Antibiotic Choice Is Independently Associated With Risk of Surgical Site Infection After Colectomy: A Population-Based Cohort Study

Association of preoperative thyroid hormone replacement with perioperative complications after major abdominal surgery

OBJECTIVE

To determine the association between preoperative thyroid hormone replacement and complications following major abdominal surgery.

METHODS

A retrospective case series was performed of patients enrolled in the Michigan Surgical Quality Collaborative (MSQC) who underwent major abdominal surgery at an academic institution over a 10-year period. The principal explanatory variable was preoperative thyroid hormone replacement. Primary outcomes were morbidity, mortality and length of stay.

RESULTS

2700 patients were identified. On multivariate analysis correcting for established predictors of operative morbidity, patients on preoperative thyroid replacement had a 1.5- fold increased risk of serious morbidity(p ​= ​0.01), and a 1.7- fold greater risk for serious sepsis(p ​= ​0.04). Thyroid replacement was associated with longer length of stay(p ​< ​0.001). While there was a high degree of missing data for surgical approach (31.1 ​% missing data), results suggest that patients on thyroid hormone replacement were more likely to undergo an open rather than minimally invasive surgery(p ​< ​0.01). Open surgery was associated with greater risk of serious morbidity(p ​= ​0.003) and longer length of stay(p ​< ​0.001).

CONCLUSIONS

Preoperative thyroid hormone replacement independently predicts operative morbidity and length of stay following major abdominal surgery.

Positive margin rates for colorectal cancer vary significantly by hospital in Michigan: Can we achieve a 0 % positive margin rate?

Background

High quality surgical care for colorectal cancer (CRC) includes obtaining a negative surgical margin. The Michigan Surgical Quality Collaborative (MSQC) is a statewide consortium of hospitals dedicated to quality improvement; a subset of MSQC hospitals abstract quality of care measures for CRC surgery, including positive margin rate. The purpose of this study was to determine whether positive margin rates vary significantly by hospital, and whether positive margin rates should be a target for quality improvement.

Methods

We performed a retrospective cohort study of patients who underwent CRC resection from 2016 to 2020. The primary outcome was the presence of a positive margin. Univariate and multivariable analyses were performed to test the association of positive margins with patient, hospital, and tumor characteristics.

Results

The cohort consisted of 4211 patients from 42 hospitals (85 % colon cancer and 15 % rectal cancer). The crude positive margin rate was 6.15 % (95 % CI 4.6-7.4 %); this ranged from 0 % to 22 % at individual hospitals. In multivariable analysis, factors independently associated with positive margins included male sex, underweight BMI, metastatic cancer, rectal cancer (vs. colon), T4 T-stage, N1c/N2 N-stage, and open surgical approach. After adjusting for these factors, there remained significant variation by hospital, with 8 hospitals being statistically-significant outliers.

Conclusions

Positive margins rates for CRC vary by hospital in Michigan, even after rigorous adjustment for case-mix. Furthermore, several hospitals achieved near-zero positive margin rates, suggesting opportunities for quality improvement through the identification of best practices among CRC surgery centers.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.

Reduction of Surgical Site Infection After Trauma Laparotomy Through Use of a Specific Protocol for Antibiotic Prophylaxis

Background: Emergency laparotomy for abdominal trauma is associated with high rates of surgical site infection (SSI). A protocol for antimicrobial prophylaxis (AMP) for trauma laparotomy was implemented to determine whether SSI could be reduced by adhering to established principles of AMP. Patients and Methods: A protocol utilizing ertapenem administered immediately before initiation of trauma laparotomy was adopted. Compliance with measures of adequate AMP were determined before and after protocol implementation, as were rates of SSI and other infections related to abdominal trauma. Univariable and multivariable analyses were performed to determine risk factors for development of infection related to trauma laparotomy. Results: Over a four-year period, 320 patient operations were reviewed. Ertapenem use for prophylaxis increased to 54% in the post-intervention cohort. Compliance with individual measures of appropriate AMP improved modestly. Overall, infections related to trauma laparotomy decreased by 46% (absolute decrease of 13%) in the post-intervention cohort. Multivariable analysis confirmed that treatment during the post-intervention phase was associated with this decrease, with a separate analysis suggesting that ertapenem use was an important factor in this decrease. Conclusions: Development of a standardized protocol for AMP in trauma laparotomy led to decreases in infectious complications after that procedure.

Is the Implementation of an Interprofessional Communication Smart Phone Application Associated With Improved Survival Among Critically Ill Surgical Patients?

INTRODUCTION

Patients admitted to intensive care units (ICUs) have high rates of mortality and morbidity. Improved communication between providers within ICUs may reduce morbidity. The goal of this study is to leverage a natural experiment of the temporally staggered implementation of a smart phone application for interprofessional communication to quantify the association with postoperative mortality and morbidity among critically ill surgical patients.

METHODS

We conducted an observational case-control study and utilized a difference-in-difference model to determine the impact of temporally staggered implementation of an interprofessional communication smart phone application on mortality, postoperative hyperglycemia, malnutrition, venous thromboembolism (VTE), and surgical site infections. Our study included patients who underwent surgical procedures and were admitted to the ICU at one of three hospitals (one academic medical center, hospital A, and two community hospitals, hospitals B and C) in a single health system between March 2018 and April 2021.

RESULTS

Our cohort consisted of 1457 patients, of which 1174 were hospitalized at hospital A and 283 at hospitals B and C. In the full cohort, 80 (5.6%) patients died during ICU admission. Difference-in-difference analysis demonstrated a relative difference in mortality of 4.8% [1.1%-8.5%] (P = 0.04) at hospitals B and C compared to hospital A after the implementation of the application. Our model demonstrated a 2.5% difference in VTEs [1.1%-3.8%], P = 0.03. There were no significant reductions in hyperglycemia, malnutrition, or surgical site infection.

CONCLUSIONS

The implementation of an interprofessional communication smart phone application is associated with reduced mortality and VTE incidence among critically ill surgical patients across three diverse hospitals.

Association of Postoperative Opioid Prescription Size and Patient Satisfaction

OBJECTIVE

To evaluate the association between postoperative opioid prescription size and patient-reported satisfaction among surgical patients.

SUMMARY BACKGROUND DATA

Opioids are overprescribed after surgery, which negatively impacts patient outcomes. The assumption that larger prescriptions increase patient satisfaction has been suggested as an important driver of excessive prescribing.

METHODS

This prospective cohort study evaluated opioid-naive adult patients undergoing laparoscopic cholecystectomy, laparoscopic appendectomy, and minor hernia repair between January 1 and May 31, 2018. The primary outcome was patient satisfaction, collected via a 30-day postoperative survey. Satisfaction was measured on a scale of 0 to 10 and dichotomized into "highly satisfied" (9-10) and "not highly satisfied" (0-8). The explanatory variable of interest was size of opioid prescription at discharge from surgery, converted into milligrams of oral morphine equivalents (OME). Hierarchical logistic regression was performed to evaluate the association between prescription size and satisfaction while adjusting for clinical covariates.

RESULTS

One thousand five hundred twenty patients met the inclusion criteria. Mean age was 53 years and 43% of patients were female. One thousand two hundred seventy-nine (84.1%) patients were highly satisfied and 241 (15.9%) were not highly satisfied. After multivariable adjustment, there was no significant association between opioid prescription size and satisfaction (OR 1.00, 95% CI 0.99-1.00). The predicted probability of being highly satisfied ranged from 83% for the smallest prescription (25 mg OME) to 85% for the largest prescription (750 mg OME).

CONCLUSIONS

In a large cohort of patients undergoing common surgical procedures, there was no association between opioid prescription size at discharge after surgery and patient satisfaction. This implies that surgeons can provide significantly smaller opioid prescriptions after surgery without negatively affecting patient satisfaction.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

This is a retrospective observational study.

SETTING

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

PATIENTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

LIMITATIONS

A limitation of this study was its retrospective study design.

CONCLUSIONS

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

ANTECEDENTES

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

OBJETIVO

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

DISEO

Estudio observacional retrospectivo.

AJUSTE

Hospital universitario terciario en Dallas.

PACIENTES

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

PRINCIPALES MEDIDAS DE DESENLACE

Elección de antibióticos preoperatorios e infección del sitio operatorio.

RESULTADOS

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

LIMITACIONES

Diseño de estudio retrospectivo.

CONCLUSIONES

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

Impact of an Antibiotic Side-Chain-Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With β-Lactam Allergies

BACKGROUND

β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar.

METHODS

An internally developed, antibiotic side-chain-based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)-Q3 (2014) (historical group) and Q3 (2016)-Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes.

RESULTS

A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility-onset Clostridiodes difficile infection, acute kidney injury, or hospital costs.

CONCLUSIONS

Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.

Bacterial Flora in the Sphenoid Sinus Changes with Perioperative Prophylactic Antibiotic Administration

The complications of endonasal transsphenoidal surgery (ETSS) include meningitis and sinusitis, and these complications are troublesome. Some reports have investigated the type of bacteria and the susceptibility of sphenoid sinus mucosal flora to drugs. However, most specimens can be collected after perioperative antibiotic administration. In this study, 95 and 103 sphenoid sinus mucosal samples collected during ETSS from September 2013 to February 2015 and from June 2017 to January 2019, respectively, were examined for bacterial culture. Sphenoid sinus mucosal samples were collected after antibiotic administration in the first period, whereas samples were collected before antibiotic administration in the second period. Hence, the specimens in the second period were not affected by antibiotics. Moreover, drug susceptibility tests for the detected bacteria were performed. Overall, 52 and 51 bacterial isolates were collected during both periods. Gram-positive cocci (GPCs), including Staphylococcus aureus and Staphylococcus epidermidis, were more common in the non-antibiotic group than in the antibiotic group (p <0.01). However, the proportion of gram-negative rods (GNRs) did not significantly differ between the two groups (p = 0.54). The antibiotic group had a significantly higher proportion of bacteria resistant to ampicillin (p <0.01) and first-generation cephalosporin (p = 0.01) than the non-antibiotic group. In conclusion, there was a difference in bacterial flora in the sphenoid sinus mucosal samples collected before and after intraoperative antibiotic administration.

Enhancing recovery: Joining the Improving Surgical Care and Recovery programme to decrease colorectal surgical site infections

AIM

Surgical site infections after colorectal surgery are a clinical and financial challenge in healthcare. The purpose of this project was to decrease the rate of surgical site infections in colorectal surgical patients in a community hospital with an academic cancer centre in the United States of America.

METHOD

The Quality Improvement Department obtained data to measure the hospital's performance with colorectal surgical patients. The data examined the surgical site infection rate and the length of stay. A multidisciplinary team was established to implement protocols to improve compliance.

RESULTS

More than 200 patients received a colorectal surgical resection at the hospital. The implemented protocols decreased both the surgical site infection rate and the length of stay (9.1-0% and median 6-4 days respectively).

DISCUSSION

Challenges with implementation of the Improving Surgical Care and Recovery programme, in a community setting, are discussed. The challenges were worked through collaboratively to achieve the best outcomes for the patients.

CONCLUSION

The interdisciplinary committee used evidence-based practices to enhance the care of the colorectal patients. Some of the protocols that emerged were: patient education, pain medication, mechanical bowel preparation and antibiotics, as well as early alimentation. The protocols are discussed in Tables 1 to 4.

Quality Indicators for Prevention of Infection in the Surgical Site: The Israeli National Program for Quality Indicators Experience

BACKGROUND AND OBJECTIVES

The Israeli National Program for Quality Indicators (INPQ) sets as its primary goal to promote high-quality health care within selected core areas in the Israeli health system. Surgical site infection is one of the most common types of acquired infections. The INPQ supports 3 distinct indicators concerning suitable antibiotic treatment in colorectal surgery, cesarean sections, and surgery for femoral neck fractures.

METHODS

We measured the number of patients who received prophylactic antibiotics, beginning an hour before the first cut and stopping after 24 hours in 1 of the 3 operations, according to the International Classification of Diseases, Ninth Revision (ICD-9) codes. Goals for success have been established annually according to the results of the previous year. Data computed for each operation included socioeconomic status, dates of hospitalization and release, date of death, date of birth, gender, date of operation, time of beginning and end of the operation, and time of beginning and end of anesthesia.

RESULTS

Within 3 to 5 years, we achieved a significant increase in appropriate prophylactic antibiotic use from 78% to 85%, 78% to 95%, and 66% to 88% for colorectal surgery (n = 9404), cesarean sections (n = 141 362), and femoral joint operations (n = 30 728), respectively. The mortality rate was lower, 1.85% versus 0.55% in patients who received proper antibiotic therapy (odds ratio [OR] = 3.141; 95% confidence interval [CI], 1.829-5.394, P < .0001), 0.031% versus 0.006% (OR = 6.741; 95% CI, 1.879-21.187; P = .003), and 5.59% versus 4.51% (OR = 1.253; 95% CI, 1.091-1.439; P = .001), respectively.

CONCLUSION

Prophylactic antibiotic treatment is strongly recommended by medical guidelines. The experience of the INPQ supports this approach. We demonstrate a significant lower mortality rate in patients who have been properly treated.

A Review of Bowel Preparation Before Colorectal Surgery

Infectious complications are the biggest problem during bowel surgery, and one of the approaches to minimize them is the bowel cleaning method. It was expected that bowel cleaning could facilitate bowel manipulation as well as prevent infectious complications and further reduce anastomotic leakage. In the past, with the development of antibiotics, bowel cleaning and oral antibiotics (OA) were used together. However, with the success of emergency surgery and Enhanced Recovery After Surgery, bowel cleaning was not routinely performed. Consequently, bowel cleaning using OA was gradually no longer used. Recently, there have been reports that only bowel cleaning is not helpful in reducing infectious complications such as surgical site infection (SSI) compared to OA and bowel cleaning. Accordingly, in order to reduce SSI, guidelines are changing the trend of only intestinal cleaning. However, a consistent regimen has not yet been established, and there is still controversy depending on the location of the lesion and the surgical method. Moreover, complications such as Clostridium difficile infection have not been clearly analyzed. In the present review, we considered the overall bowel preparation trends and identified the areas that require further research.

Cost-Effectiveness Analysis of the Prophylactic Use of Ertapenem for the Prevention of Surgical Site Infections after Elective Colorectal Surgery

Standard surgical antimicrobial prophylaxis (SAP) regimens are less effective in preventing surgical site infections (SSIs) due to rising antimicrobial resistance (AMR) rates, particularly for patients undergoing colorectal surgery. This study aimed to evaluate whether ertapenem should be a preferred strategy for the prevention of SSIs following elective colorectal surgery compared to three standard SAP regimens: amoxicillin-clavulanate, cefoxitin, and cefazolin plus metronidazole. A cost-effectiveness analysis was conducted using decision tree models. Probabilities of SSIs and AMR-SSIs, costs, and effects (in terms of quality-adjusted life-years) were considered in the assessment of the alternative strategies. Input parameters integrated real data from the Italian surveillance system for SSIs with data from the published literature. A sensitivity analysis was conducted to assess the potential impact of the decreasing efficacy of standard SAP regimens in preventing SSIs. According to our models, ertapenem was the most cost-effective strategy only when compared to amoxicillin-clavulanate, but it did not prove to be superior to cefoxitin and cefazolin plus metronidazole. The sensitivity analysis found ertapenem would be the most cost-effective strategy compared to these agents if their failure rate was more than doubled. The findings of this study suggest ertapenem should not be a preferred strategy for SAP in elective colorectal surgery.

Choice for prophylactic antibiotics: Cefazolin plus metronidazole or cefoxitin alone for endometrial cancer surgical staging

AIM

The use of prophylactic antibiotics has greatly reduced the incidence of surgical site infections after hysterectomy. It is worth discussing which antibiotic is better. The purpose of this study was to investigate the role of the combined utilization of cefazolin and metronidazole for the prevention of surgical site infection in laparoscopic staging surgery of endometrial cancer.

METHODS

A retrospective analysis was performed on the incidence of surgical site infection in patients with endometrial cancer who underwent laparoscopic surgical staging from January 2000 to June 2019 within 1 month after surgery. Logistic regression model was used for univariate and multivariate analysis.

RESULTS

A total of 1783 patients were included in this study, of which 641 were treated with cefazoline plus metronidazole (group 1) as a prophylactic antibiotic, while the other 1142 were treated with cefoxitin (group 2). There was no difference in clinical characteristics between the two groups. The rates of surgical site infection in groups 1 and 2 were 3.6% (n = 23) and 5.7% (n = 65), respectively. The most common site of infections was vaginal, with the incidence of 1.7% (n = 11) and 3.3% (n = 38) in groups 1 and 2, respectively. The multivariate analysis disclosed that cefazoline plus metronidazole significantly reduced the incidence of surgical site infections compared with cefoxitin (logistic, odds ratio = 2.213, 95% confidence interval 1.193 to 4.107).

CONCLUSION

Cefazolin plus metronidazole as prophylactic antibiotics for surgical staging of endometrial cancer can more effectively reduce the incidence of surgical site infections than cefoxitin.

Improving Quality of Surgical Care and Outcomes: Factors Impacting Surgical Site Infection after Colorectal Resection

Surgical site infections (SSIs) result in patient morbidity and increased costs. The purpose of this study was to determine reasons underlying SSI to enable interventions addressing identified factors. Combining data from the American College of Surgeons National Surgical Quality Improvement Project with medical record extraction, we evaluated 365 patients who underwent colon resection from January 2009 to December 2012 at a single institution. Of the 365 patients, 84 (23%) developed SSI. On univariate analysis, significant risk factors included disseminated cancer, ileostomy, patient temperature less than 36°C for greater than 60 minutes, and higher glucose level. The median number of cases per surgeon was 36, and a case volume below the median was associated with a higher risk of SSI. On multivariate analysis, significant risks associated with SSI included disseminated cancer (odds ratio [OR], 4.31; P < .001); surgery performed by a surgeon with less than 36 cases (OR, 2.19; P = .008); higher glucose level (OR, 1.06; P 5.017); and transfusion of five units or more of blood (OR, 3.26; P 5.029). In this study we found both modifiable and unmodifiable factors associated with increased SSI. Identifying modifiable risk factors enables targeting specific areas to improve the quality of care and patient outcomes.

Uptake of Total Mesorectal Excision and Total Mesorectal Excision Grading for Rectal Cancer: A Statewide Study

BACKGROUND

Total mesorectal excision is associated with decreased local recurrence and improved disease-free survival following rectal cancer resection. The extent to which total mesorectal excision has been adopted in the United States is unknown.

OBJECTIVE

We sought to assess trends in total mesorectal excision performance and grading in Michigan hospitals.

DESIGN

This is a retrospective cohort study from the Michigan Surgical Quality Collaborative. Trends in total mesorectal excision performance and grade assignment were analyzed by using χ tests and linear regression.

SETTINGS

Participating hospitals (initially 14 hospitals, now 38) abstracted medical records data for rectal cancer cases from 2007 to 2016.

PATIENTS

Patients who underwent rectal cancer resection were included.

MAIN OUTCOME MEASURE

The main outcome measures were surgeon-documented total mesorectal excision performance and pathologist-reported total mesorectal excision grade.

RESULTS

Of 510 rectal cancer cases, 367 (72.0%) had surgeon-reported total mesorectal excision performance and 78 (15.3%) had pathologist-reported total mesorectal excision grade. Between-hospital variability in total mesorectal excision performance ranged from 0% to 97% and total mesorectal excision grading ranged from 0% to 90%. Total mesorectal excision grading was associated with a higher likelihood of also having adequate lymph node assessment (88.5% versus 71.9%, p = 0.002). There has been a statistically significant trend toward an increase in total mesorectal excision grading in the original 14 hospitals (p = 0.001), but not in the complete cohort of all hospitals (p = 0.057).

LIMITATIONS

This is a retrospective cohort design with sampled rectal cancer cases. In addition, there is insufficient granularity to capture all factors associated with total mesorectal excision performance or grade assignment.

CONCLUSIONS

The rates of total mesorectal excision performance and grade assignment are widely variable throughout the state of Michigan. Overall, grade assignment remains very low. This suggests an opportunity for quality improvement projects to increase total mesorectal excision performance and grading, involving both the surgeons and pathologists for effective implementation. See Video Abstract at http://links.lww.com/DCR/B53. IMPLEMENTACIÓN DE LA ESCISIÓN MESORRECTAL TOTAL Y LA CLASIFICACIÓN POR ESCISIÓN MESORRECTAL TOTAL PARA EL CÁNCER RECTAL: UN ESTUDIO A NIVEL ESTATAL.: La escisión mesorrectal total se asocia con una menor recurrencia local y una mejor supervivencia libre de enfermedad después de la resección del cáncer rectal. Se desconoce hasta que punto se ha adoptado la escisión mesorrectal total en los Estados Unidos.Se intento evaluar las tendencias en el rendimiento y la clasificación de la escisión mesorrectal total en los hospitales de Michigan.Este es un estudio de cohorte retrospectivo de la "Michigan Surgical Quality Collaborative". Las tendencias en el rendimiento de la escisión mesorrectal total y la asignación de grado se analizaron mediante pruebas de chi-cuadrada y regresión lineal.Los hospitales participantes (inicialmente 14 hospitales, ahora 38) extrajeron datos de registros médicos de los casos de cáncer rectal desde 2007 hasta 2016.Pacientes que se sometieron a resección de cáncer rectal.Las principales medidas de resultado fueron el rendimiento de la escisión mesorrectal total documentado por el cirujano y el grado de escisión mesorrectal total informada por el patólogo.De 510 casos de cáncer rectal, 367 (72.0%) tenían un rendimiento de escisión mesorrectal total reportado por el cirujano y 78 (15.3%) tenían un grado de escisión mesorrectal total reportado por el patólogo. La variabilidad entre hospitales en el rendimiento de la escisión mesorrectal total varió del 0 al 97% y la clasificación de la escisión mesorrectal total varió del 0 al 90%. La clasificación de la escisión mesorrectal total se asoció con una mayor probabilidad de tener también una evaluación adecuada de los ganglios linfáticos (88.5% versus 71.9%, p = 0.002). Ha habido una tendencia estadísticamente significativa hacia un aumento en la clasificación de la escisión mesorrectal total en los 14 hospitales originales (p = 0.001), pero no en la cohorte completa de todos los hospitales (p = 0.057).Diseño de cohorte retrospectivo con casos de cáncer rectal muestreados. Además, no hay suficiente granularidad para capturar todos los factores asociados con el rendimiento de la escisión mesorrectal total o la asignación de grados.Las tasas de rendimiento de escisión mesorrectal total y asignación de grado son muy variables en todo el estado de Michigan. En general, la asignación de calificaciones sigue siendo muy baja. Esto sugiere una oportunidad para que los proyectos de mejora de la calidad aumenten el rendimiento y la clasificación de la escisión mesorrectal total, involucrando tanto a los cirujanos como a los patólogos para una implementación efectiva. Vea el resumen del video en http://links.lww.com/DCR/B53.

β-Lactam vs Non-β-Lactam Antibiotics and Surgical Site Infection in Colectomy Patients

BACKGROUND

Surgical site infections (SSIs) represent a significant preventable source of morbidity, mortality, and cost. Prophylactic antibiotics have been shown to decrease SSI rates, and β-lactam antibiotics are recommended by national guidelines. It is currently unclear whether recommended β-lactam and recommended non-β-lactam antibiotic regimens are equivalent with respect to SSI risk reduction in colectomy patients.

STUDY DESIGN

We conducted a retrospective cohort study of SSI rates between prophylactic intravenously administered recommended β-lactam and non-β-lactam in colectomy patients (25 CPT codes) collected by the Michigan Surgical Quality Collaborative from January 2013 to February 2018. Surgical site infection rates were compared as a dichotomous variable (no SSI vs SSI). Mixed-effects regression was used to compare the association between receiving a β-lactam or non-β-lactam antibiotic and likelihood of having an SSI.

RESULTS

Of 9,949 patients, 9,411 (94.6%) received β-lactam antibiotics and 538 (5.4%) received non-β-lactam antibiotics. Overall, there were 622 (6.3%) patients with SSIs. Of the patients receiving β-lactam antibiotics, SSIs developed in 571 (6.1%) compared with 51 (9.5%) patients in the non-β-lactam group. After applying mixed-effects logistic regression, prophylactic treatment with a non-β-lactam regimen was associated with significantly higher odds of surgical site infection (odds ratio 1.65; 95% CI 1.20 to 2.26; p < 0.01).

CONCLUSIONS

Colectomy patients receiving β-lactam antibiotics had a lower likelihood of SSI compared with those receiving non-β-lactam antibiotics, even when antibiotics were compliant with national recommendations. Our findings suggest that surgeons should prescribe β-lactam antibiotics for prophylaxis whenever possible, reserving alternatives for those rare patients with true allergies or clinical indications for non-β-lactam antibiotic prophylaxis.

Current U.S. Pre-Operative Bowel Preparation Trends: A 2018 Survey of the American Society of Colon and Rectal Surgeons Members

Background: The effect of an oral antibiotic preparation prior to colorectal surgery was first examined and exalted in the 1973 paper by Nichols et al. Since this commencement, enthusiasm for the oral antibiotic regimen has waxed and waned reflecting the literature focused on this topic over the past 40 years. Polling colorectal surgeons of define current practices has been performed at intervals throughout the years and has demonstrated a trend to decline in the practice. The most recent publication surveying U.S. practices was in 2010, which reported a minority, 36%, use of oral antibiotics prior to elective colorectal surgery; a marked downtrend from the 88% use described in 1990. Since this last survey, the colorectal surgery community has performed considerable research examining the benefit of oral antibiotic and mechanical bowel preparation. This manuscript evaluates the current use of oral antibiotics in colorectal surgery in the U.S. and how practice trends have developed in response to current recommendations in the literature. Methods: An electronic survey was created and distributed to U.S. colorectal surgeons to evaluate current opinions and practice trends. A total of 359 American Society of Colon and Rectal Surgeons members responded. A review of the recent literature pertaining to pre-operative bowel practices and outcomes was performed to compare with current practices. Results: A significant majority (83.2%) of respondents use pre-operative oral antibiotics routinely, and 98.6% routinely use mechanical bowel preparation. The use of a combination of parenteral antibiotics, oral antibiotics, and mechanical bowel preparation is reported by 79.3%. The most commonly employed oral antibiotic regimen is neomycin and metronidazole. The most common mechanical bowel preparation is polyethylene glycol (PEG). The most common parenteral antibiotics are cefazolin and metronidazole. There was no statistically significant difference in this practice by geographic region, Board-certified status, or practice setting. Conclusion: The majority of colorectal surgeons employ a combination of oral antibiotics, mechanical bowel preparation, and parenteral antibiotics prior to colorectal surgery. This is consistent across geographic regions, despite Board certification status or practice setting, and is reflective of the recommendations based on recent literature.

The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-analysis

OBJECTIVES

To compare the impact of the use of oral antibiotics (OAB) with or without mechanical bowel preparation (MBP) on outcome in elective colorectal surgery.

SUMMARY BACKGROUND DATA

Meta-analyses have demonstrated that MBP does not impact upon postoperative morbidity or mortality, and as such it should not be prescribed routinely. However, recent evidence from large retrospective cohort and database studies has suggested that there may be a role for combined OAB and MBP, or OAB alone in the prevention of surgical site infection (SSI).

METHODS

A meta-analysis of randomized controlled trials and cohort studies including adult patients undergoing elective colorectal surgery, receiving OAB with or without MBP was performed. The outcome measures examined were SSI, anastomotic leak, 30-day mortality, overall morbidity, development of ileus, reoperation and Clostridium difficile infection.

RESULTS

A total of 40 studies with 69,517 patients (28 randomized controlled trials, n = 6437 and 12 cohort studies, n = 63,080) were included. The combination of MBP+OAB versus MBP alone was associated with a significant reduction in SSI [risk ratio (RR) 0.51, 95% confidence interval (CI) 0.46-0.56, P < 0.00001, I = 13%], anastomotic leak (RR 0.62, 95% CI 0.55-0.70, P < 0.00001, I = 0%), 30-day mortality (RR 0.58, 95% CI 0.44-0.76, P < 0.0001, I = 0%), overall morbidity (RR 0.67, 95% CI 0.63-0.71, P < 0.00001, I = 0%), and development of ileus (RR 0.72, 95% CI 0.52-0.98, P = 0.04, I = 36%), with no difference in Clostridium difficile infection rates. When a combination of MBP+OAB was compared with OAB alone, no significant difference was seen in SSI or anastomotic leak rates, but there was a significant reduction in 30-day mortality, and incidence of postoperative ileus with the combination. There is minimal literature available on the comparison between combined MBP+OAB versus no preparation, OAB alone versus no preparation, and OAB versus MBP.

CONCLUSIONS

Current evidence suggests a potentially significant role for OAB preparation, either in combination with MBP or alone, in the prevention of postoperative complications in elective colorectal surgery. Further high-quality evidence is required to differentiate between the benefits of combined MBP+OAB or OAB alone.

Academic Hospitals Discharge Fewer Patients to Postacute Care Facilities After Colorectal Resection

BACKGROUND

Discharge to a nonhome destination (ie, skilled nursing facility, subacute rehabilitation, or long-term care facility) after surgery is associated with increased mortality and higher costs and is less desirable to patients than discharge to home.

OBJECTIVE

We sought to identify modifiable hospital-level factors that may reduce rates of nonhome discharge after colorectal resection.

DESIGN

This was a retrospective cohort study of patients undergoing colorectal resection in the Michigan Surgical Quality Collaborative (July 2012 to June 2015). Patient- and hospital-level characteristics were tested for association with nonhome discharge patterns.

SETTINGS

Patients were identified using prospectively collected data from the Michigan Surgical Quality Collaborative, a statewide collaborative encompassing 63 community, academic, and tertiary hospitals.

PATIENTS

Patients undergoing colon and rectal resections were included.

MAIN OUTCOME MEASURE

The main outcome measure was hospital use patterns of nonhome discharge.

RESULTS

Of the 9603 patients identified, 1104 (11.5%) were discharged to a nonhome destination. After adjustments for patient factors associated with nonhome discharge, we identified variability in hospital use patterns for nonhome discharge. Designation as a low utilizer hospital was associated with affiliation with a medical school (p = 0.020) and high outpatient volume (p = 0.028). After adjustments for all hospital factors, only academic affiliation maintained a statistically significant relationship (OR = 4.94; p = 0.045).

LIMITATIONS

This study had a retrospective cohort design with short-term follow-up of sampled cases. Additionally, by performing our analysis on the hospital level, there is a decreased sample size.

CONCLUSIONS

This population-based study shows that there is significant variation in hospital practices for nonhome discharge. Specifically, hospitals affiliated with a medical school are less likely to discharge patients to a facility, even after adjustment for patient and procedural risk factors. This study raises the concern that there may be overuse of subacute facility discharge in certain hospitals, and additional study is warranted. See Video Abstract at http://links.lww.com/DCR/A837.

Mechanisms of age and race differences in receiving minimally invasive inguinal hernia repair

BACKGROUND

Black patients and older adults are less likely to receive minimally invasive hernia repair. These differences by race and age may be influenced by surgeon-specific utilization rate of minimally invasive repair. In this study, we explored the association between race, age, and surgeon utilization of minimally invasive surgery (MIS) with the likelihood of receiving MIS inguinal hernia repair.

METHODS

A retrospective cohort study was performed in patients undergoing elective primary inguinal hernia repair from 2012 to 2016, using data from the Michigan Surgical Quality Collaborative, a 72-hospital clinical registry. Surgeons were stratified by proportion of MIS performed. Using hierarchical logistic regression models, we investigated the association between receiving MIS repair and race, age, and surgeon MIS utilization rate.

RESULTS

Out of 4667 patients, 1253 (27%) received MIS repair. Out of 190 surgeons, 81 (43%) performed only open repair. Controlling for surgeon MIS utilization, race was not associated with MIS receipt (OR 0.93, p = 0.775), but older patients were less likely to receive MIS repair (OR 0.41, p < 0.001).

CONCLUSIONS

Race differences were explained by surgeon MIS utilization, implicating access to MIS-performing surgeon as a mediator. Conversely, age disparity was independent of MIS utilization, even after adjusting for comorbidities, indicating some degree of provider bias against performing MIS repair in older patients. Interventions to address disparities should include systematic efforts to improve access, as well as provider and patient education for older adults.

Statewide Clinic Registries: The Michigan Surgical Quality Collaborative

Regional clinical registries provide a unique opportunity for shared learning and population-based analyses of the quality of surgical care. Through the "Michigan Model" of pay for participation in strategic Value Partnerships, exemplified by the Michigan Surgical Quality Collaborative (MSQC), the state's dominant private insurer, Blue Cross Blue Shield of Michigan, has sponsored 20 statewide clinical quality improvement collaboratives. MSQC represents a partnership among 73 Michigan hospitals with a robust data infrastructure and flexible platform for the promulgation of best practices in surgical quality improvement. This article will describe the organizational structure of the MSQC, the contributions the registry has made to quality improvement in colorectal surgery, and how future work will align to improve the reliability of improvement-relevant registry data.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BACKGROUND

Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates.

METHODS

Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI.

RESULTS

After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05).

CONCLUSION

Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

Surgeon utilization of minimally invasive techniques for inguinal hernia repair: a population-based study

BACKGROUND

MIS utilization for inguinal hernia repair is low compared to in other procedures. The impact of low adoption in surgeons is unclear, but may affect regional access to minimally invasive surgery (MIS). We explored the impact of surgeon MIS utilization in inguinal hernia repair across a statewide population.

METHODS

We analyzed 6723 patients undergoing elective inguinal hernia repair from 2012 to 2016 in the Michigan Surgical Quality Collaborative. The primary outcome was surgeon MIS utilization. The geographic distribution of high MIS-utilizing surgeons was compared across Hospital Referral Regions using Pearson's Chi-squared test. Hierarchical logistic regression was used to identify patient and hospital factors associated with MIS utilization.

RESULTS

Surgeon MIS utilization varied, with 58% of 540 surgeons performing no MIS repair. For the remaining surgeons, MIS utilization was bimodally distributed. High-utilization surgeons were unevenly distributed across region, with corresponding differences in regional MIS rate ranging from 10 to 48% (p < 0.001). MIS was used in 41% of bilateral and 38% of recurrent hernia. MIS repair was more likely with higher hospital volume and less likely for patients aged 65+ (OR 0.68, p = 0.003), black patients (OR 0.75, p = 0.045), patients with COPD (OR 0.57, p < 0.001), and patients in ASA class > 3 (OR 0.79 p < 0.001).

CONCLUSIONS

MIS utilization varies between surgeons, likely driving differences in regional MIS rates and leading to guideline-discordant care for patients with bilateral or recurrent hernia. Interventions to reduce this practice gap could include training programs in MIS repair, or regionalization of care to improve MIS access.

Evaluation of the Methods Used by Medicare's Hospital-Acquired Condition Reduction Program to Identify Outlier Hospitals for Surgical Site Infection

BACKGROUND

The Hospital Acquired Condition Reduction Program (HACRP) is a national pay-for-performance program that includes a measure of surgical site infection (SSI) after hysterectomy and colectomy. This study compares the HACRP SSI measure with other published methods.

STUDY DESIGN

This was a retrospective cohort study from the Michigan Surgical Quality Collaborative (MSQC). The outcome was 30-day, adjusted deep and organ space SSI ("complex SSI"). Observed-to-expected ratios of complex SSI for each hospital were calculated using HACRP, National Healthcare Safety Network (NHSN), and MSQC methodologies. C-statistics were compared between models. Hospital rankings were compared, and ladder plots show changes in hospitals' HACRP scores that derive from each algorithm.

RESULTS

Complex SSI occurred in 1.1% (190 of 16,672) of hysterectomies and 4.8% (n = 514 of 10,725) of colectomies. The HACRP risk-adjustment model for hysterectomy had a C-statistic of 0.55, significantly lower than NHSN (0.61, p = 0.0461) or MSQC models (0.77, p < 0.0001). For colectomy, C-statistics were 0.57, 0.66 (p < 0.0001) and 0.73 (p < 0.0001), respectively. For both operations, there were 5 high-outlier hospitals using HACRP, but fewer (4 or 3) using the other methods. Most hospitals in the bottom quartile were not statistical outliers, but would be flagged under HACRP. More than 50% of hospitals changed ranking position between models, which would result in different scores under HACRP.

CONCLUSIONS

This study showed that the HACRP SSI measure unfairly places hospitals at risk for financial penalties that are not statistical outliers. Policy makers need to weigh the burden of data collection and the accuracy needed to identify hospitals for financial reward or penalty.

Meta-analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical-site infections in elective colorectal surgery

Background

Surgical‐site infection (SSI) is a potentially serious complication following colorectal surgery. The present systematic review and meta‐analysis aimed to investigate the effect of preoperative oral antibiotics and mechanical bowel preparation (MBP) on SSI rates.

Methods

A systematic review of PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials was performed using appropriate keywords. Included were RCTs and observational studies reporting rates of SSI following elective colorectal surgery, in patients given preoperative oral antibiotic prophylaxis, in combination with intravenous (i.v.) antibiotic prophylaxis and MBP, compared with patients given only i.v. antibiotic prophylaxis with MBP. A meta‐analysis was undertaken.

Results

Twenty‐two studies (57 207 patients) were included, of which 14 were RCTs and eight observational studies. Preoperative oral antibiotics, in combination with i.v. antibiotics and MBP, were associated with significantly lower rates of SSI than combined i.v. antibiotics and MBP in RCTs (odds ratio (OR) 0·45, 95 per cent c.i. 0·34 to 0·59; P < 0·001) and cohort studies (OR 0·47, 0·44 to 0·50; P < 0·001). There was a similarly significant effect on SSI with use of a combination of preoperative oral aminoglycoside and erythromycin (OR 0·40, 0·25 to 0·64; P < 0·001), or preoperative oral aminoglycoside and metronidazole (OR 0·51, 0·39 to 0·68; P < 0·001). Preoperative oral antibiotics were significantly associated with reduced postoperative rates of anastomotic leak, ileus, reoperation, readmission and mortality in the cohort studies.

Conclusion

Oral antibiotic prophylaxis, in combination with MBP and i.v. antibiotics, is superior to MBP and i.v. antibiotic prophylaxis alone in reducing SSI in elective colorectal surgery.

Higher versus Lower Dose of Cefotetan or Cefoxitin for Surgical Prophylaxis in Patients Weighing One Hundred Twenty Kilograms or More

BACKGROUND

Clinical practice guidelines recommend a 2-g dose of cefotetan and cefoxitin for surgical prophylaxis. Pharmacokinetic data suggest benefit from higher cefotetan and cefoxitin dosing in obese patients. However, clinical studies examining higher dosing strategies in this at-risk population are lacking. The purpose of this study was to determine whether 3 g of cefotetan or cefoxitin administered pre-operatively for patients who weigh 120 kg or more is associated with a lower proportion of surgical site infection (SSI) compared with 2 g.

PATIENTS AND METHODS

Medical records of patients weighing 120 kg or more who had received cefotetan or cefoxitin (2 or 3 g) as surgical prophylaxis for intra-abdominal procedures between July 2012 and August 2015 were reviewed for the development of an SSI (primary outcome), study drug-related adverse events, and re-admissions attributed to SSIs (secondary outcomes). Relative risk calculations were performed for analysis of the primary and secondary outcomes.

RESULTS

One-hundred seventy-five procedures in 169 patients were included in the study. Cefotetan was used in 81% (141/175) of procedures. Three grams of cefotetan or cefoxitin was used in 20% (35/175) of procedures. The median body mass index (BMI) in both dosing groups was 42 kg/m² and patients who received 3 g more often weighed more than 130 kg (relative risk [RR] 1.36, 1.01-1.76; p = 0.04). Surgical site infections occurred in 20.7% within the 2-g group and 22.9% in the 3-g group (RR 1.10, 0.55-2.20; p = 0.78). There was no difference in the number of study drug-related adverse effects in the 3-g compared with the 2-g group. Thirty-day re-admissions because of SSI also did not differ between the 2-g and 3-g groups (7.9% vs. 17.1%, respectively; p = 0.11).

CONCLUSION

This small retrospective study did not find a difference in SSI rates between 3-g and 2-g surgical prophylaxis dosing for patients 120 kg or more with a median BMI >40 kg/m².

Risk assessment of morbidities after right hemicolectomy based on the National Clinical Database in Japan

OBJECTIVE

Nationwide databases are expected to provide critical data to improve medical practice. The present study used such data to develop risk models for clinically important outcomes after right hemicolectomy based on preoperative risk factors.

METHODS

Japan's National Clinical Database (NCD) identified 38 030 cases of right hemicolectomy in the years 2011 and 2012. These were used to analyze correlations between mortality and eight selected clinical outcomes of interest by Pearson's correlation coefficient (r). To construct risk models for the eight selected clinical outcomes, 80% of all the examined cases were extracted randomly as a development cohort, and preoperative risk factors for each clinical outcome were identified using a forward stepwise selection method. Morbidities predicted from the risk models were used to find areas under the receiver operator curves among the remaining 20% of the testing cohort.

RESULTS

The following clinical outcomes were identified as highly associated with operative mortality: systemic sepsis (r = .360), renal failure (r = .341), unplanned intubation (r = .316) and central nervous system (CNS) occurrences (r = .301). Risk models containing up to 21 preoperative variables were constructed for these eight postoperative clinical outcomes. Predictive values of the eight models were as follows: surgical site infections (0.634), anastomotic leakage (0.656), systemic sepsis (0.816), pneumonia (0.846), unplanned intubation (0.838), renal failure (0.883), CNS occurrences (0.833) and transfusion >5 units (0.846).

CONCLUSIONS

This study indicated that the NCD-generated risk models for six of the eight selected critical postoperative outcomes had high discrimination among right hemicolectomy patients. These risk models can accurately identify high-risk patients prior to surgery.

Use and Effectiveness of Peri-Operative Cefotetan versus Cefazolin Plus Metronidazole for Prevention of Surgical Site Infection in Abdominal Surgery Patients

BACKGROUND

Current practice guidelines for antimicrobial prophylaxis in surgery recommend a cephamycin or cefazolin plus metronidazole for various abdominal surgeries. In February 2016, cephamycin drug shortages resulted in a change in The Johns Hopkins Hospital's (JHH) recommendation for peri-operative antibiotic prophylaxis in abdominal surgeries from cefotetan to cefazolin plus metronidazole. The primary objective of this study was to quantify the percentage of abdominal surgeries adherent to JHH peri-operative antibiotic prophylaxis guidelines. A sub-group analysis investigated whether prophylaxis with cefazolin plus metronidazole was associated with a lower rate of surgical site infections (SSIs) versus cefotetan.

PATIENTS AND METHODS

This retrospective cohort study included adult inpatients who underwent an abdominal surgery at JHH in September 2015 (Study Period I: cefotetan) or February to March 2016 (Study Period II: cefazolin plus metronidazole).

RESULTS

Two hundred abdominal surgery cases were included in the primary analysis. A subset of 156 surgical cases were included in the sub-group analysis. The overall adherence rate to JHH guidelines was 75% in Study Period I versus 17% in Study Period II (p < 0.001). The largest difference in adherence was attributed to pre-operative administration time (87% vs. 23%, p < 0.001), primarily because of the longer infusion time required for metronidazole. Surgical site infections occurred in 14% (12/83) of surgeries with cefotetan versus 8.2% (6/73) with cefazolin plus metronidazole for prophylaxis (p = 0.19).

CONCLUSIONS

Adherence to an institution-specific peri-operative antibiotic prophylaxis guideline for abdominal surgeries was limited primarily by the longer infusion time required for pre-operative metronidazole. A higher percentage of SSIs occurred among abdominal surgeries with cefotetan versus cefazolin plus metronidazole for prophylaxis.

Application of antimicrobial drugs in perioperative surgical incision

Infection in surgical incision often results in poor wound healing, and one of the main factors for wound infection is the use of antimicrobial agents. Rational use of antibiotics is one of the key factors to prevent incision infection in general surgery. The number of current clinical studies on antibiotic use before and during surgery is greater than that of systematic studies on antibiotic use after surgery. For the rational use of antibiotics and improvement of wound healing rate, researchers around the world have gradually focused on the use of antibiotics after surgery. Despite the familiarity on the concept of “rational use of antibiotics”, few clear and systematic studies were conducted to elucidate the effect of different antibiotics on wound healing. Therefore, this review focuses on the use of different types of antimicrobial agents in surgical wounds.

Influence of Enhanced Recovery Pathway on Surgical Site Infection after Colonic Surgery

BACKGROUND

The present study aimed to evaluate a potential effect of ERAS on surgical site infections (SSI).

METHODS

Colonic surgical patients operated between May 2011 and September 2015 constituted the cohort for this retrospective analysis. Over 100 items related to demographics, surgical details, compliance, and outcome were retrieved from a prospectively maintained database. SSI were traced by an independent National surveillance program. Risk factors for SSI were identified by univariate and multinomial logistic regression.

RESULTS

Fifty-four out of 397 patients (14%) developed SSI. Independent risk factors for SSI were emergency surgery (OR 1.56; 95% CI 1.09-1.78, p = 0.026), previous abdominal surgery (OR 1.7; 95% CI 1.32-1.87, p = 0.004), smoking (OR 1.71; 95% CI 1.22-1.89, p = 0.014), and oral bowel preparation (OR 1.86; 95% CI 1.34-1.97, p = 0.013), while minimally invasive surgery (OR 0.3; 95% CI 0.16-0.56, p < 0.001) protected against SSI. Compliance to ERAS items of >70% was not retained as a protective factor for SSI after multivariate analysis (OR 0.94; 95% CI 0.46-1.92, p = 0.86).

CONCLUSIONS

Smoking, open and emergency surgery, and bowel preparation were risk factors for SSI. ERAS pathway had no independent impact while minimally invasive approach did. This study was registered under ResearchRegistry.com (UIN researchregistry2614).

Evidence that a Regional Surgical Collaborative Can Transform Care: Surgical Site Infection Prevention Practices for Colectomy in Michigan

BACKGROUND

Surgical site infections (SSI) after colectomy are associated with increased morbidity and health care use. Since 2012, the Michigan Surgical Quality Collaborative (MSQC) has promoted a "bundle" of care processes associated with lower SSI risk, using an audit-and-feedback system for adherence, face-to-face meetings, and support for quality improvement projects at participating hospitals. The purpose of this study was to determine whether practices changed over time.

STUDY DESIGN

We previously found 6 processes of care independently associated with SSI in colectomy. From 2012 to 2016, we promoted a bundle of 3 care measures (cefazolin/metronidazole, oral antibiotics after mechanical bowel preparation, and normoglycemia) in 52 hospitals. Primary outcome was change in use of the 3-item SSI bundle. We also used a hierarchical logistic regression model to assess the association between 6-item compliance and SSI rate, morbidity, and health care use.

RESULTS

The use of cefazolin/metronidazole increased from 18.6% to 32.3% (p < 0.001), oral antibiotic preparation increased from 42.9% to 62.0% (p < 0.001). The increase in normoglycemia was not significant. Concurrently, the SSI rate fell from 6.7% to 3.9% in the 52 hospitals (p = 0.012). Patients receiving more bundle measures had decreased rates of SSI, sepsis, and pneumonia. Morbidity and health care use significantly decreased with increased bundle compliance.

CONCLUSIONS

These data show a significant increase in use of process measures promoted by a regional quality improvement collaborative, and an associated decrease in SSI after elective colectomy. These results highlight the promise of regional collaboratives to accelerate practice change and improve outcomes.

Surgeon Variation in Complications With Minimally Invasive and Open Colectomy: Results From the Michigan Surgical Quality Collaborative

Importance

Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons.

Objective

To assess rates of complications for MIC compared with OC among surgeons.

Design, Setting, and Participants

We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches.

Main Outcomes and Measures

Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC.

Results

Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P < .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC.

Conclusions and Relevance

Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

Reducing surgical site infections after hysterectomy: metronidazole plus cefazolin compared with cephalosporin alone

BACKGROUND

Organisms that are isolated from vaginal cuff infections and pelvic abscesses after hysterectomy frequently include anaerobic vaginal flora. Metronidazole has outstanding coverage against nearly all anaerobic species, which is superior to both cefazolin and second-generation cephalosporins. Cefazolin plus metronidazole has been demonstrated to reduce infectious morbidity compared with either cefazolin or second-generation cephalosporins in other clean-contaminated procedures, which include both as colorectal surgery and cesarean delivery.

OBJECTIVE

The purpose of this study was to evaluate whether the combination of cefazolin plus metronidazole before hysterectomy was more effective in the prevention of surgical site infection than existing recommendations of cefazolin or second-generation cephalosporin.

STUDY DESIGN

This was a retrospective cohort study of patients in the Michigan Surgical Quality Collaborative from July 2012 through February 2015. The primary outcome was surgical site infection. Patients who were >18 years old and who underwent abdominal, vaginal, laparoscopic, or robotic hysterectomy for benign or malignant indications were included if they received 1 of the following prophylactic antibiotic regimens: cefazolin, second-generation cephalosporin, or cefazolin plus metronidazole. Multivariate logistic regression modeling was performed to evaluate the independent effect of an antibiotic regimen, and propensity score matching was used to validate the findings.

RESULTS

The study included 18,255 hysterectomies. The overall rate of surgical site infection was 1.8% (n=329). The unadjusted rate of surgical site infection was 1.8% (n=267) for cefazolin, 2.1% (n=49) for second-generation cephalosporin, and 1.4% (n=13) for cefazolin plus metronidazole. After adjustment for differences in patient and operative factors among the antibiotic cohorts, compared with cefazolin plus metronidazole, we found the risk of surgical site infection was significantly higher for patients who received cefazolin (odds ratio, 2.30; 95% confidence interval, 1.06-4.99) or second-generation cephalosporin (odds ratio, 2.31; 95% confidence interval, 1.21-4.41).

CONCLUSION

In this large cohort, the use of prophylactic cefazolin plus metronidazole resulted in lower surgical site infection rates after hysterectomy compared with cefazolin or second-generation cephalosporin.

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection

BACKGROUND

Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations.

METHODS

Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council.

RESULTS

This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included.

SUMMARY

The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

The role of oral antibiotics prophylaxis in prevention of surgical site infection in colorectal surgery

BACKGROUND

Surgical site infection (SSI) continues to be a challenge in colorectal surgery. Over the years, various modalities have been used in an attempt to reduce SSI risk in elective colorectal surgery, which include mechanical bowel preparation before surgery, oral antibiotics and intravenous antibiotic prophylaxis at induction of surgery. Even though IV antibiotics have become standard practice, there has been a debate on the exact role of oral antibiotics.

AIM

The primary aim was to identify the role of oral antibiotics in reduction of SSI in elective colorectal surgery. The secondary aim was to explore any potential benefit in the use of mechanical bowel preparation (MBP) in relation to SSI in elective colorectal surgery.

METHODS

Medline, Embase and the Cochrane Library were searched. Any randomised controlled trials (RCTs) or cohort studies after 1980, which investigated the effectiveness of oral antibiotic prophylaxis and/or MBP in preventing SSIs in elective colorectal surgery were included.

RESULTS

Twenty-three RCTs and eight cohorts were included. The results indicate a statistically significant advantage in preventing SSIs with the combined usage of oral and systemic antibiotic prophylaxis. Furthermore, our analysis of the cohort studies shows no benefits in the use of MBP in prevention of SSIs.

CONCLUSIONS

The addition of oral antibiotics to systemic antibiotics could potentially reduce the risk of SSIs in elective colorectal surgery. Additionally, MBP does not seem to provide a clear benefit with regard to SSI prevention.

Colorectal cancer: Quality of surgical care in Michigan

OBJECTIVE

Surgery remains the cornerstone therapy for colorectal cancer (CRC). This study assesses CRC quality measures for surgical cases in Michigan.

METHODS

In this retrospective cohort study, processes of care and outcomes for CRC resection cases were abstracted in 30 hospitals in the Michigan Surgical Quality Collaborative (2014-2015). Measures were case-mix and reliability adjusted, using logistic regression models.

RESULTS

For 871 cases (640 colon cancer, 231 rectal cancer), adjusted morbidity (27.4%) and mortality rates (1.5%) were low. Adjusted process measures showed gaps in quality of care. Mesorectal excision was documented in 59.4% of rectal cancer (RC) cases, 65% of RC cases had sphincter preserving surgery, 18.7% of cases had < 12 lymph nodes examined, 7.9% had a positive margin, 52.1% of stage II/III RC cases had neoadjuvant therapy, and 36% of ostomy cases had site marking.

CONCLUSION

This study finds gaps in quality of care measures for CRC, suggesting opportunity for regional quality improvement.