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Knisely A, Iniesta MD, Marten CA, Chisholm G, Schmeler KM, Taylor JS. Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center. Am J Obstet Gynecol 2024; 231:326.e1-326.e13. [PMID: 38599478 DOI: 10.1016/j.ajog.2024.03.043] [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: 01/15/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Surgical site infection is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin preoperatively to reduce surgical site infection rates for patients undergoing clean-contaminated surgeries such as hysterectomy. OBJECTIVE To evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on surgical site infection rate for women undergoing gynecologic surgery at a comprehensive cancer center. STUDY DESIGN This retrospective, single-center cohort study included patients who underwent surgery in the gynecologic oncology department from May 2017 to June 2023. Patients with penicillin allergies and those undergoing concomitant bowel resections and/or joint cases were excluded. The preintervention group patients had surgery from May 2017 to April 2022, and the postintervention group patients had surgery from April 2022 to June 2023. The primary outcome was a 30-day surgical site infection rate. Sensitivity analyses were performed to compare surgical site infection rates on the basis of actual antibiotics received and for those who had a hysterectomy. Factors independently associated with surgical site infection were identified using a multivariable logistic regression model adjusting for confounding variables. RESULTS Of 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre-post intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty-four percent of cases were for nononcologic (benign) indications. Preintervention patients were more likely to receive appropriate preoperative antibiotics (95.6% vs 90.7%; P<.001). The overall surgical site infection rate before the intervention was 4.7% compared with 2.6% after (P=.010). The surgical site infection rate for all patients who underwent hysterectomy was 4.9% (preintervention) vs 2.8% (postintervention) (P=.036); a similar trend was seen for benign cases (4.4% vs 2.4%; P=.159). On multivariable analysis, the odds ratio for surgical site infection was 0.49 (95% confidence interval, 0.38-0.63) for the postintervention compared with the preintervention group (P<.001). In a sensitivity analysis (n=3087), the surgical site infection rate was 4.5% for those who received cefazolin alone compared with 2.3% for those who received cefazolin plus metronidazole, with significantly decreased odds of surgical site infection for the cefazolin plus metronidazole group (adjusted odds ratio, 0.40 [95% confidence interval, 0.30-0.53]; P<.001). Among only those who had a hysterectomy performed, the odds of surgical site infection were significantly reduced for those in the postintervention group (adjusted odds ratio, 0.63 [95% confidence interval, 0.47-0.86]; P=.003). CONCLUSION The addition of metronidazole to cefazolin before gynecologic surgery decreased the surgical site infection rate by half, even after accounting for other known predictors of surgical site infection and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.
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Affiliation(s)
- Anne Knisely
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claire A Marten
- Division of Pharmacy, Department of Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gary Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Vurture G, Mendelson J, Grigorescu B, Lazarou G. Decreasing post hysterectomy surgical site infections with the implementation of a hysterectomy-specific bundle. Am J Infect Control 2024; 52:790-794. [PMID: 38395313 DOI: 10.1016/j.ajic.2024.02.009] [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: 12/05/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Surgical site infections (SSI) are a common complication of hysterectomy. Surgical bundles have been shown to reduce SSIs. Here we describe a bundle that was used to combat an abnormal rise in SSI events that resulted in a greater than 75% reduction at our institution. METHODS A hysterectomy-specific bundle was developed based on the prior success of SSI prevention bundles. Development involved longitudinal education and training to ensure accuracy and compliance. All inpatient abdominal, laparoscopic, and vaginal hysterectomies performed at a tertiary referral center were included. The preintervention, intervention, and postintervention periods were each one year in length. SSI rates were peer-reviewed monthly and overall trends were tracked, including compliance with bundle guidelines. RESULTS Preintervention, an abnormal rise in SSI was identified at 3.76%. During the intervention, 309 inpatient hysterectomies were completed. In this period, 6 posthysterectomy SSI events occurred (3.76% vs 1.94%, P = .21). Four SSIs followed laparotomy and 2 followed laparoscopy. Compliance during the intervention period ranged from 79% to 89% with a mean of 85%. In the postintervention period, there were 6 SSI following 689 hysterectomies (3.76% vs 0.87%, P = .004). The majority of SSI occurred after abdominal hysterectomy. CONCLUSIONS Implementation of a hysterectomy-specific surgical bundle allowed for a significant reduction in post hysterectomy SSI during a yearlong intervention period and a sustained, further reduction in the postintervention period.
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Affiliation(s)
- Gregory Vurture
- Department of Obstetrics and Gynecology, Jersey Shore University Medical Center, Neptune, NJ, USA.
| | - Jordan Mendelson
- Department of Urology, New York University Langone Hospital, Long Island, Mineola, NY, USA
| | - Bogdan Grigorescu
- Department of Obstetrics and Gynecology, New York University Langone Hospital, Long Island, Mineola, NY, USA
| | - George Lazarou
- Department of Obstetrics and Gynecology, New York University Langone Hospital, Long Island, Mineola, NY, USA
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Abstract
BACKGROUND Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections. METHODS A PubMed search was performed to update the evidence on skin antiseptic products and practices. RESULTS Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs. CONCLUSIONS Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.
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Balagna SJ, Boyd C, Arnold DE, Wagner CA, Veronikis DK, Short M, Butler J, Marquart S. Implementing a Bundle to Improve Surgical Site Infection Rates for Patients Undergoing Nonvaginal-Approach Hysterectomy at a Midwestern Teaching Hospital. AORN J 2023; 118:240-248. [PMID: 37750800 DOI: 10.1002/aorn.13999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 09/27/2023]
Abstract
Accrediting organizations, third-party payers, and patients review the surgical site infection (SSI) rates of health care organizations. Infection preventionists collaborate with perioperative personnel to decrease SSI rates; they also monitor and report SSI information to national organizations. The standard infection ratio is a comparison of the observed number of SSIs to the predicted number of SSIs based on national benchmark data. Leaders of a midwestern teaching hospital convened an interdisciplinary team (eg, surgeons, perioperative leaders, infection preventionists) to address a standard infection ratio after hysterectomies that was greater than 1.0. The team reviewed national guidelines and published articles on decreasing SSIs (including recommendations for vaginal preparation) before developing and implementing a hysterectomy-specific bundle for SSI prevention. The rate of SSIs decreased 68% after the implementation of the bundle. Perioperative personnel at this facility continue to use the bundle and infection preventionists monitor and report compliance with the bundle's elements.
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Morell A, Samborski A, Williams D, Anderson E, Kittel J, Thevenet-Morrison K, Wilbur M. Calculating surgical readmission rates in gynecologic oncology: The impact of patient factors. Gynecol Oncol 2023; 172:115-120. [PMID: 37027939 DOI: 10.1016/j.ygyno.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/13/2023] [Accepted: 03/21/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To determine the 30-day surgical readmission rate after major gynecologic oncology surgeries at a high-volume academic institution and correlated risk factors. METHODS Retrospective cohort study was conducted of surgical admissions from January 2016 - December 2019 at a single institution. Data were extracted from patient charts, including reason for readmission and length of stay. A readmission rate was calculated. Nested case control design was used to identify correlations between readmission and patient specific risk-factors. Multivariable logistic regression models were used to determine risk factors with readmission. RESULTS A total of 2152 patients were included. The readmission rate was 3.5%, most commonly due to GI disturbance and surgical site infection. Average readmission length was 5 days. Prior to adjusting for covariates, insurance status, primary diagnosis, index admission length, and disposition at discharge differed between patients who were and were not readmitted. After adjusting for co-variates, younger patients, index admission >2 days, and higher Charlson co-morbidity index were associated with readmission. CONCLUSIONS Our surgical readmission rate was lower than previously reported rates in gynecologic oncology patients. Patient factors associated with readmission included younger age, longer index hospital admission, and higher medical co-morbidity index scores. Provider factors and institutional practice patterns could contribute to the decreased readmission rate. These findings underscore the importance of standardizing how we calculate readmission rate and interpret these data. Varying readmission rates and institutional practice patterns deserve closer scrutiny to inform best practice and future policies.
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Affiliation(s)
- Alexandra Morell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States of America.
| | - Alexandra Samborski
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Devin Williams
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States of America
| | - Elizabeth Anderson
- Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, NY, United States of America
| | - Julie Kittel
- Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, NY, United States of America
| | - Kelly Thevenet-Morrison
- Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, NY, United States of America
| | - MaryAnn Wilbur
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, United States of America
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Sabet F, Ravan S, Shahraki AD. Prophylaxis Effect of Metronidazole Vaginal Gel in Decreasing the Risk of Surgical Site Infections after Elective Hysterectomy. J Res Pharm Pract 2023; 12:9-14. [PMID: 38213606 PMCID: PMC10779691 DOI: 10.4103/jrpp.jrpp_66_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 12/27/2022] [Indexed: 01/13/2024] Open
Abstract
Objective Infections are an important cause of morbidity and mortality after hysterectomy. Here, we aimed to investigate and evaluate the beneficial effects of metronidazole vaginal gel on the rate of surgical site infections in women undergoing elective abdominal hysterectomy. Methods This is a randomized prospective, double-blind controlled clinical trial performed in 2020 in Isfahan on 108 candidates for elective hysterectomy. At the beginning of the study, we completed a checklist of the patient's characteristics (patient age, body mass index [BMI], and history of medical conditions such as diabetes, hypertension, anemia, and immune deficiency) and the cause of hysterectomy. All patients were randomized into two groups. The first group received a lubricant vaginal gel single dosage, and the second group received a 0.75% metronidazole vaginal gel single dosage the night before surgery. Patients were visited up to 6 weeks after surgery, and the frequency of infection at the surgical site was determined. Findings The rates of infection were lower in patients who received metronidazole vaginal gel (5.8%) compared to the control group (11.6%) (P = 0.03). Patients with an estimated blood loss volume of more than 500 mL had higher rates of infection (13.46%) compared to patients with a bleeding volume of fewer than 500 mL (1.9%) (P = 0.001). We also found that patients with diabetes (13.5%) and patients with BMI more than 30 kg/m2(13.5%) had higher rates of infection compared to patients without diabetes (5.8%) and patients with BMI <30 kg/m2 (11.5%) (P = 0.001 for both). Patients with higher hospitalization duration had higher infection rates (P = 0.009). Conclusion Administration of a single dosage of metronidazole vaginal gel before abdominal hysterectomy may reduce surgical site infection and have clinical values.
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Affiliation(s)
- Fahimeh Sabet
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sara Ravan
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azar Danesh Shahraki
- Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran
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Factors associated with surgical-site infection after total laparoscopic hysterectomy. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Sood N, Lee RE, To JK, Cervellione KL, Smilios MD, Chun H, Ngai IM. Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle. Birth 2022; 49:141-146. [PMID: 34490654 DOI: 10.1111/birt.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Reduction in the incidence of surgical site infection (SSI) serves as a measure of patient safety and quality improvement. Cesarean birth (CB) accounts for 31.9% of all childbirths in the United States. However, our understanding of SSI prevention bundles predominantly stems from gynecological and colorectal surgeries. This study aimed to determine the efficacy of a standardized perioperative bundle designed to reduce SSI in CBs. METHODS All CB patients at Flushing Hospital Medical Center from 2017 to 2019 were included in a retrospective analysis. Patients were divided into three groups based on the timing of intervention: prebundle/control, transition, and postbundle. Baseline demographics and clinical characteristics were summarized using descriptive statistics. Multiple logistic regression was performed to determine the association between bundle group and SSI, considering variables different between groups at baseline (P < 0.10). RESULTS Two thousand eight hundred and seventy-five CBs were performed: 1086 in prebundle, 812 in transition, and 977 in postbundle phase. In the prebundle phase, 25 CBs (2.3%) were complicated by SSIs; in the transition phase, 10 (1.2%) had SSIs; and in the postbundle phase, 7 (0.7%; P = 0.009) had SSIs. In a logistic regression model, only use of the CB bundle (OR 0.26 [95% CI 0.07-0.94]; P = 0.04), rupture of membranes (0.29 [0.09-0.87]; P = 0.03), and operating room time (1.02 [1.01-1.04]; P = 0.01) were significant in prediction of SSI. SSI postbundle was significantly reduced from prebundle (0.04). CONCLUSIONS Thus, introduction of a hospital-wide perioperative bundle significantly reduced SSI rates, and should be developed as a mainstay of CB surgical care.
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Affiliation(s)
- Neha Sood
- Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | - Rachel E Lee
- Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | - Justin K To
- Minimally Invasive Gynecological Surgery, Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | | | | | - Hajoon Chun
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
| | - Ivan M Ngai
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY, USA
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Edmiston CE, Bond-Smith G, Spencer M, Chitnis AS, Holy CE, Po-Han Chen B, Leaper DJ. Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database. Surgery 2021; 171:1320-1330. [PMID: 34973811 DOI: 10.1016/j.surg.2021.11.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database. METHODS IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period. RESULTS Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy. CONCLUSIONS Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.
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Affiliation(s)
| | | | | | - Abhishek S Chitnis
- Medical Device Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | - Chantal E Holy
- Medical Device Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | | | - David J Leaper
- University of Newcastle and Emeritus Professor of Clinical Sciences, University of Huddersfield, UK
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Seaman SJ, Han E, Arora C, Kim JH. Surgical site infections in gynecology: the latest evidence for prevention and management. Curr Opin Obstet Gynecol 2021; 33:296-304. [PMID: 34148977 DOI: 10.1097/gco.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount. RECENT FINDINGS Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies. SUMMARY Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.
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Affiliation(s)
- Sierra J Seaman
- Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, USA
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Khalil S, Kossl K, Pasik S, Brodman M, Ascher-Walsh C. Quality metrics in minimally invasive gynecologic surgery. Curr Opin Obstet Gynecol 2021; 33:305-310. [PMID: 34016819 DOI: 10.1097/gco.0000000000000716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Quality improvement and patient safety are relevant to the advancement of clinical care, particularly in the field of minimally invasive gynecologic surgery (MIGS). Although safety and feasibility of MIGS have been established, identification of quality metrics in this field is also necessary. RECENT FINDINGS Surgical quality improvement has focused on national overarching measures to reduce mortality, surgical site infections (SSIs), and complications. Quality improvement in minimally invasive surgery has additionally led to advancements in postoperative patient recovery and long-term outcomes. Process measures in minimally invasive surgery include use of bundles and enhanced recovery after surgery (ERAS) programs. However, procedure-specific quality metrics for MIGS outcomes are poorly defined at this time. SUMMARY Quality metrics in minimally invasive gynecology are well defined for structural measures and select process measures. Creation of relevant benchmarks for outcome measures in minimally invasive gynecologic surgery are needed.
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Affiliation(s)
- Susan Khalil
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital New York
| | - Kelsey Kossl
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics, Gynecology, and Reproductive Science, Mount Sinai Hospital New York
| | | | - Michael Brodman
- Division of Minimally Invasive Gynecologic Surgery, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Mount Sinai Hospital, New York, New York
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Carty N, Leaper D, Perry L, Edmiston CE. Preliminary analysis of the antimicrobial activity of a novel surgical incise drape containing chlorhexidine gluconate against methicillin-resistant Staphylococcus aureus (MRSA) in an in vivo porcine, incisional-wound model. Am J Infect Control 2021; 49:857-861. [PMID: 33524452 DOI: 10.1016/j.ajic.2021.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgical site infections occur in at least 2%-4% of all patients. A proposed, risk-reduction strategy has been the use of adhesive, plastic incise drapes to reduce the risk of surgical site infection. The present investigation reports the efficacy of a novel chlorhexidine gluconate (CHG) adhesive surgical drape to reduce the risk of horizontal bacterial migration into surgical wounds, using a porcine model of wound contamination. METHODS Using a standardized inoculum, and a predetermined randomization schedule, a porcine model was used to assess the efficacy of a CHG-impregnated adhesive drape to prevent MRSA contamination of a simulated surgical wound and intact skin surface compared with an iodophor-impregnated incise drape and a nonantimicrobial incise drape in 0, 1, and 4-hour surgeries. RESULTS MRSA recovery from incisional wounds was lowest in sites treated with the CHG drape. The difference was statistically significant (P < .001) at all time points, both between the CHG drape and the nonantimicrobial control as well as between the CHG and iodophor drapes. Mean MRSA recovery from wounds treated with iodophor drapes was slightly lower than nonantimicrobial drapes. The difference was not statistically significant at 0- or 1-hour (P = .065 and P = .089, respectively), however the differences were significant at 4-hours (P = .024). DISCUSSION These preliminary results show that a novel CHG surgical incise drape reduced MRSA contamination of a surgical incision site and showed significant antimicrobial activity against contamination of intact skin surfaces compared with an iodophor- impregnated drape. CONCLUSIONS A novel CHG surgical drape was effective in significantly reducing MRSA contamination in an incisional wound model. Future studies are needed to assess its clinical efficacy.
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Kerezoudis P, Kelley PC, Watts CR, Heiderscheit CJ, Roskos MC. Using a Data-Driven Improvement Methodology to Decrease Surgical Site Infections in a Community Neurosurgery Practice: Optimizing Preoperative Screening and Perioperative Antibiotics. World Neurosurg 2021; 149:e989-e1000. [PMID: 33515799 DOI: 10.1016/j.wneu.2021.01.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We used a data-driven methodology to decrease the departmental surgical site infection rate to a goal of 1%. METHODS A prospective interventional study with historical controls comparing preimplementation/intervention (unknown methicillin-sensitive Staphylococcus aureus [MSSA]/methicillin-resistant Staphylococcus aureus [MRSA] status and standard weight and drug allergy-based preoperative antibiotics) with postimplementation/intervention (optimized preoperative chlorhexidine showers, MSSA/MRSA screening, MSSA/MRSA decolonization, and optimized preoperative antibiotic order set implementation). The American College of Surgeons National Surgical Quality Improvement Program was used for case surveillance. The primary outcome was the presence of a surgical site infection with a secondary outcome of cost(s) of implementation. RESULTS A total of 317 National Surgical Quality Improvement Program abstracted neurosurgical cases were analyzed, 163 cases before implementation and 154 cases after implementation. There were no significant differences between the preimplementation and postimplementation cohorts regarding patient demographics and baseline comorbidities, with the exceptions of inpatient and functional status (P < 0.001). The most common procedures were lumbar decompression (31%), lumbar discectomy (27%), and anterior cervical discectomy and fusion (10.4%). After implementation, 30 patients were MSSA positive (20%) and 4 MRSA positive (2.6%). Thirty patients received preoperative intranasal mupirocin decolonization (88%), and 4 patients received adjusted preoperative antibiotics (12%). After protocol implementation, the surgical site infection rate decreased from 6.7% (odds ratio, 2.82) to 0.96% (odds ratio, 0.91). The cost of implementation was $27,179, or $58 per patient. CONCLUSIONS The findings highlight the importance of systematically investigating areas of gap in existing clinical practice and quality improvement projects to increase patient safety and enhance the value of care delivered to neurosurgical patients.
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Affiliation(s)
| | - Parker C Kelley
- Department of Neurosurgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Charles R Watts
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurosurgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA.
| | - Chris J Heiderscheit
- Department of Clinical Quality Management, Mayo Clinic Health System, La Crosse, Wisconsin, USA
| | - Michael C Roskos
- Department of Surgery, Mayo Clinic Health System, La Crosse, Wisconsin, USA
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Intraoperative subcutaneous culture as a predictor of surgical site infection in open gynecological surgery. PLoS One 2021; 16:e0244551. [PMID: 33434238 PMCID: PMC7802959 DOI: 10.1371/journal.pone.0244551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/13/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose To analyze the relationship between intraoperative cultures and the development of surgical site infection (SSI) in women undergoing laparotomy for gynecological surgery. Methods Prospective observational cohort study. Over a six-year period, women who underwent elective laparotomy at our hospital were included. Patients’ demographics, underlying co-morbidities, surgical variables, type and etiology of postoperative surgical site infections were collected. Skin and subcutaneous samples were taken just prior to skin closure and processed for microbiological analysis. Univariate and multivariate analyses (logistic regression model) were conducted to explore the association of the studied variables with SSIs. Results 284 patients were included in our study, of which 20 (7%) developed surgical site infection, including 11 (55%) superficial and nine (45%) organ-space. At univariate analysis, length of surgery, colon resection, transfusion and positive intraoperative culture were associated with surgical site infection occurrence. Skin and subcutaneous cultures were positive in 25 (8.8%) and 20 (7%) patients, respectively. SSI occurred in 35% of women with positive subcutaneous culture and in 20% of those with positive skin cultures. Using multivariate analysis, the only independent factor associated with surgical site infection was a positive subcutaneous culture (OR 10.4; 95% CI 3.5–30.4; P<0.001). Conclusion Intraoperative subcutaneous cultures before skin closure may help early prediction of surgical site infection in open gynecological procedures.
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Surgical-Site Infection Prevention After Hysterectomy: Use of a Consensus Bundle to Guide Improvement. J Healthc Qual 2021; 42:188-194. [PMID: 31652167 DOI: 10.1097/jhq.0000000000000224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Hysterectomy is one of the most commonly performed surgeries in women. Surgical-site infections (SSI) after hysterectomy can lead to increased morbidity and mortality as well as readmission, which is associated with increased costs for health systems. The aim of the project was to improve standardization of preoperative education on infection prevention and incorporate the use of preoperative chlorhexidine (CHG) bathing for patients undergoing hysterectomy to decrease rates of SSI. Data on SSI after hysterectomy were reviewed. Tracer methodology was used to identify gaps in the preoperative process by comparing the current process to the Council on Patient Safety in Women's Health Care Patient Safety Bundle "Prevention of Surgical Site Infection after Gynecologic Surgery." After implementation, survey data were collected on adherence to the washing protocol, and SSI data were monitored. Survey results reflected high compliance with the CHG washing protocol, provision of patient education, and overall patient satisfaction with the process. Before implementation in 2016, we reported 8 deep or organ/space SSI to the National Healthcare Safety Network. After implementation in 2018, we reported 3 deep or organ/space SSI. Standardizing infection prevention processes to align with safety bundles improves the quality of care provided to patients.
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Reducing abdominal hysterectomy surgical site infections: A multidisciplinary quality initiative. Am J Infect Control 2020; 48:1292-1297. [PMID: 32389628 DOI: 10.1016/j.ajic.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND To investigate abdominal hysterectomy surgical site infection (SSI) rates before and after implementation of an SSI care bundle. METHODS An SSI bundle for abdominal hysterectomies was introduced in our hospital in April 2014 to reduce the SSI rate. The practices were divided into bundle elements around preoperative, intraoperative, and postoperative care. We conducted a retrospective cohort study around implementation of the SSI care bundle. Women were included if they underwent abdominal hysterectomy between 2012 and 2015. They were then divided into 2 study groups: prebundle and postbundle. The primary study outcome was SSI rate. The superficial SSI rate was the secondary outcome. RESULTS The overall SSI rate was 6.18% in the prebundle group, with a median monthly SSI rate of 7.03%. After bundle implementation, the overall SSI rate declined to 2.51% (P = .02). The reduction remained significant after multivariate analysis (adjusted odds ratio 0.38; 95% confidence interval 0.15-0.88; P = .03) indicating a 62% reduction in SSI postbundle as compared to prebundle.When comparing rates based on infection classification, superficial SSIs declined significantly from 3.73% in the prebundle group to 0.90% in the postbundle group (P = 0.02). Patient demographics and pre-existing medical conditions were similar pre- and postbundle. Compliance with bundle elements was high. CONCLUSIONS A significant reduction in SSI rate in abdominal hysterectomies was seen following implementation of an infection prevention bundle.
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Brown O, Geynisman-Tan J, Gillingham A, Collins S, Lewicky-Gaupp C, Kenton K, Mueller M. Minimizing Risks in Minimally Invasive Surgery: Rates of Surgical Site Infection Across Subtypes of Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2020; 27:1370-1376.e1. [DOI: 10.1016/j.jmig.2019.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
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19
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Stone R, Carey E, Fader AN, Fitzgerald J, Hammons L, Nensi A, Park AJ, Ricci S, Rosenfield R, Scheib S, Weston E. Enhanced Recovery and Surgical Optimization Protocol for Minimally Invasive Gynecologic Surgery: An AAGL White Paper. J Minim Invasive Gynecol 2020; 28:179-203. [PMID: 32827721 DOI: 10.1016/j.jmig.2020.08.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023]
Abstract
This is the first Enhanced Recovery After Surgery (ERAS) guideline dedicated to standardizing and optimizing perioperative care for women undergoing minimally invasive gynecologic surgery. The guideline was rigorously formulated by an American Association of Gynecologic Laparoscopists Task Force of US and Canadian gynecologic surgeons with special interest and experience in adapting ERAS practices for patients requiring minimally invasive gynecologic surgery. It builds on the 2016 ERAS Society recommendations for perioperative care in gynecologic/oncologic surgery by serving as a more comprehensive reference for minimally invasive endoscopic and vaginal surgery for both benign and malignant gynecologic conditions. For example, the section on preoperative optimization provides more specific recommendations derived from the ambulatory surgery and anesthesia literature for the management of anemia, hyperglycemia, and obstructive sleep apnea. Recommendations pertaining to multimodal analgesia account for the recent Food and Drug Administration warnings about respiratory depression from gabapentinoids. The guideline focuses on workflows important to high-value care in minimally invasive surgery, such as same-day discharge, and tackles controversial issues in minimally invasive surgery, such as thromboprophylaxis. In these ways, the guideline supports the American Association of Gynecologic Laparoscopists and our collective mission to elevate the quality and safety of healthcare for women through excellence in clinical practice.
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Affiliation(s)
- Rebecca Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs. Stone, Fader, and Weston).
| | - Erin Carey
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina (Dr. Carey)
| | - Amanda N Fader
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs. Stone, Fader, and Weston)
| | - Jocelyn Fitzgerald
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr. Fitzgerald)
| | - Lee Hammons
- Allegheny Women's Health, Pittsburgh, Pennsylvania (Dr. Hammons)
| | - Alysha Nensi
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada (Dr. Nensi)
| | - Amy J Park
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio (Drs. Park and Ricci)
| | - Stephanie Ricci
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio (Drs. Park and Ricci)
| | | | - Stacey Scheib
- Department of Obstetrics and Gynecology, Tulane University, New Orleans, Louisiana (Dr. Scheib)
| | - Erica Weston
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland (Drs. Stone, Fader, and Weston)
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20
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Kuznicki M, Mallen A, McClung EC, Robertson SE, Todd S, Boulware D, Martin S, Quilitz R, Vargas RJ, Apte SM. Dual antibiotic prevention bundle is associated with decreased surgical site infections. Int J Gynecol Cancer 2020; 30:1411-1417. [PMID: 32727930 DOI: 10.1136/ijgc-2020-001515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain. STUDY DESIGN A retrospective cohort study was performed to compare surgical site infection rates for patients undergoing hysterectomy over a 1-year period surrounding the implementation of an institutional infection prevention bundle. The bundle comprised pre-operative, intra-operative, and post-operative interventions including a dual-agent antibiotic surgical prophylaxis with cefazolin and metronidazole. Cohorts consisted of patients undergoing surgery during the 6 months prior to this intervention (pre-bundle) versus those undergoing surgery during the 6 months following the intervention (post-bundle). Secondary outcomes included length of stay, readmission rates, compliance measures, and infection microbiology. Data were compared with pre-specified one-sided exact test, Chi-square test, Fisher's exact test, or Kruskal-Wallis test as appropriate. RESULTS A total of 358 patients were included (178 PRE, 180 POST). Median age was 58 (range 23-90) years. The post-bundle cohort had a 58% reduction in surgical site infection rate, 3.3% POST vs 7.9% PRE (-4.5%, 95% CI -9.3% to -0.2%, p=0.049) as well as reductions in organ space infection, 0.6% POST vs 4.5% PRE (-3.9%, 95% CI -7.2% to -0.7%, p=0.019), and readmission rates, 2.2% POST vs 6.7% PRE (-4.5%, 95% CI -8.7% to -0.2%, p=0.04). Gram-positive, Gram-negative, and anaerobic bacteria were all prevalent in surgical site infection cultures. There were no monomicrobial infections in post-cohort cultures (0% POST vs 58% PRE, p=0.04). No infections contained methicillin-resistant Staphylococcus aureus. CONCLUSION Implementation of a dual antibiotic infection prevention bundle was associated with a 58% reduction in surgical site infection rate after hysterectomy in a surgically diverse gynecologic oncology practice.
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Affiliation(s)
- Michelle Kuznicki
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Adrianne Mallen
- Gynecologic Oncology, University of South Florida, Tampa, Florida, USA.,Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Emily Clair McClung
- Gynecologic Oncology, University of Arizona Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Sharon E Robertson
- Gynecologic Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Gynecologic Oncology, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana, USA
| | - Sarah Todd
- Gynecologic Oncology, University of Louisville, Louisville, Kentucky, USA
| | - David Boulware
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Stacy Martin
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Rod Quilitz
- Pharmacy, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, United States
| | - Roberto J Vargas
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sachin M Apte
- Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
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Mehtar S, Wanyoro A, Ogunsola F, Ameh EA, Nthumba P, Kilpatrick C, Revathi G, Antoniadou A, Giamarelou H, Apisarnthanarak A, Ramatowski JW, Rosenthal VD, Storr J, Osman TS, Solomkin JS. Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases. Int J Infect Dis 2020; 100:123-131. [PMID: 32712427 PMCID: PMC7378004 DOI: 10.1016/j.ijid.2020.07.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/19/2020] [Indexed: 12/26/2022] Open
Abstract
Surgical site infection (SSI) rates in low- and middle-income countries (LMICs) range from 8 to 30% of procedures, making them the most frequent healthcare-acquired infection (HAI) with substantial morbidity, mortality, and economic impacts. Presented here is an approach to surgical site infection prevention based on surveillance and focused on five critical areas identified by international experts. These five areas include 1. Collecting valid, high-quality data; 2. Linking HAIs to economic incapacity, underscoring the need to prioritize infection prevention activities; 3. Implementing SSI surveillance within infection prevention and control (IPC) programs to enact structural changes, develop procedural skills, and alter healthcare worker behaviors; 4. Prioritizing IPC training for healthcare workers in LMICs to conduct broad-based surveillance and to develop and implement locally applicable IPC programs; and 5. Developing a highly accurate and objective international system for defining SSIs, which can be translated globally in a straightforward manner. Finally, we present a clear, unambiguous framework for successful SSI guideline implementation that supports developing sustainable IPC programs in LMICs. This entails 1. Identifying index operations for targeted surveillance; 2. Identifying IPC “champions” and empowering healthcare workers; 3. Using multimodal improvement measures; 4. Positioning hand hygiene programs as the basis for IPC initiatives; 5. Use of telecommunication devices for surveillance and healthcare outcome follow-ups. Additionally, special considerations for pediatric SSIs, antimicrobial resistance development, and antibiotic stewardship programs are addressed.
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Affiliation(s)
- Shaheen Mehtar
- Infection Control Africa Network, Cape Town, South Africa
| | - Anthony Wanyoro
- Department of Obstetrics and Gynecology, Kenyatta University, Nairobi, Kenya
| | - Folasade Ogunsola
- Infection Control African Network, College of Medicine, University of Lagos, Nigeria
| | - Emmanuel A Ameh
- Division of Paediatric Surgery National Hospital, Abuja, Nigeria
| | - Peter Nthumba
- Clinical Epidemiologist and Plastic Surgeon, AIC Kijabe Hospital, and GCB, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland.
| | | | - Gunturu Revathi
- Microbiology Laboratory, Aga Khan University Hospital, Nairobi, Kenya
| | | | | | | | - John W Ramatowski
- International Federation for Infectious Diseases, Boston, United States
| | | | - Julie Storr
- Consultant with S2 Incorporated, Geneva, Switzerland
| | - Tamer Saied Osman
- Global Disease Detection, US Naval Medical Research Unit 3, Cairo, Egypt
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22
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Guo XM, Runge M, Miller D, Aaby D, Milad M. A bundled intervention lowers surgical site infection in hysterectomy for benign and malignant indications. Int J Gynaecol Obstet 2020; 150:392-397. [DOI: 10.1002/ijgo.13257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/22/2020] [Accepted: 06/01/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Xiaoyue Mona Guo
- Department of Obstetrics and Gynecology Northwestern University Feinberg School of Medicine Chicago IL USA
| | - Megan Runge
- Department of Obstetrics and Gynecology Northwestern University Feinberg School of Medicine Chicago IL USA
| | - Deborah Miller
- Department of Obstetrics and Gynecology Northwestern University Feinberg School of Medicine Chicago IL USA
| | - David Aaby
- Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL USA
| | - Magdy Milad
- Department of Obstetrics and Gynecology Northwestern University Feinberg School of Medicine Chicago IL USA
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23
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Rastogi S, Glaser L, Friedman J, Carter IV, Milad MP. Tolerance of Chlorhexidine Gluconate Vaginal Cleansing Solution: A Randomized Controlled Trial. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Supriya Rastogi
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Laura Glaser
- Department of Obstetrics and Gynecology, Northwestern Prentice Women's Hospital, Chicago, IL
| | - Jaclyn Friedman
- Department of Obstetrics and Gynecology, Northwestern Prentice Women's Hospital, Chicago, IL
| | - Isabelle V. Carter
- Department of Obstetrics and Gynecology, Northwestern Prentice Women's Hospital, Chicago, IL
| | - Magdy P. Milad
- Department of Obstetrics and Gynecology, Northwestern Prentice Women's Hospital, Chicago, IL
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24
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Surgical site infection in gynecology. GINECOLOGIA.RO 2020. [DOI: 10.26416/gine.30.4.2020.3944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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25
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Murji A, Lam M, Allen B, Richard L, Shariff SZ, Austin PC, Callum J, Lipscombe L. Risks of preoperative anemia in women undergoing elective hysterectomy and myomectomy. Am J Obstet Gynecol 2019; 221:629.e1-629.e18. [PMID: 31310749 DOI: 10.1016/j.ajog.2019.07.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications. OBJECTIVE The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality. STUDY DESIGN In this retrospective, population-based cohort study, we followed up adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) between the years 2013 and 2015 for benign indications in Ontario, Canada. We used linked administrative data from a government-administered, single-payer provincial health care system using Canadian Classification of Health Interventions intervention codes, International Classification of Diseases, 10th revision, diagnostic codes, physician billing codes, and laboratory data from both community and hospital laboratories across the province. Our exposure of interest was preoperative anemia, defined as a hemoglobin value <12 g/dL on the complete blood count measured closest to the date of surgery. Our primary outcome was the composite of 30 day postoperative morbidity and mortality. Secondary outcomes were 5 individual components of the primary outcome: death, transfusion, surgical site infection, venothromboembolism, and return to the hospital within 30 days. To adjust for confounding, we generated a propensity score using a multiple logistic regression model in which the presence of anemia was regressed on all baseline characteristics. We matched anemic to nonanemic patients on the logit of the propensity score. Using an unadjusted log-binomial model estimated using generalized estimating equations to account for the matched pairs, we calculated the relative risk, 95% confidence intervals, and P values to evaluate the effect of anemia on outcomes. RESULTS Of the 16,218 women in the cohort, 3664 (22.6%) had anemia. After propensity matching, standardized differences in all baseline characteristics (n = 3261 per group) were <0.10. In the matched cohort, the primary outcome (death, complications, or readmission) occurred in 41.2% of anemic patients and 36.2% of nonanemic patients (relative risk, 1.14, 95% confidence interval, 1.07-1.21, P < .0001; absolute risk reduction, 5.03%, 95% confidence interval, 2.70-7.36; (number needed to harm = 20). The risk of transfusion was significantly higher in anemic patients (relative risk, 3.25, 95% confidence interval, 2.67-3.95, P < .0001; absolute risk reduction, 8.34%, 95% confidence interval, 7.06-9.63; number needed to harm = 12). There was no difference in other secondary outcomes. In a subgroup analysis (women >55 years vs ≤55, n = 736), older women were at increased risk of the primary outcome (relative risk, 1.40, 95% confidence interval, 1.12-1.76, P = .004), transfusion (relative risk, 4.20, 95% confidence interval, 1.65-10.72, P = .003), surgical site infection (relative risk, 1.35, 95% confidence interval, 1.01-1.81, P = .04), and return to the hospital (relative risk, 2.36, 95% confidence interval, 1.54-3.62, P < .0001). CONCLUSION Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.
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Affiliation(s)
- Ally Murji
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | | | | | | | | | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada; ICES Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Lorraine Lipscombe
- Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada; ICES Toronto, Toronto, Ontario, Canada; Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
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26
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Croke L. Preventing surgical site infections after gynecologic procedures. AORN J 2019; 110:P8-P10. [PMID: 31355428 DOI: 10.1002/aorn.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
Application of antiseptic products to the skin plays an important role in prevention of a variety of health care-associated infections. Preoperative bathing or showering is widely recommended to reduce the risk of surgical site infections. Evidence of the impact of this measure on surgical site infection rates is mixed, and further prospective trials comparing standardized protocols for showering with plain soap or chlorhexidine gluconate (CHG)-containing soap, or bathing with 2% CHG-impregnated cloths are needed to establish the most effective approach. Current evidence favors the use of alcohol-containing solutions, often containing CHG or povidone-iodine, for surgical site preparation of the skin. Preparation of vaginal mucosa prior to gynecologic surgery may be performed using either povidone-iodine or CHG. Surgical hand antisepsis can be performed by scrubbing with an antimicrobial soap or by handrubbing using an alcohol-based handrub. Addition of CHG to alcohol-based handrubs intended for surgical hand antisepsis is not necessary if they meet recommended efficacy criteria. Daily CHG bathing of intensive care unit patients has been shown to reduce a variety of health care-associated infections, most commonly bloodstream infections (BSIs). Achieving and maintaining optimum application protocols may be challenging, suggesting the need for ongoing staff education, monitoring, and feedback. Additional studies are needed to determine the impact of daily CHG bathing of non-intensive care unit patients. Alcoholic CHG is currently the preferred antiseptic for skin preparation prior to insertion of central and arterial intravascular catheters. CHG-impregnated dressings have been shown to reduce catheter-associated BSI. Because of the widespread use of antiseptics, especially CHG, surveillance for emergence of increased tolerance or resistance is warranted. Antiseptics are applied to the skin for a variety of purposes in health care. Common scenarios in which topical antiseptics are used include preoperative bathing, surgical site preparation, surgical hand hygiene, daily bathing of intensive care unit patients, and prevention of intravascular catheter-associated BSI. The purpose of this article is to review recent evidence regarding the best products for skin antisepsis.
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Safety Bundles in Gynecology. Clin Obstet Gynecol 2019; 62:621-626. [PMID: 31145114 DOI: 10.1097/grf.0000000000000463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient safety bundles and checklists have been shown to improve outcomes in medicine, surgery, and obstetrics. Until recently, there has been less study into their use in the gynecology setting. Here, we review the available evidence and examples of successful checklist and bundle implementation in gynecology and encourage more robust implementation and standardization in our field going forward.
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Decreased Surgical Site Infection Rate in Hysterectomy: Effect of a Gynecology-Specific Bundle. Obstet Gynecol 2018; 132:1064-1065. [PMID: 30247344 DOI: 10.1097/aog.0000000000002893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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In Reply. Obstet Gynecol 2018; 132:1065. [PMID: 30247345 DOI: 10.1097/aog.0000000000002894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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