Progress in the prevention of surgical site infection:

Primary versus delayed primary skin closure in operated patients due to perforated peptic ulcer disease: a randomized controlled clinical trial

PURPOSE

Perforated peptic ulcer (PPU) is a life-threatening complication of peptic ulcer disease. This condition is characterized by a dirty abdomen that predisposes to postoperative wound infection. Delayed primary skin closure is occasionally preferred over primary closure to reduce the risk of surgical site infection in dirty abdominal wounds. In primary skin closure, the skin is sutured immediately after surgery. Meanwhile, in delayed primary skin closure, the incision is left open, and sutured after 2-5 days. The current research aimed to compare the risk for surgical site infection, length of hospitalization, and mortality rate between primary versus delayed primary skin closure among patients who underwent surgery for PPU.

METHODS

This single-blind randomized clinical trial included 120 patients who were randomly allocated into the primary and delayed primary closure groups. A research assistant who was blinded to the study examined the wounds for surgical site infection based on the 1992 Center for Disease Control criteria. The outcomes were mortality rate and duration of hospitalization.

RESULTS

The delayed primary and primary closure groups did not significantly differ in terms of postsurgical wound infection occurring on the 3rd, 7th, 14th, and 30th days after surgery, mortality rate, and duration of hospitalization.

CONCLUSION

In patients who underwent surgery for PPU, delayed primary closure is not recommended over primary closure due to the risk of postoperative surgical site infection.

Incidence and risk factors of neurosurgical site infections: results of a prospective multicenter cohort study on 6359 surgeries

BACKGROUND

Neurosurgical surgical site infections (SSI) are life-threatening complications, requiring medical treatment and additional surgeries and remain a substantial cause of morbidity. In order to identify the incidence and the main risk factors for SSI, we developed the Prophylaxis with Antibiotic Protocol for Neurosurgical Site Infections Study (PASSIS), a prospective observational multicenter cohort study for examining a large number of neurosurgical procedures.

METHODS

The study PASSIS involved four Italian departments of neurosurgery applying the same antibiotic prophylaxis (ABP) protocol on 6359 consecutive neurosurgical procedures. In high-risk conditions (intra-operative contamination and/or postoperative cerebro-spinal fluid [CSF], and/or subcutaneous drainage and/or postoperative hyperpyrexia) and in presence of wound complication (CSF leak and/or CSF collection and/or wound diastasis), a prolongation protocol was prescribed.

RESULTS

The crude rate of SSI in the whole series was and 1.7% for patient and 1.5% for procedure. Patient related SSI risk factors: Younger patients (≤14 years) had a significantly higher SSI risk compared with older patients (RR: 2.17; 95% CI: 1.13-4.14). Patients underwent two surgeries were at increased SSI risk (RR: 3.80; 95% CI: 2.33-6.18), and the risk increased with the number of surgeries. Surgeries lasting longer than 3 hours (RR: 2.27; 95% CI: 1.15-4.50), undergoing two or more surgeries and the presence of prosthetic implants (RR: 2.40; 95% CI: 1.53-3.77) were procedure related SSI risk factors positively associated with SSI. In high-risk conditions and in wound complication as defined previously, ABP prolongation showed limited efficacy (RR:1.97; 95% CI: 1.21-3.22 and 9.31; 95% CI: 5.90-14.68 respectively).

CONCLUSIONS

The subjects submitted to complicated, repeated, long lasting craniotomies, especially if experiencing postoperative deterioration, display the higher risk of SSIs, as a final life-threatening complication. In order to reduce the SSI rate, further studies should address to design tailored prophylaxis protocols for each high risk situation as hereby defined; the wound complications deserve an increased microbiological surveillance, focusing the attention on the timing and source of infections.

Bacterial adhesion to suture material in a contaminated wound model: Comparison of monofilament, braided, and barbed sutures

Contaminated suture material plays an important role in the physiopathology of surgical site infections. Recently, suture material has been developed characterized by barbs projecting from a monofilament base. Claimed advantages for barbed sutures are a shortened wound closure time and reduced maximum wound tension. It has also been suggested that these sutures would be advantageous microbiologically. The aim of this study was to test the microbiological characteristics of the barbed Quill in comparison to the monofilament Ethilon II and the braided sutures Vicryl and triclosan-coated Vicryl Plus. In our study, sutures were cultivated on color-change agar with Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecium, Escherichia coli, and Pseudomonas aeruginosa and the halo size was measured. In a second study arm with longer cultivation bacterial growth was followed by antibiotic treatment. Ethilon II and Quill showed good comparable results, whereas large halos were found around Vicryl. Vicryl Plus results depended on triclosan sensitivity. After longer bacterial cultivation and antibiotic treatment, halos were up to 3.6 times smaller on Quill than on Vicryl (p < 0.001), but 1.4 times larger than on Ethilon II (p < 0.001) regarding S. aureus. Confocal microscopy analysis showed bacterial colonization between the braided filaments on Vicryl and beneath the barbs on Quill. From a microbiological perspective, barbed sutures can be recommended in aseptic surgery, but should only be used carefully in septic surgery. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:925-933, 2017.

Intraoperative Fluid Restriction in Pancreatic Surgery: A Double Blinded Randomised Controlled Trial

Background

Perioperative fluid restriction in a variety of operations has shown improvement of: complications, recovery of gastrointestinal function and length of stay (LOS). We investigated effects of crystalloid fluid restriction in pancreatic surgery. Our hypothesis: enhanced recovery of gastrointestinal function.

Methods

In this double-blinded randomized trial, patients scheduled to undergo pancreatoduodenectomy (PD) were randomized: standard (S:10ml/kg/hr) or restricted (R:5ml/kg/hr) fluid protocols. Primary endpoint: gastric emptying scintigraphically assessed on postoperative day 7.

Results

In 66 randomized patients, complications and 6-year survival were analyzed. 54 patients were analyzed in intention to treat: 24 S-group and 30 R-group. 32 patients actually underwent a PD and 16 patients had a palliative gastrojejunostomy bypass operation in the full protocol analysis. The median gastric emptying time (T½) was 104 minutes (S-group, 95% confidence interval: 74–369) versus 159 minutes (R-group, 95% confidence interval: 61–204) (P = 0.893, NS). Delayed gastric emptying occurred in 10 patients in the S-group and in 13 patients in the R-group (45% and 50%, P = 0.779, NS). The primary outcome parameter, gastric emptying time, did not show a statistically significant difference between groups.

Conclusion

A fluid regimen of 10ml/kg/hr or 5ml/kg/hr during pancreatic surgery did not lead to statistically significant differences in gastric emptying. A larger study would be needed to draw definite conclusions about fluid restriction in pancreatic surgery.

Trial registration

ISRCTN62621488

Antibacterial effects on dry-fast and traditional water-based surgical scrubbing methods: a two-time points experimental study

This study determined the in-use effects of dry-fast and traditional hand-washing surgical scrubs among operating room staff members. This is a static group comparison study with purposive sampling. A total of 156 staff members were recruited in an operating room in a medical center located in southern Taiwan. The participants were divided into traditional and dry-fast hand-washing groups. Microbial counts were measured right after the two groups finished surgical scrubbing and at the completion of surgery. The results showed that the use of dry-fast antisepsis has a better persistent effect (P = 0.001), more nurses chose dry-fast antisepsis than surgeons (P = 0.012), and the post-operation number of colonies for nurses was significantly higher than that for surgeons (P = 0.003). Operating room nurses are long-term and frequent users of antibacterial agents, and their requirement of skin protection is higher. The dry-fast technique has the advantage of being less irritating to the skin and less time consuming; therefore, brush-free and dry-fast antisepsis is recommended.

Impact of a surgical site infection (SSI) surveillance program in orthopedics and traumatology

Surveillance of surgical site infections (SSI) is a priority. One of the fundamental principles for the surveillance of SSI is based on receiving effective field feedback (retro-information). The aim of this study was to report the results of a program of SSI surveillance and validate the hypothesis that there is a correlation between creating a SSI surveillance program and a reduction in SSI.

MATERIALS AND METHODS

The protocol was based on the weekly collection of surveillance data obtained directly from the different information systems in different departments. A delay of 3 months was established before extraction and analysis of data and information from the surgical teams. The NNIS index (National Nosocomial Infections Surveillance System) developed by the American surveillance system and the reduction of length of hospital stay index Journées d'hospitalisation évitées (JHE).

RESULTS

Since the end of 2009, 7156 surgical procedures were evaluated (rate of inclusion 97.3%), and 84 SSI were registered with a significant decrease over time from 1.86% to 0.66%. A total of 418 days of hospitalization have been saved since the beginning of the surveillance system.

DISCUSSION

Our surveillance system has three strong points: follow-up is continuous, specifically adapted to orthopedic traumatology and nearly exhaustive. The extraction of data directly from hospital information systems effectively improves the collection of data on surgical procedures. The implementation of a SSI surveillance protocol reduces SSI.

LEVEL OF EVIDENCE

Level III. Prospective study.

Bacterial colonization of the skin following aseptic preoperative preparation and impact of the use of plastic adhesive drapes

Surgical site contamination, for example, with coagulase-negative staphylococci, probably derives from both the patient's own skin flora and those of the surgical team. Despite preoperative antiseptic preparation with chlorhexidine solution, complete sterilization of the skin is not possible and gradual recolonization will occur. Plastic adhesive drape is an established method used to prevent direct wound contamination from adjacent skin. In this study, the time to skin recolonization after antiseptic preparation was measured and the impact of using plastic adhesive drape on this recolonization was evaluated. Repeated bacterial sampling using three different methods over 6 hr was conducted after antiseptic preparation in 10 volunteers. Recolonization of skin was observed after 30 min with plastic drape and after 60 min without plastic drape; there were significantly more positive cultures with the plastic drape than without (31% vs. 7.5%, respectively, p < .001). Sampling with a rayon swab was the most sensitive sampling method. In conclusion, covering the skin with a plastic adhesive drape seems to hasten recolonization of the skin after antiseptic preparation. However, clinical trials to confirm this finding are warranted.

Postoperative sepsis

PURPOSE OF REVIEW

Postoperative sepsis is a major cause of surgical associated morbidity and mortality. Our goal is to describe its incidence, pathophysiology, and contributing factors. In addition, we will review preventive measures and treatment options that may possibly reduce its healthcare burden.

RECENT FINDINGS

We review epidemiologic data and clinical tools presented in multiple current studies, which may help lower incidence and improve outcome of postoperative sepsis.

SUMMARY

The incidence of postoperative sepsis has not declined over the past years, although mortality is trending downwards. Several biochemical and genetic markers may allow early diagnosis. Prevention and prompt treatment may lower mortality.

Factors associated with the prevalence of antibiotic use for the treatment of hospital-acquired infections at 393 French hospitals: a regional variation analysis

OBJECTIVE

The present study investigated regional variations in antibiotic use for the treatment of hospital-acquired infections (HAIs) in France by means of a multilevel analysis, to identify targets for quality improvement.

METHODS

Data were obtained from the 2001 and 2006 French national point-prevalence surveys of HAIs and antibiotic use. The present study was conducted using data from 393 nonteaching public hospitals. Data included patient characteristics calculated at the hospital level (mean age and proportion of patients with the following: HAI, presence of a vascular catheter, presence of a urinary catheter, surgical procedure, and immunodeficiency) and hospital characteristics (size and presence of an intensive care unit). The regional effect was measured using a random intercept on a regional variable.

RESULTS

Overall, the prevalence of antibiotic use was 5.35% for both study years. The most commonly used antibiotics for HAIs were fluoroquinolones (2001, 1.33%; 2006, 1.35%) and combinations of penicillins with a β-lactamase inhibitor (2001, 0.92%; 2006, 1.02%). Mapping of antibiotic use showed wide variation between regions. The regional effect explained 3% of antibiotic variation in the unadjusted analysis. In the multivariable analysis, hospital size, high prevalence of patients with immunodeficiency, and infection characteristics explained 45% of the variability in antibiotic use. The regional effect was not retained in the final model.

CONCLUSION

The pattern of antibiotic use for HAIs differed over time, and regional variations were mostly explained by patient characteristics; there was no regional effect. Models that take data hierarchy into account are essential to better approach antibiotic use and develop relevant strategies for improvement.

Bacterial contamination of surgical suture resembles a biofilm

BACKGROUND

Although much attention is currently directed to studying microbial biofilms on a variety of surfaces, few studies are designed to study bacterial growth on surgical suture. The purpose of this study was to compare the kinetic development of Staphylococcus aureus and Enterococcus faecalis on five surgical suture materials and to clarify factors that might influence this growth.

METHODS

Pure cultures of S. aureus and E. faecalis were incubated with five types of suture for four days using either tissue culture medium or a bacterial growth medium. Suture-associated bacteria were quantified daily. In selected experiments, the bacterial growth medium was supplemented with heparin, a substance known to promote S. aureus biofilm formation. The ultrastructure of S. aureus biofilm developing on braided suture was studied with scanning electron microscopy.

RESULTS

Staphylococcus aureus and E. faecalis were recovered in greater numbers (typically p < 0.01) from braided than from monofilament suture, and the numbers of bacteria were greater (often p < 0.01) on sutures incubated in bacterial growth medium rather than tissue culture medium. Addition of heparin 1,000 U/mL to silk or braided polyglactin 910 suture incubated three days with S. aureus resulted in greater numbers of bacteria on day one but not on subsequent days. Scanning electron microscopy showed a maturing S. aureus biofilm that developed from small clusters of cells among amorphous material and fibrillar elements to larger clusters of cells that appeared covered by more consolidated extracellular material.

CONCLUSIONS

Bacterial growth was favored on braided vs. monofilament suture, and heparin enhanced bacterial adherence after day one, but not at subsequent times. Staphylococcus aureus adhered to suture material and formed a structure consistent with a bacterial biofilm.

Preventing surgical site infections

The risk of surgical site infection (SSI) is approximately 1-3% for elective clean surgery. Apart from patient endogenous factors, the role of external risk factors in the pathogenesis of SSI is well recognized. However, among the many measures to prevent SSI, only some are based on strong evidence, for example, adequate perioperative administration of prophylactic antibiotics, and there is insufficient evidence to show whether one method is superior to any other. This highlights the need for a multimodal approach involving active post-discharge surveillance, as well as measures at every step of the care process, ranging from the operating theater to postoperative care. Multicenter or supranational intervention programs based on evidence-based guidelines, 'bundles' or safety checklists are likely to be beneficial on a global scale. Although theoretically reducible to zero, the maximal realistic extent by which SSI can be decreased remains unknown.