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Kirkham AM, Candeliere J, Mai T, Nagpal SK, Brandys TM, Dubois L, Shorr R, Stelfox HT, McIsaac DI, Roberts DJ. Risk Factors for Surgical Site Infection after Lower Limb Revascularisation Surgery: a Systematic Review and Meta-Analysis of Prognostic Studies. Eur J Vasc Endovasc Surg 2024; 67:455-467. [PMID: 37925099 DOI: 10.1016/j.ejvs.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/27/2023] [Accepted: 10/30/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE To systematically review and meta-analyse adjusted risk factors for surgical site infection (SSI) after lower limb revascularisation surgery. DATA SOURCES MEDLINE, Embase, Evidence Based Medicine Reviews, and the Cochrane Central Register of Controlled Trials (inception to 28 April 2022). REVIEW METHODS Systematic review and meta-analysis conducted according to PRISMA guidelines. After protocol registration, databases were searched. Studies reporting adjusted risk factors for SSI in adults who underwent lower limb revascularisation surgery for peripheral artery disease were included. Adjusted odds ratios (ORs) were pooled using random effects models. GRADE was used to assess certainty. RESULTS Among 6 377 citations identified, 50 studies (n = 271 125 patients) were included. The cumulative incidence of SSI was 12 (95% confidence interval [CI] 10 - 13) per 100 patients. Studies reported 139 potential SSI risk factors adjusted for a median of 12 (range 1 - 69) potential confounding factors. Risk factors that increased the pooled adjusted odds of SSI included: female sex (pooled OR 1.41, 95% CI 1.20 - 1.64; high certainty); dependent functional status (pooled OR 1.18, 95% CI 1.03 - 1.35; low certainty); being overweight (pooled OR 1.82, 95% CI 1.29 - 2.56; moderate certainty), obese (pooled OR 2.20, 95% CI 1.44 - 3.36; high certainty), or morbidly obese (pooled OR 1.65, 95% CI 1.08 - 2.52; moderate certainty); chronic obstructive pulmonary disease (pooled OR 1.42, 95% CI 1.17 - 1.71; high certainty); chronic limb threatening ischaemia (pooled OR 1.67, 95% CI 1.22 - 2.29; moderate certainty); chronic kidney disease (pooled OR 2.13, 95% CI 1.18 - 3.83; moderate certainty); intra-operative (pooled OR 1.23, 95% CI 1.02 - 1.49), peri-operative (pooled OR 1.92, 95% CI 1.27 - 2.90), or post-operative (pooled OR 2.21, 95% CI 1.44 - 3.39) blood transfusion (moderate certainty for all); urgent or emergency surgery (pooled OR 2.12, 95% CI 1.22 - 3.70; moderate certainty); vein bypass and or patch instead of endarterectomy alone (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty); an operation lasting ≥ 3 hours (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty) or ≥ 5 hours (pooled OR 1.60, 95% CI 1.18 - 2.17; moderate certainty); and early or unplanned re-operation (pooled OR 4.50, 95% CI 2.18 - 9.32; low certainty). CONCLUSION This systematic review identified evidence informed SSI risk factors following lower limb revascularisation surgery. These may be used to develop improved SSI risk prediction tools and to identify patients who may benefit from evidence informed SSI prevention strategies.
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Affiliation(s)
- Aidan M Kirkham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jasmine Candeliere
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Trinh Mai
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy M Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Luc Dubois
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Faculty of Medicine, Western University, London, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Departments of Critical Care Medicine, Medicine, and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Daniel I McIsaac
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Derek J Roberts
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada; The O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada.
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Zhao AH, Kwok CHR, Jansen SJ. How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence. Ann Vasc Surg 2021; 78:336-361. [PMID: 34543711 DOI: 10.1016/j.avsg.2021.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/16/2021] [Accepted: 06/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND This review aims to identify and review the current evidence for preventing postoperative surgical site infections in abdominal aortic aneurysm surgery or infrainguinal arterial surgery. METHODS Extended literature review of clinical trials that examined the prevention of postoperative surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. Searches were conducted on Ovid MEDLINE (1950 - 13 March 2020) using key terms for vascular surgery, surgical site infections and specific preventative techniques. Articles were included if they discussed a relationship between a preventative technique and surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. The GRADE guidelines were used to assess the quality of evidence. RESULTS 21 techniques and 81 studies were included. Prophylactic antibiotics and negative pressure wound therapy have a high quality of evidence for the prevention of surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. A moderate quality evidence base was identified for gentamicin containing collagen implant (confined to high surgical site infection risk centers). Currently, there is a low or very low quality of evidence to suggest a reduction in the surgical site infection rate for combination therapy, glycaemic control, Methicillin-resistant Staphylococcus aureus screening and absorbable suture. Evidence suggests no beneficial effect for nutritional supplementation, chlorhexidine bath, hair removal therapy, Staphylococcus aureus nasal eradication, cyanoacrylate microsealant, silver grafts, rifampicin bonded grafts, triclosan coated suture and postoperative wound drains. Endoscopic saphenous vein harvest may reduce surgical site infection rate (very low quality of evidence) but may lower long-term patency. Autologous vein grafts may increase surgical site infections (very low quality of evidence) but may provide better long-term patency rates in above-knee infrainguinal bypass surgery. There was no identified evidence for perioperative normothermia, electrosurgical bipolar vessel sealer or Dermabond and Tegaderm for surgical site infection prevention in vascular surgery. CONCLUSIONS Prophylactic antibiotics and postoperative negative pressure wound therapy are effective in the prevention of postoperative surgical site infection in abdominal aortic aneurysm or infrainguinal arterial surgery. There exists a significant risk of bias in the literature for many preventative techniques and further studies are required to investigate the efficacy of gentamicin containing collagen implant, and specific combination therapies.
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Affiliation(s)
- Adam Hanting Zhao
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia.
| | - Chi Ho Ricky Kwok
- Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia
| | - Shirley Jane Jansen
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia; Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Western Australia, Nedlands, Western Australia, Australia; Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia; Heart and Vascular Research Institute, Harry Perkins Institute for Medical Research, Nedlands, Western Australia, Australia
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Wound Complications and Reoperations after Transtibial Amputation of the Leg. Ann Vasc Surg 2020; 69:292-297. [PMID: 32474142 DOI: 10.1016/j.avsg.2020.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/30/2020] [Accepted: 05/09/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Transtibial amputations (TTAs) of the leg have been associated with high rates of wound complications. We assessed outcomes of TTAs to determine if bundled interventions implemented at our hospital had an impact on lowering wound complications, including surgical site infections. METHODS We assessed the impact of a surgical site infection prevention bundle (negative-pressure wound therapy, minimizing the use of staples, and a decontamination protocol for methicillin-resistant Staphylococcus aureus) on 90-day wound complications. The year of implementation of the prevention bundle was excluded, and the pre-eras and posteras were defined as the four-year period before and after implementation. The study sample consisted of a single-center cohort, with TTA cases identified using operating room scheduling software. RESULTS A total of 182 TTAs were performed: 110 in the pre-era and 72 in the postera. The wound complication rate decreased from 22 to 17% despite fewer two-stage operations, less imaging to identify peripheral artery disease, and an increased proportion of patients with end-stage renal disease. Wound complications and revision to a higher level of amputation were more associated with indication (especially no-option peripheral artery disease with ischemic rest pains) than with any particular aspect of surgical technique. The use of drains was associated with reoperations but not higher level revision. CONCLUSIONS Higher rates of wound complications and revision to a higher level of amputations should be expected among patients with no-option peripheral artery disease with ischemic rest pains undergoing TTAs. Drains should be avoided.
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