Elliott IA, Chan C, Russell TA, Dann AM, Williams JL, Damato L, Chung H, Girgis MD, Hines OJ, Reber HA, Donahue TR. Distinction of Risk Factors for Superficial vs Organ-Space Surgical Site Infections After Pancreatic Surgery.
JAMA Surg 2017;
152:1023-1029. [PMID:
28700780 DOI:
10.1001/jamasurg.2017.2155]
[Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance
Surgical site infection (SSI) rates are increasingly used as a quality metric. However, risk factors for SSI in pancreatic surgery remain undefined.
Objective
To stratify superficial and organ-space SSIs after pancreatectomy and investigate their modifiable risk factors.
Design, Setting, and Participants
This retrospective analysis included 201 patients undergoing pancreatic surgery at a university-based tertiary referral center from July 1, 2013, through June 30, 2015, and 10โฏ371 patients from National Surgical Quality Improvement Program-Hepatopancreaticobiliary (NSQIP-HPB) Collaborative sites from January 1, 2014, through December 31, 2015.
Main Outcomes and Measures
Superficial, deep-incisional, and organ-space SSIs, as defined by NSQIP.
Results
Among the 201 patients treated at the single center (108 men [53.7%] and 93 women [46.3%]; median age, 48.6 years [IQR, 41.4-57.3 years]), 58 had any SSI (28.9%); 28 (13.9%), superficial SSI; 8 (4%), deep-incisional SSI; and 24 (11.9%), organ-space SSI. Independent risk factors for superficial SSI were preoperative biliary stenting (odds ratio [OR], 4.81; 95% CI, 1.25-18.56; Pโ=โ.02) and use of immunosuppressive corticosteroids (OR, 13.42; 95% CI, 1.64-109.72; Pโ=โ.02), whereas soft gland texture was the only risk factor for organ-space SSI (OR, 4.45; 95% CI, 1.35-14.66; Pโ=โ.01). Most patients with organ-space infections also had grades B/C fistulae (15 of 24 [62.5%] vs 4 of 143 [2.8%] in patients with no SSI; Pโ<โ.001). Organ/space but not superficial SSI was associated with an increased rate of sepsis (7 of 24 [29.2%] vs 4 of 143 [2.8%]; Pโ<โ.001) and prolonged length of hospital stay (12 vs 8 days; Pโ=โ.04). Among patients in the NSQIP-HPB Collaborative, 2057 (19.8%) had any SSI; 719 (6.9%), superficial SSI; 207 (2%), deep-incisional SSI; and 1287 (12.4%), organ-space SSI. Preoperative biliary stenting was confirmed as an independent risk factor for superficial SSI (OR, 2.07; 95% CI, 1.58-2.71; Pโ<โ.001). In this larger data set, soft gland texture was an independent risk factor for superficial SSI (OR, 1.45; 95% CI, 1.14-1.85; Pโ=โ.002) but was more strongly and significantly associated with organ-space SSI (OR, 2.32; 95% CI, 1.88-2.85; Pโ<โ.001).
Conclusions and Relevance
Preoperative biliary stenting and coriticosteroid use increase superficial SSI, even in patients receiving perioperative piperacillin-tazobactam. Additional measures, including extended broad-spectrum perioperative antibiotic treatment, should be considered in these patients. Organ/space SSIs appear to be related to pancreatic fistulae, which are not modifiable. Reporting these different subtypes as a single, overall rate may be misleading.
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