[Quality improvement program of nosocomial infection in colorectal cancer surgery]

Development and pilot study of an essential set of indicators for general surgery services

INTRODUCTION

At present there is a lack of appropriate quality measures for benchmarking in general surgery units of Spanish National Health System. The aim of this study is to present the selection, development and pilot-testing of an initial set of surgical quality indicators for this purpose.

METHODS

A modified Delphi was performed with experts from the Spanish Surgeons Association in order to prioritize previously selected indicators. Then, a pilot study was carried out in a public hospital encompassing qualitative analysis of feasibility for prioritized indicators and an additional qualitative and quantitative three-rater reliability assessment for medical record-based indicators. Observed inter-rater agreement, prevalence adjusted and bias adjusted kappa and non-adjusted kappa were performed, using a systematic random sample (n=30) for each of these indicators.

RESULTS

Twelve out of 13 proposed indicators were feasible: 5 medical record-based indicators and 7 indicators based on administrative databases. From medical record-based indicators, 3 were reliable (observed agreement >95%, adjusted kappa index >0.6 or non-adjusted kappa index >0.6 for composites and its components) and 2 needed further refinement.

CONCLUSIONS

Currently, medical record-based indicators could be used for comparison purposes, whilst further research must be done for validation and risk-adjustment of outcome indicators from administrative databases. Compliance results in the adequacy of informed consent, diagnosis-to-treatment delay in colorectal cancer, and antibiotic prophylaxis show room for improvement in the pilot-tested hospital.

[Benchmarking in the emergency unit process in 7 hospitals from different autonomous communities]

OBJECTIVE

To identify and to share the results among hospitals regarding the process of attention at the Emergency Unit, and to detect the practices that explain the differences.

MATERIAL AND METHOD

SETTING

7 hospitals of different regions in Spain.

PERIOD OF STUDY

2005-2007. Firstly the comparability criteria were defined assuring the homotecia in the «emergency process». In order to fulfil the study objectives, 11 criteria were selected and every center sent the information of each one. 7 indicators were identified to compare hospitals processes'. Data regarding all the attentions provided during the study period was analyzed, establishing the benchmark among the centers. Finally, a questionnaire was elaborated for the process analysis, considering all the stages of the process, the resources and the procedures used in every stage, to be fulfilled in each hospital.

RESULTS

The homotecia has been verified in the 7 hospitals, with some differences between centers. 7 indicators have been analyzed in the different hospitals, corresponding to 1,526,890 patients attended in the study period. A benchmark has been identified, with the best results in four of seven indicators: % of admissions from urgencies: 8.3%, emergency pressure: 56.14%, emergency length of stay: 2 hs 20min, and % of patients with length stay > 24h: 0.05%. Differences between the stages of the process, resources and procedures used in every stage in the benchmark center have been analyzed.

CONCLUSIONS

A set of indicators to compare Emergency Departments has been identified, letting us establish the benchmark.

Species distribution and antimicrobial susceptibility of gram-negative aerobic bacteria in hospitalized cancer patients

Background

Nosocomial infections pose significant threats to hospitalized patients, especially the immunocompromised ones, such as cancer patients.

Methods

This study examined the microbial spectrum of gram-negative bacteria in various infection sites in patients with leukemia and solid tumors. The antimicrobial resistance patterns of the isolated bacteria were studied.

Results

The most frequently isolated gram-negative bacteria were Klebsiella pneumonia (31.2%) followed by Escherichia coli (22.2%). We report the isolation and identification of a number of less-frequent gram negative bacteria (Chromobacterium violacum, Burkholderia cepacia, Kluyvera ascorbata, Stenotrophomonas maltophilia, Yersinia pseudotuberculosis, and Salmonella arizona). Most of the gram-negative isolates from Respiratory Tract Infections (RTI), Gastro-intestinal Tract Infections (GITI), Urinary Tract Infections (UTI), and Bloodstream Infections (BSI) were obtained from leukemic patients. All gram-negative isolates from Skin Infections (SI) were obtained from solid-tumor patients. In both leukemic and solid-tumor patients, gram-negative bacteria causing UTI were mainly Escherichia coli and Klebsiella pneumoniae, while gram-negative bacteria causing RTI were mainly Klebsiella pneumoniae. Escherichia coli was the main gram-negative pathogen causing BSI in solid-tumor patients and GITI in leukemic patients. Isolates of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, and Acinetobacter species were resistant to most antibiotics tested. There was significant imipenem -resistance in Acinetobacter (40.9%), Pseudomonas (40%), and Enterobacter (22.2%) species, and noticeable imipinem-resistance in Klebsiella (13.9%) and Escherichia coli (8%).

Conclusion

This is the first study to report the evolution of imipenem-resistant gram-negative strains in Egypt. Mortality rates were higher in cancer patients with nosocomial Pseudomonas infections than any other bacterial infections. Policies restricting antibiotic consumption should be implemented to avoid the evolution of newer generations of antibiotic resistant-pathogens.

Microbial spectrum and antibiotic susceptibility profile of gram-positive aerobic bacteria isolated from cancer patients

PURPOSE

Cancer patients are particularly susceptible to nosocomial infections because of their compromised immune system, and because of the nature of treatment practices they experience. Recently, a shift of the microbial spectrum of cancer patients from gram-negative to gram-positive has been demonstrated. This study analyzed the distribution and the antimicrobial resistance of gram-positive bacteria isolated from cancer patients in Egypt.

PATIENTS AND METHODS

We examined the microbial spectrum of gram-positive bacteria in patients with hematologic malignancies and solid tumors. In addition, we also studied the antimicrobial resistance of pathogens accounting for the majority of gram-positive infections in these cancer patients.

RESULTS

Most of gram-positive isolates from urinary tract (100%), respiratory tract (89.7%), and bloodstream infections (BSIs; 65.5%) were obtained from leukemic patients. All gram-positive isolates from skin infections were isolated from solid-tumor patients. In both leukemic and solid-tumor patients, gram-positive bacteria causing nosocomial BSI were mainly Coagulase-negative staphylococcus (CNS) and S. aureus, whereas gram-positive bacteria causing nosocomial RTI were mainly alpha-hemolytic streptococci and CNS. Gram-positive bacteria were not isolated from GI tract infections. S. aureus, CNS, and alpha-hemolytic streptococci demonstrated methicillin resistance (81.5%, 92.3%, and 90% resistance, respectively). S. aureus and CNS were susceptible to linezolid (15.4% and 0% resistance, respectively), and vancomycin (15.5% and 11% resistance, respectively).

CONCLUSION

This is the first study to report the emergence of vancomycin- and linezolid-resistant S. aureus in Egypt. Newer generation quinolones (moxifloxacin and gatifloxacin) were more active than older quinolones (ciprofloxacin and ofloxacin) against S. aureus and CNS, suggesting the use of newer generation quinolones in the prophylaxis of cancer patients.

Bacterial contamination of hospital bed-control handsets in a surgical setting: a potential marker of contamination of the healthcare environment

INTRODUCTION

Patients undergoing colorectal surgical resections have a high incidence of surgical site infection (SSI). Many patient-specific risk factors have been recognised in association with SSI in such patients, but environmental contamination is increasingly recognised as a contributor to hospital-acquired infection (HAI). This study set out to describe the bacterial contamination of the patient environment, using hospital bed-control handsets, as they are frequently handled by both staff and patients and represent a marker of environmental contamination.

PATIENTS AND METHODS

On two unannounced sampling events, 1 week apart, 140 bacteriological assessments were made of 70 hospital bed control handsets within a specialist colorectal surgical unit.

RESULTS

Of the handsets examined, 67 (95.7%) demonstrated at least one bacterial species (52.9% grew 1, 30% grew 2 and 12.9% grew 3 or more bacterial species). Of these, 29 (41.4%) bed-control handsets grew bacteria known to cause nosocomial infection, including 22 (31.4%) handsets which grew Enterococcus spp., 9 (12.9%) which grew MRSA, 2 (2.9%) which grew MSSA, 2 (2.9%) which grew coliforms, and 1 (1.4%) handset which grew anaerobes. At 1-week follow-up, 31 bed-control handsets showed evidence of contamination by the same bacterial species.

CONCLUSIONS

This study revealed high levels of bacteria known to cause HAI, contaminating hospital bed-control handsets in a surgical setting. Further study is now required to confirm whether hospital environmental contamination is causally involved in SSI.

[Effect of surveillance on surgical site infection rate in knee and hip arthroplasty]

OBJECTIVE

To determine whether continuous surveillance of hospital-associated infections with regular feedback to the staff reduces the infection rate in orthopedic surgery.

MATERIAL AND METHODS

Prospective surveillance in two time periods in an orthopedic surgery department at a Spanish university hospital. Two infection control nurses and an epidemiologist surveyed all patients over a 3-year period for infections and potential risk factors. After an initial 24-month period (period A), surveillance for 12 months was conducted (period B). Between them adherence to recommendations was reinforced.

MAIN RESULTS

A total of 1,088 patients were surveyed. In period A, 3.3% of all operations were followed by an infection, compared with 2.0% in period B (p = 0.14). Adherence to recommended schedule of surgical prophylaxis increased from 8.7% in the first year to 32.7% in the last year (p < 0,001). We also determined the NNIS (National Nosocomial Infections Surveillance) index risk in 383 patients, the NNIS index-risk 2 being more frequent in period A (16.8%) than in period B (5.4%) (p<0.001). Renal failure frequency was higher in period A (3.4% vs. 1.6%; p = 0.04). However, diabetes and neoplasms were the same in both periods. In period B, chronic obstructive pulmonary disease (COPD) (14.6 vs. 11.0; p = 0.05) and obesity (12.8 vs. 10.3; p = 0.12) predominated. The means for surgical intervention, hospital stay, and age, were very similar in both periods.

CONCLUSIONS

Surveillance of hospital-associated infections including regular feedback to the staff is accompanied by a reduction in infection rates, possibly with lower cost and most patient safety. Therefore, such a surveillance program for orthopedic surgery department seems to be beneficial.

Efecto de la vigilancia sobre la tasa de infección de la herida quirúrgica en prótesis de cadera y rodilla

OBJECTIVE

To determine whether continuous surveillance of hospital-associated infections with regular feedback to the staff reduces the infection rate in orthopedic surgery.

MATERIAL AND METHODS

Prospective surveillance in two periods of time in an orthopedic surgery department at a Spanish university hospital. Two infection control nurses and an epidemiologist surveyed all patients over a 3-year period for infections and potential risk factors. After an initial 24-month period (period A), surveillance for 12 months was conducted (period B). Between these periods, adherence to recommendations was reinforced.

RESULTS

A total of 1,088 patients were surveyed. In period A, 3.3% of all operations were followed by an infection, compared with 2.0% in period B (p = 0.14). Adherence to recommended schedule of surgical prophylaxis increased from 8.7% in the first year to 32,7% in the last year (p = 0.001). We also determined the NNIS (National Nosocomial Infections Surveillance) index risk in 383 patients, with the NNIS index-risk 2 as more frequent in period A (16.8%) than the period B (5.4%) (p < 0.001). Renal failure frequency was higher in period A (3.4% vs. 1.6%; p = 0.04). However, diabetes and neoplasms were the same in both periods. In period B, chronic obstructive pulmonary disease (14.6 vs. 11.0; p = 0.05) and obesity (12.8 vs. 10.3; p = 0.12) predominated. The means for surgical intervention, hospital stay, and age, were very similar in both periods.

CONCLUSIONS

Surveillance of hospital-associated infections including regular feedback to the staff is accompanied by a reduction in infection rates, possibly with lower cost and more patient safety. Thus, such a surveillance program for orthopedic surgery department seems to be beneficial.

Dosis única preoperatoria de metronidazol más gentamicina para profilaxis antibiótica en cirugía colorrectal

BACKGROUND AND OBJECTIVE

To prove that a single-preoperative dose (SD) of metronidazole plus gentamicin guarantees the same clinical effectiveness than the same dose administered in a multiple-perioperative schedule (MD), with a reduction of the direct costs.

PATIENTS AND METHOD

A retrospective cohort study with patients undergoing elective colorectal surgery between 1995 and 2003 was designed. Patients in the cohort of cases received a SD of metronidazole 1500 mg plus gentamicin 240 mg between 1999 and 2003. Patients included in the cohort of controls received the same dose of antibiotics in a MD schedule between 1995 and 1997. Clinical effectiveness was evaluated as length of stay, mortality and rate of surgical-related infections. Economic analysis was performed using direct costs of therapy exclusively.

RESULTS

414 patients were included in the cohort of MD and 978 were included in the cohort of SD. Total length of stay (standard deviation) was 15.1 (16.2 days), with a significant reduction in the SD cohort versus the MD cohort: 14.0 (15.4) days versus 17.5 (17.8) days (p < 0.001). No differences in mortality (overall rate 3.2%) or surgical infection rate (overall rate 8.6%) between cohorts were found. SD schedule produces a 35% cost-reduction per procedure.

CONCLUSIONS

Attending the clinical effectiveness, no differences between SD and MD cohorts were found. Therefore, according to logistics advantages and costs reduction, the SD of antibiotic is considered the most efficient option.

Surveillance and risk factors on hysterectomy wound infection rate in Gran Canaria, Spain

OBJECTIVES

Surveillance programs for nosocomial infection control may find out opportunities for improvement. The aim of this study was to determine the incidence of surgical site infection and their potential risk factors after hysterectomy in a tertiary hospital in Gran Canaria, Spain.

STUDY DESIGN

Prospective study on patients undergoing abdominal or vaginal hysterectomy between 1st June 2000 and 31st December 2004. Surgical site infection incidence rates were calculated according to procedure, and National Nosocomial Infection Surveillance (NNIS) system risk categories. We also reviewed antimicrobial prophylaxis use and morbidity. To determine associate risk factors a multivariate analysis was performed.

RESULTS

A total of 1540 women were surveyed; neoplasm (30.5%), obesity (24.3%), and diabetes (16.2%) grouped the main morbidity. About 81 cases (5.2%) met criteria for postoperative surgical site infection (6.0% for abdominal procedure and 3.1% for vaginal procedure). Most patients (86.4%) had adequate antimicrobial prophylaxis, but inadequacy was more frequent by vaginal (17.6%) than abdominal procedure (12.0%) (p=0.005). NNIS high-risk patients had significantly higher infection rates than did low-risk patients (p=0.01). The most common causative organism isolated was Escherichia coli (17.5%). Multivariate analysis showed obesity, inadequate antimicrobial prophylaxis, and abdominal procedure as the main risk factors.

CONCLUSION

Rate of surgical site infection is high. Enhanced and multidisciplinary efforts are needed.