

This study aims to evaluate the adherence to surgical antibiotic prophylaxis (SAP) guidelines in elective neurosurgery and assess the impact on surgical site infection (SSI) rates in a tertiary teaching hospital in Malaysia.

METHOD

A retrospective review was conducted on patients who underwent elective neurosurgical procedures from January 1, 2021, to December 31, 2021, in a 1600-bed tertiary teaching hospital. The study assessed adherence to national and hospital SAP guidelines, focusing on the choice of antibiotic, dosage, timing, and duration. Additionally, a survey was conducted among neurosurgeons to evaluate their knowledge, attitudes, and practices regarding SAP.

RESULT

Out of 202 patients included, there was a 99% compliance rate with antibiotic choice and 69.8% with the antibiotic duration. The SSI rate was identified at 6.4%. The knowledge, attitudes, and practices survey highlighted a strong awareness of SAP guidelines among surgeons, albeit with variations in practice, particularly in antibiotic duration and choice of antibiotics.

CONCLUSIONS

While there is high adherence to the correct choice of antibiotic for SAP in elective neurosurgery, there are gaps in compliance with the recommended duration of antibiotic use. The study highlights the need for targeted interventions to improve adherence to SAP guidelines, which could potentially reduce the incidence of SSI in neurosurgery. Ongoing education and auditing are essential to optimize SAP practices and enhance patient outcomes in neurosurgery.

Relationship between preoperative nutritional status assessed using anthropometric measures and postoperative complications in pediatric surgical patients

AIM

To determine the relationship between preoperative nutritional status assessed using anthropometric measures and postoperative complications in pediatric surgical patients.

METHODOLOGY

This prospective observational cohort study included 650 patients from 6 months to 18 years undergoing elective surgery at our institution. Elective surgery included procedures such as herniotomy, orchidopexy, urethroplasty, cystoscopy, PUV fulguration, pyeloplasty, ureteric reimplantation, stoma formation/closure, anorectoplasty, pull-through, choledochal cyst excision and repair, VP shunt insertion, lipomyelomeningocele repair, diastematomyelia excision and repair, and cyst excision. Nutritional status was standardized using Z scores for weight, length, and BMI. Patients were monitored for a month following surgery to detect any complications, and they were classified into five grades using the Clavien-Dindo classification. The duration of hospital stays and readmission within 30 days following discharge were secondary outcomes.

RESULTS

There were 627 patients of both sexes involved in the study: 350 patients aged 6 months to 5 years (Group A), while 277 were aged between 5 and 18 years (Group B). Wasting status was 47.71% in Group A and 41.52% in Group B. In Group A, 40% of patients were stunted, while 83.75% were in Group B. Group A had 57.14% underweight patients. The complication rate was 39.14% in Group A and 38.99% in Group B. The incidence of postoperative complications was not significantly different in malnourished patients. The patients with prolonged duration of surgery (> 2 h) developed more complications in both groups (Group A-67.2%, Group B-82.6%; p < 0.0001). In addition, the patients who experienced complications had lengthier hospital stays (p < 0.001 in both groups) and increased readmission rates (p = 0.016 in Group A and p = 0.008 in Group B).

CONCLUSION

In our study, half of the patients in Group A and nearly two-third in Group B were malnourished. The preoperative poor nutritional status based on anthropometric parameters is not associated with increased postoperative complications. Randomized control trials linking preoperative malnutrition based on anthropometric measures and clinical outcomes in pediatric surgery patients are necessary to provide more robust information on this subject.

Examining cefazolin utilization and perioperative anaphylaxis in patients with and without a penicillin allergy label: A cross-sectional study

STUDY OBJECTIVE

To compare the occurrence of cefazolin perioperative anaphylaxis (POA) in patients with and without a penicillin allergy label (PAL) to determine whether the prevalence of cefazolin POA differs based on the presence of a PAL.

DESIGN

Cross-sectional study.

SETTING

A large U.S. healthcare system in the Baltimore-D.C. region, July 2017 to July 2020.

PATIENTS

112,817 surgical encounters across inpatient and outpatient settings in various specialties, involving 90,089 patients. Of these, 4876 (4.3%) encounters had a PAL.

INTERVENTIONS

Perioperative cefazolin administration within 4 h before surgery to 4 h after the procedure began.

MEASUREMENTS

The primary outcome was cefazolin POA in patients with and without PALs. Potential POA cases were identified based on tryptase orders or diphenhydramine administrations within the initial cefazolin administration to 6 h postoperatively. Verification included two validation steps. The first checked for hypersensitivity reaction (HSR) documentation, and the second, led by Allergy specialists, identified POA and the probable culprit. The secondary outcome looked at cefazolin use trends in patients with a PAL, stratified by setting and specialty.

MAIN RESULTS

Of 112,817 encounters, 1421 (1.3%) had possible cefazolin HSRs. Of these, 22 (1.5%) had POA, resulting in a 0.02% prevalence. Of these, 13 (59.1%) were linked to cefazolin and 9 (40.9%) attributed to other drugs. Only one cefazolin POA case had a PAL, indicating no significant difference in cefazolin POA prevalence between patients with and without PALs (p = 0.437). Perioperative cefazolin use in patients with PALs steadily increased from 2.6% to 6.0% between 2017 and 2020, specifically in academic settings.

CONCLUSIONS

The prevalence of cefazolin POA does not exhibit significant differences between patients with and without PALs, and notably, the incidence remains remarkably low. Based on these findings, it is advisable to view cefazolin as an acceptable choice for prophylaxis in patients carrying a PAL.

Time-Dependent Bacterial Contamination of a Surgical Suction Tip

Background: No in vitro surgical study has evaluated the time-dependent contamination of surgical suction tips compared with controls. Our purpose was to determine the difference in suction tip bacterial contamination rates between suction-positive and suction-negative tips. Materials and Methods: A matched-pair analysis of the contamination of surgical suction tips over a six-hour period was performed in two clean operating rooms. One suction tip was connected to standard wall suction (suction-positive group), with a matched control tip not connected to wall suction (suction-negative group). At time zero and then at hourly intervals for six hours, the distal 3 cm of suction tips were removed, placed in nutrient broth for 48 hours, then plate cultured. One hundred tips were collected for each time interval. Results: Eighty-two of 700 (11.7%) suction tips had bacterial contamination. Sixty-three (18.0%) of 350 suction-positive tips were contaminated, with 19 (5.4%) of the 350 suction-negative tips contaminated (χ2 = 26.7, p < 0.001). Suction tip contamination was time-dependent with the first significant difference between groups occurring after two hours of continuous suction (χ2 = 4.0, p = 0.04). Contamination rate in the suction-positive group increased significantly after one hour compared with time-zero controls (χ2 = 7.1, p = 0.008). There was no significant difference in frequency of positive cultures over time in the suction-negative group compared with time-zero controls. Conclusions: This is the first controlled laboratory study suggesting a time-dependent increase in positive suction tip cultures. From our data, operating room staff should have an awareness that suction tips represent a potential source of bacterial concentration. We recommend that when not in use, suction tip valves be closed if this feature is available, that hosing be manipulated to cease suction when not needed, that suckers be disconnected from tubing, or that suckers be exchanged at frequent intervals. Doing so may reduce bacterial contamination on the suction tip.

Risk factors for surgical site infection following orthopaedic surgery for fracture by trauma: a nested case-control study

BACKGROUND

Surgical site infection (SSI) is associated with higher medical expenses and lower patient quality of life.

AIM

To identify specific modifiable risk factors for SSI after orthopaedic surgery for fractures caused by trauma.

METHODS

This nested case-control study used a nationwide trauma registry, the Japan Trauma Data Bank (JTDB) database. Patient data from 280 hospitals between January 2004 and May 2019 were retrieved from the JTDB. Patients with SSI and identified patients without SSI as control subjects were included, using propensity score matching adjusted for unmodifiable factors. Risk factors associated with SSI after orthopaedic trauma surgery were assessed using multi-level mixed-effects logistic regression models.

FINDINGS

In total, 15,910 patients were included in the analysis. Of these patients, 377 (2.4%) had SSI. After propensity score matching, 258 patients with SSI and 2580 matched patients without SSI were selected. In the multi-level mixed-effects logistic regression analysis, blood transfusion within 24 h (odds ratio (OR): 1.51; 95% confidence interval (CI): 1.06-2.13) was a significant risk factor for SSI following orthopaedic fracture surgery. The OR (95% CI) values for external fixation, transcatheter arterial embolization, and tourniquet for SSI following orthopaedic fracture surgery were 1.40 (0.96-2.03), 1.66 (0.81-3.38), and 2.99 (0.60-14.87), respectively.

CONCLUSION

These findings highlight the necessity of exercising caution when implementing blood transfusion within 24 h as a risk factor associated with SSI following orthopaedic trauma surgery.

Examining barriers to implementing a surgical-site infection bundle

BACKGROUND

Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain.

OBJECTIVE

We sought to understand the implementation of SSI prevention bundles in 6 US hospitals.

DESIGN

Qualitative study.

METHODS

We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts.

SETTING

The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital.

PARTICIPANTS

In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists.

RESULTS

Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation.

CONCLUSIONS

The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability.

Characterizing the molecular epidemiology of anaesthesia work area transmission of Staphylococcus aureus sequence type 5

BACKGROUND

Staphylococcus aureus sequence type 5 (ST5) is an emerging global threat.

AIM

To characterize the epidemiology of ST5 transmission in the anaesthesia work area.

METHODS

The retrospective cohort study analysed transmitted, prophylactic antibiotic-resistant Staphylococcus aureus isolates involving anaesthesia work area reservoirs. Using whole-genome analysis, the epidemiology of ST5 transmission was characterized by reservoir(s) of origin, transmission location(s), portal of entry, and mode(s) of transmission. All patients were followed for at least 30 days for surgical site infection (SSI) development.

FINDINGS

Forty-one percent (18/44; 95% confidence interval: 28-56%) of isolates were ST5. Provider hands were the reservoir of origin for 28% (5/18) of transmitted ST5 vs 4% (1/26) for other STs. Provider hands were the transmission location for 28% (5/18) of ST5 vs 7% (2/26) of other STs. Stopcock contamination occurred for 8% (1/13) of ST5 isolates vs 12% (3/25) of other STs. Sixty-three percent of transmission events occurring between cases on separate operative dates involved ST5. ST5 was more likely to harbour resistance traits (ST5 median (interquartile range) 3 (2-3) vs 2 (1-2) other STs; P < 0.001) and had greater resistance to cefazolin, piperacillin-tazobactam, and/or ciprofloxacin (ST5: 3 (2-3) vs 2 (1-3) other STs; P = 0.02). ST5 was associated with three of six SSIs.

CONCLUSION

ST5 is prevalent among transmitted, prophylactic antibiotic-resistant isolates in the anaesthesia work area. Transmission involves provider hands and one patient to another on future date(s). ST5 is associated with a greater number of resistance traits and reduced in-vitro susceptibility vs other intraoperative meticillin-resistant S. aureus.

A Practical Approach to Predicting Surgical Site Infection Risk Among Patients Before Leaving the Operating Room

A surgical site infection (SSI) prediction model that identifies at-risk patients before leaving the operating room can support efforts to improve patient safety. In this study, eight pre-operative and five perioperative patient- and procedure-specific characteristics were tested with two scoring algorithms: 1) count of positive factors (manual), and 2) logistic regression model (automated). Models were developed and validated using data from 3,440 general and oncologic surgical patients. In the automated algorithm, two pre-operative (procedure urgency, odds ratio [OR]: 1.7; and antibiotic administration >2 hours before incision, OR: 1.6) and three intraoperative risk factors (open surgery [OR: 3.7], high-risk procedure [OR: 3.5], and operative time OR: [2.6]) were associated with SSI risk. The manual score achieved an area under the curve (AUC) of 0.831 and the automated algorithm achieved AUC of 0.868. Open surgery had the greatest impact on prediction, followed by procedure risk, operative time, and procedure urgency. At 80% sensitivity, the manual and automated scores achieved a positive predictive value of 16.3% and 22.0%, respectively. Both the manual and automated SSI risk prediction algorithms accurately identified at-risk populations. Use of either model before the patient leaves the operating room can provide the clinical team with evidence-based guidance to consider proactive intervention to prevent SSIs.

Reduction of methicillin-resistant Staphylococcus aureus biofilm growth and development using arctic berry extracts

Introduction

Surgical site infection remains a devastating and feared complication of surgery caused mainly by Staphylococcus aureus (S. aureus). More specifically, methicillin-resistant S. aureus (MRSA) infection poses a serious threat to global health. Therefore, developing new antibacterial agents to address drug resistance are urgently needed. Compounds derived from natural berries have shown a strong antimicrobial potential.

Methods

This study aimed to evaluate the effect of various extracts from two arctic berries, cloudberry (Rubus chamaemorus) and raspberry (Rubus idaeus), on the development of an MRSA biofilm and as treatment on a mature MRSA biofilm. Furthermore, we evaluated the ability of two cloudberry seed-coat fractions, hydrothermal extract and ethanol extract, and the wet-milled hydrothermal extract of a raspberry press cake to inhibit and treat biofilm development in a wound-like medium. To do so, we used a model strain and two clinical strains isolated from infected patients.

Results

All berry extracts prevented biofilm development of the three MRSA strains, except the raspberry press cake hydrothermal extract, which produced a diminished anti-staphylococcal effect.

Discussion

The studied arctic berry extracts can be used as a treatment for a mature MRSA biofilm, however some limitations in their use exist.

The importance of targeting intraoperative transmission of bacteria with antibiotic resistance and strain characteristics

BACKGROUND

Evidence-based intraoperative infection control measures can reduce Staphylococcus aureus transmission and infections. We aimed to determine whether transmitted S. aureus isolates were associated with increased risk of multidrug resistance and associated traits.

METHODS

S. aureus isolates obtained from intraoperative environmental, patient skin, and provider hand reservoirs among 274 operating room case pairs (1st and 2nd case of the day) across 3 major academic medical centers from March 2009 to February 2010 underwent systematic-phenotypic-genomic analysis to identify clonal transmission events. The association of clonal S. aureus transmission with multidrug resistance and resistance traits was investigated. Transmission dynamics were characterized.

RESULTS

Transmitted isolates (N=58) were associated with increased risk of multi-drug antibiotic resistance [33% (19/58) transmitted vs. 10% (12/115) other isolates, risk ratio 3.14, 99% CI 1.34-7.38, P=0.0006]. Transmission was associated with a significant increase in resistance traits including mecA [40% transmitted isolates vs. 17% other isolates, risk ratio 2.28, P=0.0026] and ant (6)-Ia [26% transmitted isolates vs. 9% other isolates, risk ratio 2.97, P=0.0050]. Provider hands were a frequent reservoir of origin, between-case a common mode of transmission, and patient skin and provider hands frequent transmission locations for multidrug resistant pathogens.

CONCLUSIONS

Intraoperative S. aureus transmission was associated with multidrug resistance and resistance traits. Proven infection control measures should be leveraged to target intraoperative transmission of multidrug resistant pathogens.

Risk factors and prediction model for inpatient surgical site infection after elective abdominal surgery

BACKGROUND

Surgical site infections (SSIs) are the commonest healthcare-associated infection. In addition to increasing mortality, it also lengthens the hospital stay and raises healthcare expenses. SSIs are challenging to predict, with most models having poor predictability. Therefore, we developed a prediction model for SSI after elective abdominal surgery by identifying risk factors.

AIM

To analyse the data on inpatients undergoing elective abdominal surgery to identify risk factors and develop predictive models that will help clinicians assess patients preoperatively.

METHODS

We retrospectively analysed the inpatient records of Shaanxi Provincial People’s Hospital from January 1, 2018 to January 1, 2021. We included the demographic data of the patients and their haematological test results in our analysis. The attending physicians provided the Nutritional Risk Screening 2002 (NRS 2002) scores. The surgeons and anaesthesiologists manually calculated the National Nosocomial Infections Surveillance (NNIS) scores. Inpatient SSI risk factors were evaluated using univariate analysis and multivariate logistic regression. Nomograms were used in the predictive models. The receiver operating characteristic and area under the curve values were used to measure the specificity and accuracy of the model.

RESULTS

A total of 3018 patients met the inclusion criteria. The surgical sites included the uterus (42.2%), the liver (27.6%), the gastrointestinal tract (19.1%), the appendix (5.9%), the kidney (3.7%), and the groin area (1.4%). SSI occurred in 5% of the patients (n = 150). The risk factors associated with SSI were as follows: Age; gender; marital status; place of residence; history of diabetes; surgical season; surgical site; NRS 2002 score; preoperative white blood cell, procalcitonin (PCT), albumin, and low-density lipoprotein cholesterol (LDL) levels; preoperative antibiotic use; anaesthesia method; incision grade; NNIS score; intraoperative blood loss; intraoperative drainage tube placement; surgical operation items. Multivariate logistic regression revealed the following independent risk factors: A history of diabetes [odds ratio (OR) = 5.698, 95% confidence interval (CI): 3.305-9.825, P = 0.001], antibiotic use (OR = 14.977, 95%CI: 2.865-78.299, P = 0.001), an NRS 2002 score of ≥ 3 (OR = 2.426, 95%CI: 1.199-4.909, P = 0.014), general anaesthesia (OR = 3.334, 95%CI: 1.134-9.806, P = 0.029), an NNIS score of ≥ 2 (OR = 2.362, 95%CI: 1.019-5.476, P = 0.045), PCT ≥ 0.05 μg/L (OR = 1.687, 95%CI: 1.056-2.695, P = 0.029), LDL < 3.37 mmol/L (OR = 1.719, 95%CI: 1.039-2.842, P = 0.035), intraoperative blood loss ≥ 200 mL (OR = 29.026, 95%CI: 13.751-61.266, P < 0.001), surgical season (P < 0.05), surgical site (P < 0.05), and incision grade I or III (P < 0.05). The overall area under the receiver operating characteristic curve of the predictive model was 0.926, which is significantly higher than the NNIS score (0.662).

CONCLUSION

The patient’s condition and haematological test indicators form the bases of our prediction model. It is a novel, efficient, and highly accurate predictive model for preventing postoperative SSI, thereby improving the prognosis in patients undergoing abdominal surgery.

The detection and prediction of surgical site infections using multi-modal sensors and machine learning: Results in an animal model

Introduction

Surgical Site Infection (SSI) is a common healthcare-associated infection that imposes a considerable clinical and economic burden on healthcare systems. Advances in wearable sensors and digital technologies have unlocked the potential for the early detection and diagnosis of SSI, which can help reduce this healthcare burden and lower SSI-associated mortality rates.

Methods

In this study, we evaluated the ability of a multi-modal bio-signal system to predict current and developing superficial incisional infection in a porcine model infected with Methicillin Susceptible Staphylococcus Aureus (MSSA) using a bagged, stacked, and balanced ensemble logistic regression machine learning model.

Results

Results demonstrated that the expression levels of individual biomarkers (i.e., peri-wound tissue oxygen saturation, temperature, and bioimpedance) differed between non-infected and infected wounds across the study period, with cross-correlation analysis indicating that a change in bio-signal expression occurred 24 to 31 hours before this change was reflected by clinical wound scoring methods employed by trained veterinarians. Moreover, the multi-modal ensemble model indicated acceptable discriminability to detect the presence of a current superficial incisional SSI (AUC = 0.77), to predict an SSI 24 hours in advance of veterinarian-based SSI diagnosis (AUC = 0.80), and to predict an SSI 48 hours in advance of veterinarian-based SSI diagnosis (AUC = 0.74).

Discussion

In sum, the results of the current study indicate that non-invasive multi-modal sensor and signal analysis systems have the potential to detect and predict superficial incisional SSIs in porcine subjects under experimental conditions.

Impact of Patient-Reported Penicillin Allergy on Antibiotic Prophylaxis and Surgical Site Infection Among Patients Undergoing Colorectal Surgery

BACKGROUND

Surgical site infections are a major preventable source of morbidity, mortality, and increased health care expenditures after colorectal surgery. Patients with penicillin allergy may not receive the recommended preoperative antibiotics, putting them at increased risk for surgical site infections.

OBJECTIVE

This study aimed to evaluate the impact of patient-reported penicillin allergy on preoperative antibiotic prophylaxis and surgical site infection rates among patients undergoing major colon and rectal procedures.

DESIGN

This is a retrospective observational study.

SETTING

This study was conducted at a tertiary teaching hospital in Dallas.

PATIENTS

Adults undergoing colectomy or proctectomy between July 2012 and July 2019 were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were preoperative antibiotic choice and surgical site infection.

RESULTS

Among 2198 patients included in the study, 12.26% (n = 307) reported a penicillin allergy. Patients with penicillin allergy were more likely to be white (82%) and female (54%; p < 0.01). The most common type of allergic reaction reported was rash (36.5%), whereas 7.2% of patients reported anaphylaxis. Patients with self-reported penicillin allergy were less likely to receive beta-lactam antibiotics than patients who did not report a penicillin allergy (79.8% vs 96.7%, p < 0.001). Overall, 143 (6.5%) patients had surgical site infections. On multivariable logistic regression, there was no difference in rates of surgical site infection between patients with penicillin allergy vs those without penicillin allergy (adjusted OR 1.14; 95% CI, 0.71-1.82).

LIMITATIONS

A limitation of this study was its retrospective study design.

CONCLUSIONS

Self-reported penicillin allergy among patients undergoing colorectal surgery is common; however, only a small number of these patients report any serious adverse reactions. Patients with self-reported penicillin allergy are less likely to receive beta-lactam antibiotics and more likely to receive non-beta-lactam antibiotics. However, this does not affect the rate of surgical site infection among these patients, and these patients can be safely prescribed non-beta-lactam antibiotics without negatively impacting surgical site infection rates. See Video Abstract at http://links.lww.com/DCR/B838 .IMPACTO DE LA ALERGIA A LA PENICILINA INFORMADA POR EL PACIENTE EN LA PROFILAXIS ANTIBIÓTICA Y LA INFECCIÓN DEL SITIO OPERATORIO ENTRE PACIENTES DE CIRUGÍA COLORECTAL.

ANTECEDENTES

Las infecciones del sitio operatorio son una de las principales fuentes prevenibles de morbilidad, mortalidad y aumento del gasto sanitario después de cirugía colorrectal. Es posible que los pacientes con alergia a la penicilina no reciban los antibióticos preoperatorios recomendados, lo que los pone en mayor riesgo de infecciones en el sitio operatorio.

OBJETIVO

Este estudio tuvo como objetivo evaluar el impacto de la alergia a la penicilina informada por el paciente sobre la profilaxis antibiótica preoperatoria y las tasas de infección del sitio operatorio entre pacientes sometidos a procedimientos mayores de colon y recto.

DISEO

Estudio observacional retrospectivo.

AJUSTE

Hospital universitario terciario en Dallas.

PACIENTES

Adultos sometidos a colectomía o proctectomía entre julio de 2012 a julio de 2019.

PRINCIPALES MEDIDAS DE DESENLACE

Elección de antibióticos preoperatorios e infección del sitio operatorio.

RESULTADOS

Entre los 2198 pacientes incluidos en el estudio, el 12,26% (n = 307) informó alergia a la penicilina. Los pacientes con alergia a la penicilina tenían más probabilidades de ser blancos (82%) y mujeres (54%) ( p < 0,01). El tipo más común de reacción alérgica notificada fue erupción cutánea (36,5%), mientras que el 7,2% de los pacientes notificó anafilaxia. Los pacientes con alergia a la penicilina autoinformada tenían menos probabilidades de recibir antibióticos betalactámicos en comparación con los pacientes que no informaron alergia a la penicilina (79,8% frente a 96,7%, p < 0,001). En general, hubo 143 (6,5%) pacientes con infecciones del sitio operatorio. En la regresión logística multivariable no hubo diferencias en las tasas de infección del sitio operatorio entre los pacientes con alergia a la penicilina frente a los que no tenían alergia a la penicilina (razón de probabilidades ajustada 1,14; intervalo de confianza del 95%, 0,71-1,82).

LIMITACIONES

Diseño de estudio retrospectivo.

CONCLUSIONES

La alergia a la penicilina autoinformada entre los pacientes de cirugía colorrectal es común, sin embargo, solo un pequeño número de estos pacientes informan reacciones adversas graves. Los pacientes con alergia a la penicilina autoinformada tienen menos probabilidades de recibir antibióticos betalactámicos y más probabilidades de recibir antibióticos no betalactámicos. Sin embargo, esto no afecta la tasa de infección del sitio quirúrgico entre estos pacientes y se les puede recetar de forma segura con antibióticos no betalactámicos sin afectar negativamente las tasas de infección del sitio quirúrgico. Consulte Video Resumen en http://links.lww.com/DCR/B838 . (Traducción-Dr. Juan Carlos Reyes ).

Novel In Vitro Study to Assess Microbial Barrier Properties of Polyurethane-Based Tissue Adhesives in Comparison to the Gold Standard Dermabond®

Tissue adhesives as a physical barrier to microorganism penetration provide an alternative method with many advantages for wound closure in surgical settings compared to the clinical standard. This raises the need of developing and conducting in vitro methods that are sensitive and reproducible to assess their microbial barrier properties. In this study, three different polyurethane-based tissue adhesives with different physicochemical properties were evaluated in comparison to Dermabond® as a clinical gold standard for topical wound closure. Here, physicochemical properties varied in lactide concentration, viscosity, processing, and the full polymerization time. To evaluate the microbial barrier function, a 5 μl aliquot of E. coli Lux inoculum containing at least 1 × 109 CFU/ml was applied to the surface of each test adhesive and sterile filter paper as the control that was placed on an agar plate and incubated at 37°C. Plates were observed for bacterial growth (morphology), the adhesion of the adhesive/filter paper, and bioluminescence after 24, 48, and 72 hours. The data presented in this in vitro model indicated that polyurethane-based tissue adhesives with lactide concentration ≥ 5% provided a suitable barrier against microbial penetration with 95% confidence of 99% efficacy for 72 h along with Dermabond®. Interestingly, the here described method was able to discriminate between the different physicochemical properties showing a better microbial barrier function with increasing lactide concentration of the adhesive. Overall, the results of this study showed the noninferiority between Dermabond® and the two abovementioned polyurethane-based tissue adhesives.

Hypericum and neem oil for dehisced post-surgical wounds: a randomised, controlled, single-blinded phase III study

OBJECTIVE

To evaluate the clinical efficacy of a hypericum and neem oil dressing, Primary Wound Dressing [ONE] (1PWD) (Kerecis AG, Switzerland), in a patient population with dehiscence of surgical wounds with critical colonisation/infection. Efficacy was defined as resolution of inflammatory/infective symptoms.

METHOD

A randomised, controlled, single-blinded, parallel-arms phase III study was conducted comparing the experimental medication to silver-based dressings. All patients were evaluated at enrolment, on days 7, 14, 21 and 28. Improvement of inflammatory/infective symptoms was measured by detecting seven items of the Bates-Jensen Wound Assessment Tool (BWAT). Pain was assessed using the Numeric Rating Scale (NRS).

RESULTS

The study enrolled 99 patients. Follow-up was completed in 49 patients in the experimental group and 48 patients in the control group. Overall BWAT evaluation demonstrated similar outcomes between the groups: t=0.23, p-value=0.81, 95% confidence interval (CI): -13.3-10.8. Furthermore, when evaluating the seven items of the BWAT relating to inflammatory signs, there was not a significant difference between the groups: t=0.38, p=0.35, 95% CI: -2.8-2.7. However, when an analysis using the NRS pain scale was performed, a statistically significant pain reduction was demonstrated in favour of the experimental group: t=7.8, p<0.0001, 95% CI: 2.918-4.8819.

CONCLUSION

This randomised controlled trial confirmed the efficacy of 1PWD, an investigational product, in the management of surgical dehiscence with critical colonisation or infection, with the added benefit of significant pain reduction when compared with a silver-based dressing.

Effectiveness of Triclosan-Coated Sutures Compared with Uncoated Sutures in Preventing Surgical Site Infection after Abdominal Wall Closure in Open/Laparoscopic Colorectal Surgery

BACKGROUND

Previous randomized trials have assessed the effectiveness of triclosan-coated sutures in fascia closure after midline laparotomy in preventing surgical site infections (SSIs); however, available evidence remain inconclusive. We aimed to evaluate the effectiveness of triclosan-coated sutures in abdominal fascia closure to prevent postoperative SSIs.

STUDY DESIGN

This study was a multicenter prospective trial conducted within 24 Japanese secondary and tertiary care centers and a propensity score (PS)-matched analysis. Patients 20 years of age or older who underwent elective surgery for colorectal cancer (CRC) were included. Between July 2016 and July 2019, 2,207 patients were prospectively enrolled into the triclosan-coated sutures or uncoated sutures groups. The per-protocol population comprised 2,195 patients. The PS matching was performed for 1,579 patients: 926 patients in the coated group and 653 patients in the uncoated group. The abdominal fascia after midline laparotomy was closed with triclosan-coated or uncoated sutures depending on group. The primary endpoint was the incidence of an SSI. Secondary endpoints were length of hospital stay and surgical complication rates.

RESULTS

The recorded SSI rates were 4.2% in the triclosan-coated group and 6.74% in the uncoated suture group (p = 0.028). There were no serious adverse events in the groups. The final logistic regression model showed that several variables affected the occurrence of SSI. Our meta-analysis included six phase-III trials, and our study evaluated 4,797 patients. The results show a significant superiority of triclosan-coated sutures over uncoated suture material.

CONCLUSION

Triclosan-coated sutures reduce the incidence of SSI after elective CRC surgery.

Effectiveness and feasibility of an evidence-based intraoperative infection control program targeting improved basic measures: a post-implementation prospective case-cohort study

STUDY OBJECTIVE

A randomized controlled study demonstrated that an optimized intraoperative infection control program targeting basic preventive measures can reduce Staphylococcus aureus transmission and surgical site infections. In this study we address potential limitations of operating room heterogeneity of infections and compliance with behavioral interventions following adoption into clinical practice.

DESIGN

A post-implementation prospective case-cohort study.

SETTING

Twenty-three operating rooms at a large teaching hospital.

PATIENTS

A total of 801 surgical patients [425 (53%) women; 350 (44%) ASA > 2, age 54.6 ± 15.9 years] were analyzed for the primary and 804 for the secondary outcomes.

INTERVENTIONS

A multifaceted, evidence-based intraoperative infection control program involving hand hygiene, vascular care, and environmental cleaning improvements was implemented for 23 operating room environments. Bacterial transmission monitoring was used to provide monthly feedback for intervention optimization.

MEASUREMENTS

S. aureus transmission (primary) and surgical site infection (secondary).

MATERIALS AND METHODS

The incidence of S. aureus transmission and surgical site infection before (3.5 months) and after (4.5 months) infection control optimization was assessed. Optimization was defined by a sustained reduction in anesthesia work area bacterial reservoir isolate counts. Poisson regression with robust error variances was used to estimate the incidence risk ratio (IRR) of intraoperative S. aureus transmission and surgical site infection for the independent variable of optimization.

MAIN RESULTS

Optimization was associated with decreased S. aureus transmission [24% before (85/357) to 9% after (42/444), IRR 0.39, 95% CI 0.28 to 0.56, P < .001] and surgical site infections [8% before (29/360) and 3% after (15/444) (IRR 0.42, 95% CI 0.23 to 0.77, P = .005; adjusted for American Society of Anesthesiologists' physical status, aIRR 0.45, 95% CI 0.25 to 0.82, P = .009].

CONCLUSION

An optimized intraoperative infection control program targeting improvements in basic preventive measures is an effective and feasible approach for reducing S. aureus transmission and surgical site infection development.

Effect of the Implementation of a Surgical Care Bundle in the Incidence of Surgical Site Infection in Spine Surgery: A Quasi-Experimental Study

STUDY DESIGN

Quasi-experimental intervention study.

OBJECTIVE

To assess the effect of a clinical safety and quality improvement plan for patients undergoing spinal fusion surgery on the incidence of surgical site infection (SSI).

SUMMARY OF BACKGROUND DATA

In recent years, infection surveillance and control programs based on care bundles have been included in surgical protocols. These have proven to be essential tools for the prevention and control of SSI, providing indicators for improvement and allowing the characterization of related risk factors.

METHODS

A quasi-experimental study was carried out with analysis before and after the introduction of a preventive care bundle (clinical safety and quality improvement plan). Patients who underwent spinal fusion surgery were included. The incidence of SSI up to 90 days after surgery (maximum incubation period) was assessed. The effect of the intervention was evaluated with the adjusted odds ratio (oR) using a logistic regression model.

RESULTS

A total of 1554 patients were included, 690 in the period 2007 to 2011 (before) and 864 during 2012 to 2018 (after). SSI incidence decreased from 4.2% to 1.9% after the plan (OR: 0.43; 95% confidence interval: 0.23-0.80; P  = 0.006). There was also an improvement in the adequacy of antibiotic prophylaxis, preoperative preparation, and hair removal procedure after the introduction of the care bundle.

CONCLUSION

After implementation of the care bundle, the incidence of SSI in spine fusion surgery decreased significantly. Multivariate analysis showed that the care bundle was an independent protective factor. The implementation of these measures should be reinforced on the routine medical practice to reduce the SSI incidence.Level of Evidence: 3.

Single-center experience with perioperative antibiotic prophylaxis and surgical site infections in kidney transplant recipients

Background

Infections in kidney transplant recipients are particularly challenging owing to the immunosuppressive treatment, usually long history of chronic illness, comorbidities and prior exposures to antibiotics. Among the most common complications early after surgery are surgical site infections. The aim of this study was to identify risk factors and evaluate epidemiological data regarding surgical site infections. Moreover, we were able to compare the current results with historical data from our institution when different perioperative antibiotic prophylaxis was practiced.

Methods

We conducted a retrospective case–control study in a group of 254 deceased donor renal graft recipients transplanted in a single Central European institution. We evaluated epidemiological findings and resistance patterns of pathogens causing surgical site infections. We used multivariable logistic regression to determine risk factors for surgical site infections.

Results

We revealed no differences in baseline characteristics between patients with and without surgical site infections. Ten surgical site infections (3.9%) were diagnosed (six superficial incisional, two deep incisional, and two organ/space). Eight species (19 strains) were identified, most of which were multi-drug resistant (63%). The most common was extended-spectrum β-lactamase producing Klebsiella pneumoniae (26%). We showed that statistically significant differences were present between reoperated and non-reoperated patients (adjusted odds ratio: 6.963, 95% confidence interval 1.523–31.842, P = .012).

Conclusions

Reoperation is an individual risk factor for surgical site infection after kidney transplantation. According to our experience, cefazolin-based prophylaxis can be safe and is associated with relatively low prevalence of surgical site infections.

Forced air contamination risk in the OR

Introduction

Forced-air warming (FAW) is a commonly used method of patient warming to reduce perioperative hypothermia and minimize associated surgical complications.

Objectives

The primary objective of this study was to demonstrate even when properly managed, FAW units may contribute to greater environmental bacterial load and infection risk.

Methods

A study conducted in 2018 revealed that FAW contamination occurs more than expected in the surgical environment. The study demonstrated that 42.5 percent of the 320 samples collected were higher than the minimum accepted pathogen levels.

Results

The present study provided a retrospective-research correlation between samples collected in the 2018 analysis, along with evidence of any associated Surgical Site Infections (SSIs).

Conclusion

In a retrospective study of these cases, 3.4 percent of OB/GYN, 5.6 percent of colon cases, 1.4 percent of GI cases, and 5.3 percent of amputation cases developed an SSI. The results indicate that when FAW is in use, the risk for SSI is present.

•

Forced-air warming is a commonly used to warm patients, reducing perioperative hypothermia.

•

Maintaining patient normothermia reduces associated surgical complications and infection risk.

•

Even when properly managed, Forced-Air Warming units may contribute to greater environmental bacterial load.

•

Surgical environment contamination occurs more than expected when Forced-Air Warming is utilized.

•

When Forced-Air Warming is in use, there is an increased chance of Surgical Site Infection.

OUP accepted manuscript

Background

Surgical site infection (SSI) is a common complication after abdominal surgery. The effectiveness of wound edge protectors in reducing infection of the surgical sites is still unclear. The purpose of this study was to determine the clinical effectiveness of a wound edge protector (WEP) in reducing SSI rates after abdominal surgery.

Methods

PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched to obtain relevant articles published up to September 2021. Publications were retrieved if they contain primary data on the use of WEPs in reducing SSI compared with standard care in patients undergoing abdominal surgery. Subgroup analyses were performed for different WEP types, surgical sites, and levels of contamination. The outcome of interest was a clinically defined SSI. Qualitative variables were pooled using risk ratios (RRs).

Results

Twenty-two eligible randomized clinical trials involving 4492 patients were included in this meta-analysis. WEP was associated with the reduced incidence of overall SSI (RR = 0.66; 95 per cent c.i. 0.53 to 0.83; P = 0.0003), and superficial SSI (RR = 0.59; 95 per cent c.i. 0.38 to 0.91; P = 0.02). In addition, WEP also successfully reduced the risk of SSI in clean-contaminated wounds (RR = 0.61; 95 per cent c.i. 0.40 to 0.93; P = 0.02) as well as in contaminated wounds (RR = 0.47; 95 per cent c.i. 0.33 to 0.67; P < 0.0001); however, WEP did not reduce SSI incidence in colorectal surgery (RR = 0.68; 95 per cent c.i. 0.46 to 1.01; P = 0.05).

Conclusion

This study suggests that WEP was efficient in reducing superficial SSI. Both double-ringed and single-ringed devices were efficient in reducing SSI. WEP was effective in reducing SSI incidence in clean-contaminated and contaminated surgery; however, its use does not reduce the SSI rate in colorectal surgery.

Sanguiin H-6 Fractionated from Cloudberry (Rubus chamaemorus) Seeds Can Prevent the Methicillin-Resistant Staphylococcus aureus Biofilm Development during Wound Infection

Staphylococcus aureus is the most common cause of surgical site infections and its treatment is challenging due to the emergence of multi-drug resistant strains such as methicillin-resistant S. aureus (MRSA). Natural berry-derived compounds have shown antimicrobial potential, e.g., ellagitannins such as sanguiin H-6 and lambertianin C, the main phenolic compounds in Rubus seeds, have shown antimicrobial activity. The aim of this study was to evaluate the effect of sanguiin H-6 and lambertianin C fractionated from cloudberry seeds, on the MRSA growth, and as treatment of a MRSA biofilm development in different growth media in vitro and in vivo by using a murine wound infection model where sanguiin H-6 and lambertianin C were used to prevent the MRSA infection. Sanguiin H-6 and lambertianin C inhibited the in vitro biofilm development and growth of MRSA. Furthermore, sanguiin H-6 showed significant anti-MRSA effect in the in vivo wound model. Our study shows the possible use of sanguiin H-6 as a preventive measure in surgical sites to avoid postoperative infections, whilst lambertianin C showed no anti-MRSA activity.

Incidence and Predictors of Surgical Site Infection Complications in Diabetic Patients Undergoing Lower Limb Amputation

BACKGROUND

Surgical site infections (SSIs) following lower extremity amputations (LEAs) are a major cause of patient morbidity and mortality. The objectives of this study are to investigate the annual incidence of SSI and risk factors associated with SSI after LEA in diabetic patients.

METHODS

LEAs performed on diabetic patients between 2005 and 2017 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Incidence rates were calculated and analyzed for temporal change. Multivariable logistic regression was conducted to identify the independent predictors of SSIs in LEA.

RESULTS

In 21,449 diabetic patients, the incidence of SSIs was 6.8% after LEA, with an overall decreasing annual trend (P = 0.013). Amputation location (below-knee in reference to above-knee) [OR (95% CI): 1.35 (1.20 - 1.53), P <0.001], smoking [OR (95% CI): 1.25 (1.11 - 1.41), P <0.001)], female sex [OR (95% CI): 1.16 (1.03 - 1.30)], preoperative sepsis [OR (95% CI): 1.24 (1.10 - 1.40), P <0.001], P = 0.013], emergency status [OR (95% CI): 1.38 (1.17 - 1.63), P <0.001], and obesity [OR (95% CI): 1.59 (1.12 - 2.27), P = 0.009] emerged as independent predictors of SSIs, while moderate/severe anemia emerged as a risk-adjusted protective factor [OR (95% CI): 0.75 (0.62 - 0.91), P = 0.003]. Sensitivity analysis found that moderate/severe anemia, not body mass index (BMI) class, remained a significant risk factor in the development of SSIs in below-the-knee amputations; in contrast, higher BMI, not preoperative hematocrit, was significantly associated with an increased risk for SSI in above-the-knee amputations.

CONCLUSIONS

The incidence of SSIs after LEA in diabetic patients is decreasing. Overall, below-knee amputation, smoking, emergency status, and preoperative sepsis appeared to be associated with SSIs. Obesity increased SSIs in above-the-knee amputations, while moderate/severe preoperative anemia appears to protect against below-the-knee SSIs. Surgeons should take predictors of SSI into consideration while optimizing care for their patients, and future studies should investigate the role of preoperative hematocrit correction and how it may influence outcomes positively or negatively.

Subcutaneous irrigation with rifampicin vs. povidone-iodine for the prevention of incisional surgical site infections following caesarean section: a prospective, randomised, controlled trial

The aim is to investigate the effect of irrigation of subcutaneous tissue with saline, rifampicin, or povidone-iodine on incisional surgical site infections following caesarean section. Three hundred patients scheduled for caesarean section were randomly assigned into one of three groups of 100 members each, as follows: the subcutaneous tissue was irrigated with saline in group 1 (control); saline + rifampicin in group 2; saline + 10% povidone-iodine in group 3. Patients who developed a superficial incisional surgical site infection within 30 days were recorded. The surgical site infection rate did not differ when using rifampicin or povidone-iodine (p = .202). It was observed that there was a statistically significant increase in the rate of incisional surgical site infections as the existence of comorbidities (p = .001), perioperative blood transfusion (p = .020), and midline incision (p = .004). Irrigation of subcutaneous tissue with rifampicin or 10% povidone-iodine is not effective in preventing surgical site infections after caesarean section.IMPACT STATEMENTWhat is already known on this subject? An increase has recently been observed in the incidence of SSI particularly in caesarean sections due to reasons, such as that elderly mothers are more commonly operated on compared to the past and long and complicated operations (Lachiewicz et al. 2015) and there are no clear decisions on measures to be taken. Also, there are not many studies on this subject (De Nardo et al. 2016; Solomkin et al. 2017).What do the results of this study add? In our study, we investigated the effectiveness of subcutaneous agents that have been used by many surgeons for years and we've revealed that it's not effective. There is no study in the literature comparing 3 different irrigation agents as we did in our study. For this reason, we think that we will make an important contribution to the measures to be taken in this important issue.What are the implications of these findings for clinical practice and/or further research? This study may contribute to reaching a sufficient level of evidence on surgical wound infections after caesarean sections, which are still missing in the literature, and that may be guiding for the studies that will be conducted on this subject in the future.

Incidence, risk factors and management of post cesarean section surgical site infection (SSI) in a tertiary hospital in Egypt: a five year retrospective study

BACKGROUND

Surgical site infection (SSI) is one of the commonest complications following cesarean section (CS) with a reported incidence of 3-20%. SSI causes massive burdens on both the mother and the health care system. Moreover, it is associated with high maternal morbidity and mortality rate of up to 3%. This study aims to determine the incidence, risk factors and management of SSI following CS in a tertiary hospital.

METHODS

This was an observational case control retrospective study which was conducted at Minia maternity university hospital, Egypt during the period from January 2013 to December 2017 (Five years). A total of 15,502 CSs were performed during the studied period, of these, 828 cases developed SSI following CS (SSI group). The control group included 1500 women underwent cesarean section without developing SSI. The medical records of both groups were reviewed regarding the sociodemographic and the clinical characteristics.

RESULTS

The incidence of SSI post-cesarean section was 5.34%. Significant risk factors for SSI were; chorioamnionitis (adjusted odds ratio (AOR) 4.51; 95% CI =3.12-6.18), premature rupture of membranes (PROM) (AOR 3.99; 95% CI =3.11-4.74), blood loss of > 1000 ml (AOR 2.21; 95% CI =1.62-3.09), emergency CS (AOR 2.16; 95% CI =1.61-2.51), duration of CS of > 1 h (AOR 2.12; 95% CI =1.67-2.79), no antenatal care (ANC) visits (AOR 2.05; 95% CI =1.66-2.37), duration of labor of ≥24 h (AOR 1.45; 95% CI =1.06-2.01), diabetes mellitus (DM) (AOR 1.37; 95% CI =1.02-2.1 3), obesity (AOR 1.34; 95% CI =0.95-1.84), high parity (AOR 1.27; 95% CI = 1.03-1.88), hypertension (AOR 1.19; 95% CI = 0.92-2.11) and gestational age of < 37 wks (AOR 1.12; 95% CI = 0.94-1.66). The mortality rate due to SSI was 1.33%.

CONCLUSIONS

The obtained incidence of SSI post CS in our study is relatively lower than other previous studies from developing countries. The development of SSI is associated with many factors rather than one factor. Management of SSI is maninly medical but surgical approach may be needed in some cases.

REGISTRATION

Local ethical committee (Registration number: MOBGYN0040).

Do Preoperative Nasal Antiseptic Swabs Reduce the Rate of Surgical Site Infections After Adult Thoracolumbar Spine Surgery?

INTRODUCTION

Surgical site infection (SSI) remains a major complication after adult spinal surgery. We investigated whether adding preoperative nasal decontamination by antiseptic swab (skin and nasal antiseptic povidone-iodine, SNA-PI) to our antimicrobial protocol reduces the SSI rate among our patients undergoing thoracolumbar spinal surgery.

METHODS

We retrospectively reviewed all adult thoracolumbar spinal surgeries performed between June 2015 and May 2017 at a single hospital. Patients were divided into those who received nasal decontamination (SNA-PI+) and those who did not (SNA-PI-). SSI rates and responsible pathogens were compared between the cohorts.

RESULTS

A total of 1,555 surgeries with nasal decontamination (SNA-PI+) and 1,423 surgeries without (SNA-PI-) were included. The SSI rate in the SNA-PI+ group was 13 of 1,555 (0.8%) versus 10 of 1,423 (0.7%) for SNA-PI- group (P = 0.68). The infection rate was the highest among posterior instrumented fusions in the SNA-PI+ group (1.4%). Methicillin-sensitive Staphylococcus aureus was responsible for 70% of infections in the SNA-PI- group and 38% in the SNA-PI+ group (P = 0.13).

CONCLUSIONS

Routine nasal antiseptic swab before spine surgery did not affect the overall rate of SSI in thoracolumbar spinal surgeries. The incidence of methicillin-sensitive S aureus was lower in patients who received nasal decontamination (5/1,555, 0.3%) compared with those who did not (7/1,423, 0.5%); however, this result was not statistically significant (P = 0.57).

Preoperative hair removal to reduce surgical site infection

BACKGROUND

Hair has traditionally been removed from the surgical site before surgery; however, some studies claim that this increases surgical site infections (SSIs) and should be avoided. This is the second update of a review published in 2006 and first updated in 2011.

OBJECTIVES

To determine whether routine preoperative hair removal (compared with no removal) and the method, timing, or setting of hair removal effect SSI rates.

SEARCH METHODS

In November 2019, for this second update we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies, and scanned the reference lists of included studies plus reviews to identify additional studies. We applied no date or language restrictions.

SELECTION CRITERIA

We included randomised controlled trials or quasi-randomised trials that compared: · hair removal with no hair removal; · different methods of hair removal; and · hair removal at different times before surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the relevance of each study. Data were extracted independently by both review authors and cross-checked. We carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool and assessed the certainty of evidence according to GRADE. Sensitivity analyses excluding studies at high risk of bias were conducted.

MAIN RESULTS

We included 11 new studies in this update resulting in a total of 19 randomised and 6 quasi-randomised trials (8919 participants). Clipping compared with no hair removal Low certainty evidence suggests there may be little difference in risk of SSI when no hair removal is compared with hair removal using clippers (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.65 to 1.39; three studies with 1733 participants). Shaving with a razor compared with no hair removal Moderate certainty evidence suggests the risk of SSI is probably increased in participants who have hair removal with a razor compared with no removal (RR 1.82, 95% CI 1.05 to 3.14; seven studies with 1706 participants). In terms of absolute risk this represents 17 more SSIs per 1000 in the razor group compared with the no hair removal group (95% CI 1 more to 45 more SSI in the razor group). Based on low-certainty evidence, it is unclear whether there is a difference in stitch abscesses between hair removal with a razor and no hair removal (1 trial with 80 participants; RR 1.00, 95% CI 0.21 to 4.66). Based on narrative data from one trial with 136 participants, there may be little difference in length of hospital stay between participants having hair removed with a razor compared with those having no hair removal (low-certainty evidence). Based on narrative data from one trial with 278 participants, it is uncertain whether there is a difference in cost between participants having hair removed by shaving with a razor compared with no hair removal (very low certainty evidence). Depilatory cream compared with no hair removal Low certainty evidence suggests there may be little difference in SSI risk between depilatory cream or no hair removal, although there are were wide confidence intervals around the point estimate that included benefit and harm (RR 1.02, 95% CI 0.45 to 2.31; low-certainty evidence; 1 trial with 267 participants). Based on narrative data from one trial with 267 participants, it is uncertain whether there is a difference in cost between participants having hair removed with depilatory cream compared with no hair removal (very low certainty evidence). Shaving with a razor compared with clipping Moderate-certainty evidence from 7 studies with 3723 participants suggests the risk of SSI is probably increased by shaving with a razor compared with clipping (RR 1.64, 95% CI 1.16 to 2.33). Moderate-certainty evidence suggests the risk of skin injury is probably increased in people who have hair removal with a razor rather than clipping (3 trials with 1333 participants; RR 1.74, CI 95% 1.12 to 2.71). Shaving with a razor compared with depilatory cream Moderate-certainty evidence from 9 studies with 1593 participants suggests there is probably more SSI risk when razors are used compared with depilatory cream (RR 2.28, 95% CI 1.12 to 4.65). Low-certainty evidence suggests the risk of skin injury may be increased when using a razor rather than depilatory cream for hair removal (RR 6.95, CI 95% 3.45 to 13.98; 5 trials with 937 participants). Based on narrative data from three trials with 402 participants, it is uncertain whether depilatory cream is more expensive than shaving (very low certainty evidence). Hair removal on the day of surgery compared with one-day preoperatively Low-certainty evidence suggests that there may be a small reduction in SSI risk when hair is removed on the day of surgery compared with the day before surgery although there are were wide confidence intervals around the point estimate that included benefit and harm (one trial, 977 participants; RR 0.83, 95% CI 0.54 to 1.30).

AUTHORS' CONCLUSIONS

Compared with no hair removal, there may be little difference in risk of SSI when clippers or depilatory cream are used (low-certainty evidence). However, there are probably fewer SSIs when hair is not removed compared with shaving with a razor (moderate-certainty evidence). If hair has to be removed, moderate-certainty evidence suggests using clippers or depilatory cream probably results in fewer SSIs and other complications compared with shaving using a razor. There may be a small reduction in SSIs when hair is removed on the day of, rather than the day before, surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association of Disposable Perioperative Jackets With Surgical Site Infections in a Large Multicenter Health Care Organization

Importance

To help prevent surgical site infections (SSIs), recommendations by a national organization led to implementation of a mandatory operating room policy in a large multicenter health care organization of required use of disposable perioperative jackets.

Objective

To assess whether the use of perioperative disposable jackets is associated with the incidence of SSIs.

Design, Setting, and Participants

Surgical site infection data for patients undergoing clean surgical procedures were retrospectively reviewed from 12 hospitals in a large multicenter health care organization during a 55-month period from January 1, 2014, to July 31, 2018. The incidence of SSI was analyzed for all National Healthcare Safety Network monitored and reported procedures. The patient population was split into 2 groups; the preintervention group consisted of 29 098 patients within the 26 months before the policy starting March 1, 2016, and the postintervention group consisted of 30 911 patients within 26 months after the policy.

Main Outcome and Measures

Comparison of the incidence of SSIs before and after intervention periods underwent statistical analysis. The total number of disposable jackets purchased and total expenditures were also calculated.

Exposures

Implementation of the mandated perioperative attire policy.

Results

A total of 60 009 patients (mean [SD] age, 62.8 [13.9] years; 32 139 [53.6%] male) were included in the study. The overall SSI incidence for clean wounds was 0.87% before policy implementation and 0.83% after policy implementation, which was not found to be significant (odds ratio [OR], 0.96; 95% CI, 0.80-1.14; P = .61). After accounting for possible confounding variables, a multivariable analysis demonstrated no significant reduction in SSIs (OR, 0.85; 95% CI, 0.71-1.01; P = .07). During the postintervention study period (26 months), a total of 2 010 040 jackets were purchased, which amounted to a cost of $1 709 898.46.

Conclusions and Relevance

The results of this study suggest that the use of perioperative disposable jackets is not associated with reductions in SSI for clean wounds in a large multicenter health care organization and presents a fiscal burden.

Impact of a surgical safety checklist on surgical site infections, antimicrobial resistance, antimicrobial consumption, costs and mortality

BACKGROUND

In 2010, following the recommendations of the World Health Organization (WHO), our hospital implemented a surgical safety programme centred around a surgical safety checklist.

AIM

The aim of this study was to compare indicators of surgical site infection, antimicrobial consumption, antimicrobial resistance, costs and in-hospital mortality before (January 2006 to July 2010) and after (August 2010 to December 2014) implementation of the programme.

METHODS

A case-control study was carried out matching patients with surgical site infection (SSI) to surgical patients without infection to examine the impact of the intervention.

FINDINGS

Use of the surgical checklist was associated with a significant reduction in SSI. When comparing the two time periods, we also identified a reduction in infections due to micro-organisms in the ESKAPE group (from 90.7% to 73.9%, P<0.001), a reduction of SSI in patients with contaminated, infected and potentially contaminated wounds, and for those in whom perioperative antimicrobial prophylaxis was discontinued in less than 48 hours. Overall, there was a reduction in antimicrobial resistance, though there was increased resistance to carbapenems for, to glycopeptides for Enterococcus faecium, and to clindamycin for Staphylococcus aureus. We also detected increased antimicrobial consumption of second- and third-generation cephalosporins and clindamycin. We observed a reduction in hospital deaths from 6.4% to 3.2% (P=0.001), but we did not observe any reduction in costs.

CONCLUSIONS

Implementation of a surgical checklist was an independent predictor of SSI reduction, and was also associated with a decrease in antimicrobial resistance and reduced in-hospital mortality.

Subcuticular sutures versus staples for skin closure in patients undergoing abdominal surgery: A meta-analysis of randomized controlled trials

Background

Surgical site infections (SSIs) are common postoperative complications. Whether the use of staples or sutures makes a difference in abdominal surgery’s infection rate remains elusive.

Methods

A systematic review was performed to identify randomized clinical trials comparing staples and sutures after abdominal surgeries. Eligibility criteria involved the SSI occurrence as the primary outcome and the incidence of wound dehiscence, closure time, cosmesis, and patient satisfaction as the secondary outcomes.

Results

Of the 278 studies identified, seven randomized controlled trials representing 3705 patients were included in this review. There was no significant difference in SSI rates between sutures and staples in general (OR = 0.98, 95% CI = 0.79–1.22, I² = 44%, P = 0.1) or in a subgroup of gastrointestinal surgery, where subcuticular suturing was found with a comparable SSI risk with skin stapling (OR = 0.85, 95% CI = 0.66–1.09). Staple closure was associated with a shorter surgery duration, whereas sutures appeared to provide better cosmesis and patient satisfaction. Sutures and staples achieved a comparable incidence of dehiscence. There was no significant between-study publication bias.

Conclusion

Our study demonstrated similar outcomes in SSI rate between subcuticular sutures and staples for skin closure in patients undergoing abdominal surgery.

Intrawound vancomycin application after spinal surgery: a propensity score-matched cohort analysis

OBJECTIVE

Surgical site infection (SSI) following spine surgery is associated with increased morbidity and healthcare costs. In an effort to reduce SSI rates, the application of intrawound vancomycin powder has gained popularity. However, there is limited high-quality evidence to support the safety and efficacy of this practice. The authors sought to determine if intrawound application of vancomycin powder improves 90-day overall SSI rates.

METHODS

The authors performed a retrospective, vancomycin exposure-matched cohort study at a single tertiary care hospital over 21 months. They included all patients undergoing elective spinal surgery and stratified the patients into two groups: those who received intrawound vancomycin powder application and those who received no application of vancomycin powder. The primary outcome of interest was the 90-day overall SSI rate. Secondary outcomes included rates of superficial SSI, deep SSI, wound disruption, and a post hoc analysis of the microbiology and minimum inhibitory concentrations. Baseline patient demographics, clinical presentation, comorbidities, perioperative factors, and 90-day postoperative outcomes were manually abstracted from patient charts. To mitigate bias, we performed 1:1 matching after calculating propensity scores and identified 1 patient from the no-vancomycin cohort for each patient in the vancomycin cohort.

RESULTS

A total of 997 patients met our inclusion criteria (473 patients receiving vancomycin and 524 patients not receiving vancomycin). Propensity score matching produced 221 matched pairs. Risk-adjusted analysis demonstrated similar overall SSI rates between the groups (OR 1.9, p = 0.329). On unadjusted analysis, the overall 90-day SSI rate was greater in the vancomycin group (n = 10 [4.5%]) than in the no-vancomycin group (n = 5 [2.3%]) (p < 0.001), as were the superficial SSI rate (7 [3.2%] vs 4 [1.8%], p < 0.001), deep SSI rate (3 [1.4%] vs 1 [0.5%], p < 0.001), and wound disruption rate (5 [2.3%] vs 1 [0.5%], p < 0.001). No cultured isolate demonstrated vancomycin resistance.

CONCLUSIONS

The authors observed no difference in SSI rates after the intrawound application of vancomycin powder during spine surgery. Vancomycin use did not contribute to antimicrobial resistance; however, it may select out gram-negative bacteria and increase rates of wound disruption.

Improving surgical site infection prevention in Asia-Pacific through appropriate surveillance programs: Challenges and recommendation

BACKGROUND

Surgical site infections (SSIs) represent a substantial clinical and economic burden on patients and the healthcare system. The prevention of SSIs entails surveillance activities which lead to effective mitigation strategies, which are lacking across Asia Pacific (APAC). This manuscript aims to document gaps and challenges across APAC that affect the undertaking of a successful SSI surveillance activities and to provide recommendations on overcoming such challenges.

METHODS

A targeted literature review with relevance to APAC identified a series of salient points pertaining to SSI prevention guidelines, implementation, surveillance and outcomes, which was discussed in July 2019 at the APAC Surgical Site Infection Prevention Symposium. An expert panel, comprising eight multidisciplinary experts from APAC and the USA, subsequently amalgamated the key discussion points from the Symposium and their clinical experiences in developing this article.

RESULTS

The barriers to implementing a successful and effective APAC SSI surveillance program were identified as: (a) lack of standardized definitions, reporting methodology and accountability, (b) lack of fiscal resources, (c) reporting variability and under-reporting, and (d) lack of safety culture. Implementing an effective surveillance program in APAC will require countries to develop a well-designed and robust surveillance plan and ensure adequate training for staffs involved.

CONCLUSION

To improve SSI prevention in the region, it is imperative to encourage implementation of national programs with standardized methodologies and accountabilities. An ongoing APAC information exchange, including data and methodologies, will enable continuous learning within the APAC region.

Surgical handwashing practices of operating room staff: An observational study

OBJECTIVE

This descriptive and cross-sectional study aims to assess the surgical handwashing practices of operating room staff.

DESIGN

Single-blind study.

METHODS

The study was conducted with 66 staff (surgeons and operating room nurses) employed in the surgery department of a university hospital in Turkey. Data were collected using a Staff Information Form prepared in light of the literature to collect the participants' sociodemographic data and the Surgical Hand Washing Procedure Checklist developed according to the guidelines of the Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and Association of Surgical Technologists (AST). The staff assigned to operating rooms were identified, and then, their surgical handwashing practices were observed by one of the researchers.

FINDINGS

Of the participants, 77.3% were dressed suitable to the operating room field, 56.1% appropriately wet both of their hands and forearms, and 72.7% used a sufficient amount of antiseptic solution (3-5 ml) in their palms. More than half of them (51.5%) inappropriately performed the procedure of surgical handwashing (applying an antiseptic solution to hands and arms with circular motions, starting from the fingertips up to 3-5 cm above their elbows for a minute), and 47% incorrectly performed the procedure of rinsing hands and arms while keeping the hands above the elbows under running water and passing arms through the water in one direction during this process.

CONCLUSION

In the study, it was determined that none of the team members completed the preparation, application and drying steps of the surgical handwashing procedure. Therefore, it is necessary to make arrangements that will facilitate the handwashing procedures of the personnel. Personnel-related problems, such as the duration of washing and drying methods, are possible to be avoided with periodic in-service training and with posters demonstrating the washing stages, which might lead to behavioural changes.

Antibiotic Prophylaxis in Plastic Surgery Correlation Between Practice and Evidence

Background:

The use of appropriate preoperative antibiotic prophylaxis decreases the risk of surgical site infections (SSI); however, the breadth of plastic surgery procedures makes it challenging to ensure appropriate use for each unique procedure type. Currently, plastic surgeons lack a cohesive and comprehensive set of evidence-based guidelines (EBG) for surgical prophylaxis. We sought to profile the perioperative antibiotic prescribing patterns for plastic surgeons in British Columbia to investigate if they are congruent with published recommendations. In doing so, we aim to determine risk factors for antibiotic overprescribing in the context of surgical prophylaxis.

Methods:

A literature review identifying EBG for antibiotic prophylaxis use during common plastic surgery procedures was performed. Concurrently, a provincial survey of plastic surgery residents, fellows, academic and community plastic surgeons was used to identify their antibiotic prophylaxis prescribing practices. These findings were then compared to recommendations identified from our review. The compliance of the provincial plastic surgery community with current EBG was determined for 38 surgical scenarios to identify which clinical factors and procedure types were associated with unsupported antibiotic use.

Results:

Within the literature, 31 of the 38 categories of surveyed plastic surgery operations have EBG for use of prophylactic antibiotics. When surgical procedures have EBG, 19.5% of plastic surgery trainees and 21.9% of practicing plastic surgeons followed recommended prophylaxis use. Average adherence to EBG was 59.1% for hand procedures, 24.1% for breast procedures, and 23.9% for craniofacial procedures. Breast reconstruction procedures and contaminated craniofacial procedures were associated with a significant reduction in adherence to EBG resulting in excessive antibiotic use.

Conclusion:

Even when evidence-based recommendations for antibiotic prophylaxis exist, plastic surgeons demonstrate variable compliance based on their reported prescribing practices. Surgical procedures with low EBG compliance may reflect risk avoidant behaviors in practicing surgeons and highlight the importance of improving education on the benefits of antibiotic prophylaxis in these clinical situations.

Reducing Caesarean Section Surgical Site Infection (SSI) by 50%: A Collaborative Approach

OBJECTIVE

Caesarean section surgical site infection (SSI) is a surgical wound site infection occurring within 30 days of surgery with a reported incidence of 3-15%. This quality improvement (QI) project aimed to reduce caesarean section SSI by 50% in a tertiary maternity center.

METHODS

Using multidisciplinary team approach, the project was designed with evidence-based interventions. The Royal College of Physicians of Ireland/Royal College of Surgeons in Ireland "Preventing Surgical Site Infections Key Recommendations for Practice" guideline was used as standard perioperative care. A care bundle was designed targeting preoperative personal patient preparation, preoperative prophylactic antibiotics, and strict skin preparation technique, all measured using a patient survey. The rate of SSI was followed for 14 months. The Model for Improvement methodology was used to implement change.

RESULTS

Surgical site infection rate decreased from 6.7% (n = 684 caesarean sections, n = 46 SSI) to 3.45% (n = 3,206 caesarean sections, n = 110 SSI), p = .0006. Reduction occurred in both elective (4.4%-2.7%) and emergency (9.1%-4.1%) caesarean section groups. There was excellent adherence to all three elements of the care bundle. The 50% reduction in caesarean section SSI was sustained over the 14-month period, significantly reducing maternal morbidity.

CONCLUSIONS

The success of this QI project is attributable to frontline ownership and empowerment of patients and staff.

Whole Genome Sequencing and Antimicrobial Resistance of Staphylococcus aureus from Surgical Site Infections in Ghana

Staphylococcus aureus (S. aureus) is a common cause of surgical site infections (SSIs) globally. Data on the occurrence of methicillin-susceptible S. aureus (MSSA) as well as methicillin-resistant S. aureus (MRSA) among patients with surgical site infections (SSIs) in sub-Saharan African are scarce. We characterized S. aureus from SSIs in Ghana using molecular methods and antimicrobial susceptibility testing (AST). Wound swabs or aspirate samples were collected from subjects with SSIs. S. aureus was identified by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF-MS); AST was performed by Kirby-Bauer disk diffusion, and results were interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guideline. Detection of spa, mecA, and pvl genes was performed by polymerase chain reaction (PCR). Whole-genome sequencing (WGS) was done using the Illumina MiSeq platform. Samples were collected from 112 subjects, with 13 S. aureus isolates recovered. Of these, 92% were sensitive to co-trimoxazole, 77% to clindamycin, and 54% to erythromycin. Multi-drug resistance was detected in 5 (38%) isolates. The four mecA gene-positive MRSA isolates detected belonged to ST152 (n = 3) and ST5 (n = 1). In total, 62% of the isolates were positive for the Panton-Valentine leukocidin (pvl) toxin gene. This study reports, for the first time, a pvl-positive ST152-t355 MRSA clone from SSIs in Ghana. The occurrence of multi-drug-resistant S. aureus epidemic clones suggests that continuous surveillance is required to monitor the spread and resistance trends of S. aureus in hospital settings in the country.

Utilization of neurosurgical perioperative antimicrobial prophylaxis in a Chinese teaching hospital

Background Audits of antimicrobial prophylaxis is an essential strategy to identify practice gaps in antimicrobial prescribing in healthcare facilities. There is a lack of studies on the costs, quality, and antimicrobial use density of neurosurgical perioperative antimicrobial prophylaxis in China. Objectives Evaluate the appropriateness of perioperative antimicrobial prophylaxis in neurosurgeries and analyze the costs, quality, and antimicrobial use density of neurosurgical perioperative antimicrobial prophylaxis. Setting Beijing Tsinghua Changgung Hospital, a teaching hospital in Beijing. Methods This retrospective study was conducted among 262 neurosurgical patients without infections during 2017. The appropriateness of perioperative antimicrobial prophylaxis was determined based on relevant international and Chinese perioperative antimicrobial prophylaxis guidelines. Main outcome measures Discrepancy rates in perioperative antimicrobial prophylaxis, including indication, choice of antimicrobials, dose, route of administration, time of administration of the first dose, re-dosing, and duration, were analyzed. Results Discrepancies were observed between current practice and relevant guidelines. A total of 51 (32.1%) procedures failed to administer intraoperative re-dosing as needed, and the perioperative antimicrobial prophylaxis duration of 217 (82.8%) procedures was inappropriately prolonged. The choice of antimicrobial agents was optimal in 249 (95%) procedures, and the timing of perioperative antimicrobial prophylaxis was appropriate in all procedures. If perioperative antimicrobial prophylaxis was implemented according to guidelines, the defined daily dose per 100 procedures would decrease from 31.97 to 16.99, and the total cost would reduce from $2000 to $490. Conclusions Effective antimicrobial stewardship is urgently needed to promote the appropriateness of neurosurgical perioperative antimicrobial prophylaxis in China.

Prevention of spinal fusion post-operative wound infections in pediatric patients with scoliosis: a quality improvement initiative

PURPOSE

Post-operative wound infections increase patient morbidity and mortality as well as the length of hospital stay, with a profound personal and institutional cost. The aim of this study was to decrease post-operative infections through development of a surgical antibiotic prophylaxis policy based on institution-specific risk factors and microbiology data.

METHODS

We conducted a retrospective review of deep wound infections at our institution over a 5-year period (2014-2018). 399 spinal fusion procedures were performed with a 2.5% post-operative infection rate. Patients with neuromuscular scoliosis were six times more likely to develop deep wound infections (7.6%) compared to patients with congenital and idiopathic scoliosis (combined rate of 1.25%). The microbiology data revealed that polymicrobial, extended spectrum beta-lactamase (ESBL) gram negative organisms predominated in patients with neuromuscular scoliosis. Based on these findings, we implemented an evidence-based quality improvement intervention: all patients with neuromuscular scoliosis undergoing spinal fusion were given a single 15 mg/kg dose of amikacin, in addition to our standard practice of perioperative cefazolin plus vancomycin with intra-operative betadine wash and vancomycin powder application. This intervention was put into practice in January 2019.

RESULTS

Since the implementation of our quality improvement initiative, the overall post-operative infection rate decreased to 1.1% (2 infections in 176 cases). Ninety-eight percent of the 43 neuromuscular scoliosis patients who underwent spinal fusion in the post-intervention time frame have remained infection free.

CONCLUSION

Examination of post-operative infection and microbiology data at the institution level can guide the development of institution specific, evidence-based quality improvement initiatives that reduce post-operative wound infections.

Incidence and predictors of surgical site infection following cesarean section in North-west Ethiopia: a prospective cohort study

BACKGROUND

Following delivery by caesarean section, surgical site infection is the most common infectious complication. Despite a large number of caesarean sections performed at Debre Markos Referral Hospital, there was no study documenting the incidence of surgical site infection after caesarean section. Therefore, this study aimed to estimate the incidence of surgical site infection following caesarean section at Debre-Markos Referral Hospital in Amhara region, North-west Ethiopia.

METHODS

A prospective cohort study was conducted among 520 pregnant women who had a caesarean section between March 28, 2019 and August 31, 2019. Preoperative, intraoperative, and postoperative data were collected using a standardized questionnaire. Data was entered using EpiData™ Entry Version 4.1 software and analyzed using R Version 3.6.1 software. A descriptive analysis was conducted using tables, interquartile ranges and median. The time to development of surgical site infection was estimated using Kaplan-Meier method. The Cox regression model for bivariable and multivariable analyses was done. Adjusted Hazard Ratio (AHR) with 95% Confidence Interval (CI) was reported to show the strength of association.

RESULT

The mean age of the study cohort was 27.4 ± 4.8 years. The overall cumulative incidence of surgical site infection was 25.4% with an incidence of 11.7 (95% CI:9.8,13.9) per 1000 person/days. Not able to read and write (AHR = 1.30,95% CI:1.19,2.11), no antenatal care (AHR = 2.16, 95%CI:1.05,4.53), previous history of CS (AHR = 1.21, 95% CI:1.11,2.31), HIV positive (AHR = 1.39, 95% CI:1.21,2.57), emergency procedure (AHR = 1.13, 95% CI:1.11,2.43), vertical type of incision (AHR = 2.60, 95% CI:1.05,6.44), rupture of membrane (AHR = 1.50, 95% CI:1.31,1.64), multiple vaginal examination (AHR = 1.88, 95% CI: 1.71, 3.20) were significant predictors of surgical site infection in this study.

CONCLUSION

This study concluded that the incidence of surgical site infection following caesarean section was relatively high compared to previous studies. Not able to read and write, have no ante natal care, previous history of caesarean section, HIV, emergency surgery, vertical type of incision, rupture of membranes before caesarean section, and multiple vaginal examinations were significant predictors of surgical site infection in this study. Therefore, intervention programs should focus on and address the identified factors to minimize and prevent the infection rate after caesarean section.

The Cutaneous Wound Innate Immunological Microenvironment

The skin represents the first line of defense and innate immune protection against pathogens. Skin normally provides a physical barrier to prevent infection by pathogens; however, wounds, microinjuries, and minor barrier impediments can present open avenues for invasion through the skin. Accordingly, wound repair and protection from invading pathogens are essential processes in successful skin barrier regeneration. To repair and protect wounds, skin promotes the development of a specific and complex immunological microenvironment within and surrounding the disrupted tissue. This immune microenvironment includes both innate and adaptive processes, including immune cell recruitment to the wound and secretion of extracellular factors that can act directly to promote wound closure and wound antimicrobial defense. Recent work has shown that this immune microenvironment also varies according to the specific context of the wound: the microbiome, neuroimmune signaling, environmental effects, and age play roles in altering the innate immune response to wounding. This review will focus on the role of these factors in shaping the cutaneous microenvironment and how this ultimately impacts the immune response to wounding.

The Association Between Incorrect Use of Antibiotic Prophylaxis and in-Hospital Surgical Site Infections - A Prospective Observational Study

Background

Surgical site infection (SSI) is the most prevalent in developing countries where 61–90% of cases develop in-hospital. The study aimed to assess the correctness of antibiotic prophylaxis (AP) use, the incidence of in-hospital SSI, and its determinants.

Patients and Methods

A 3-month hospital-based prospective observational study design was used on general surgery patients. The criteria for identification of SSI were performed based on the Center for Disease Control and Prevention’s (CDC’s) definition of SSI. The correctness of AP was performed based on the American Society of Health System Pharmacist 2013 guideline (ASHP). Multiple stepwise backward logistic regression analysis was used at p-value <0.05 to predict SSI.

Results

Of 269 adult patients, the type of admission was almost equal between emergency and elective surgery. The mean (± SD) age of the study participants was 41.95±17.764. Only 19.7% of the study participants used AP correctly. The incidence rate of in-hospital SSI was 16.7% (45/269), which corresponds to 45/4736 or 9.5/1000 person-days. Independent predictors for SSI were American Society of Anesthesiology (ASA) class III–IV (p-value <0.0001), patients with age-adjusted Charlson co-morbidity index (CCI) of ≥1 score (p value=0.008), and incorrect use of AP (p-value =0.025).

Conclusion

Incorrect antibiotic prophylaxis use contributed to an increased risk of SSI, which needs urgent attention in the present study area.

Prevention of surgical site infection under different ventilation systems in operating room environment

Biological particles in the operating room (OR) air environment can cause surgical site infections (SSIs). Various ventilation systems have been employed in ORs to ensure an ultraclean environment. However, the effect ofdifferent ventilation systems on the control ofbacteria-carrying particles (BCPs) released from the surgical staff during surgery is unclear. In this study, the performance of four different ventilation systems (vertical laminar airflow ventilation (VLAF), horizontal laminar airflow ventilation (HLAF), differential vertical airflow ventilation (DVAF), and temperature-controlled airflow ventilation (TAF)) used in an OR was evaluated and compared based on the spatial BCP concentration. The airflow field in the OR was solved by the Renormalization Group (RNG) k-ε turbulence model, and the BCP phase was calculated by Lagrangian particle tracking (LPT) and the discrete random walk (DRW) model. It was found that the TAF system was the most effective ventilation system among the four ventilation systems for ensuring air cleanliness in the operating area. This study also indicated that air cleanliness in the operating area depended not only on the airflow rate of the ventilation system but also on the airflow distribution, which was greatly affected by obstacles such as surgical lamps and surgical staff.

Bioactivity and antibacterial activity of strontium and silver ion releasing titanium

To overcome problems associated with loosening of orthopedic implants and surgical site infections, we developed a novel, titanium (Ti)-based material that releases both strontium and silver ions (CaSrAg-Ti) based on alkali-and-heat treatment. The results of commercially pure Ti (cp-Ti), Ti that releases Sr ions only (CaSr-Ti), and the novel CaSrAg-Ti material were compared. Mechanical tests were performed to evaluate the in vivo bonding properties of CaSrAg-Ti and the bone-implant contact (BIC) ratio in histological specimens was determined at 4 and 8 weeks after implantation in a rat femur. Also, the in vitro antibacterial activities of this material against methicillin-susceptible Staphylococcus aureus (MSSA) were evaluated after a 24 h incubation period by assaying colony-forming units. In addition, antibacterial activities were evaluated in vivo at 7 days after implantation in a rat subcutaneous pocket model. There was direct contact between the bone and CaSrAg-Ti in histological specimens and no apparent signs of argyrosis in any rat. The bone-bonding strength and the BIC ratio were increased by 2.7- and 2.3-fold for CaSrAg-Ti vs. cp-Ti at 4 weeks and 2.2- and 2.0-fold at 8 weeks, respectively. As compared with cp-Ti, the number of viable MSSA remaining on CaSrAg-Ti was reduced by 100 ± 0% in vitro and 94.2 ± 6.9% in vivo. Ti that releases Sr and Ag ions is a promising material that exhibits both bone-bonding properties and anti-MSSA activities.