Gender-Specific Differences in Surgical Site Infections: An Analysis of 438,050 Surgical Procedures from the German National Nosocomial Infections Surveillance System

Epidemiology of non-trauma orthopedic conditions among inpatients admitted at a tertiary teaching and referral hospital in Kenya: A chart review

Non-traumatic orthopedic conditions are pathological conditions involving musculoskeletal system that includes muscles, tendons, bone and joints and associated with frequent medical and surgical care and high treatment costs. There is paucity of information on the pattern of non-traumatic orthopedic conditions in low and middle income countries. The purpose of this study was to determine the epidemiology of non-traumatic orthopedic conditions among inpatients at the Kenyatta National Hospital in Kenya. This was a cross-sectional study with a sample of 175 charts reviewed. Approximately, 70.3% of the inpatients were aged between 25 to 64 years of age with the mean age of 39.97 years (STD 18.78). Ever married tended to be older 53.5 (95% CI: 46.8-60.2) years than other marital statuses. Approximately, 60.6% were males, 38.9% had comorbidities and 49.1% were casuals or unemployed. All inpatients were Kenyans with Nairobi County comprising 52.6% of all inpatients. Approximately, 77.7% were self-referrals. The commonest non-trauma orthopaedic conditions were infection and non-union (35.4%) and spinal degenerative diseases (20.60%) and the least was limb deformities (1.70%). Compared to females, males were 3.703 (p<0.001) times more likely to have infection and non-union. Patients with primary, secondary and tertiary education were 88.2% (p<0.001), 75.6% (p<0.001) and 68.1% (p = 0.016) less likely to have infection and non-union compared to those with no or preschool education. Widows were 8.500 (p = 0.028) times more likely to have spinal degenerative disease than married. Males were 70.8% (p = 0.031) less likely to have osteoarthritis than females. Inpatients with secondary education were 5.250 (p = 0.040) times more likely to have osteoarthritis than those with no or preschool education. In conclusion, majority of inpatients were young and middle aged adults. Infection and non-union and spinal degenerative diseases were the most common non-trauma orthopedic conditions. While males and those with low education were more likely to have infection and non-union, married were more likely to have spinal degenerative disease. Osteoarthritis was more likely among female admissions.

Sex differences in surgical site infections following coronary artery bypass grafting: a retrospective observational study

BACKGROUND

Surgical site infection (SSI) following cardiac surgery poses a significant challenge for healthcare providers. Despite advances in surgical techniques and infection control measures, SSI remains a leading cause of morbidity and mortality, in addition to being a significant economic burden on healthcare services. Current literature suggests there is a reproducible difference in the incidence of SSI following cardiac surgery between sexes. We aim to assess the sex-specific predictive risk factors for sternal SSI following coronary artery bypass grafting (CABG) in addition to identifying any differences in the causative organisms between groups.

METHODS

Adult patients undergoing isolated CABG between January 2012 and December 2022 in one UK hospital organization were included. In this 10-year, retrospective observational study, a total of 10,208 patients met the inclusion criteria. Pre-operative risk factors were identified using univariate analysis. To assess dependence between sex and organism or Gram stain, a Pearson Chi-squared test with Yates correction for continuity was performed.

RESULTS

In total there were 8457 males of which 181 developed a sternal SSI (2.14%) and 1751 females, 128 of whom had a sternal SSI (7.31%). Male patients were found to be significantly more likely to develop an SSI secondary to a Gram-positive organism, whereas female patients were more likely to have a Gram-negative causative organism (P<0.00001). Staphylococcus was statistically more likely to be the causative organism genus in male patients. Pseudomonas aeruginosa was found to be twice as common in the female cohort compared with the male group.

CONCLUSION

In our study, we found a statistically significant difference in the causative organisms and Gram stain for post-CABG sternal SSIs between males and females. Male patients predominately have Gram-positive associated SSIs, whereas female SSI pathogens are more likely to be Gram negative. The preoperative risk profiles of both cohorts are similar, including being an insulin-dependent diabetic and triple vessel coronary artery disease. Given these findings, it prompts the question, should we be tailoring our SSI treatment strategies according to sex and associated risk profiles?

A Health Economic Analysis Exploring the Cost Consequence of Using a Surgical Site Infection Prevention Bundle for Hip and Knee Arthroplasty in Germany

Background

According to the European Centre for Disease Prevention and Control, surgical site infections (SSIs) constitute over 50% of all hospital-acquired infections. Reducing SSIs can enhance healthcare efficiency.

Objective

This study explores the cost consequences of implementing an SSI prevention bundle (SPB) in total hip and knee arthroplasty (THKA).

Methods

A health-economic model followed a cohort of THKA patients from admission to 90 days postdischarge. The perioperative process was modeled using a decision tree, and postoperative recovery and potential SSI evaluated using a Markov model. The model reflects the hospital payers' perspective in Germany. The SPB includes antimicrobial incision drapes, patient warming, and negative pressure wound therapy in high-risk patients. SSI reduction associated with these interventions was sourced from published meta-analyses. An effectiveness factor of 70% was introduced to account for potential overlap of effectiveness when interventions are used in combination. Sensitivity analyses were performed to assess the robustness of model outcomes.

Results

The cost with the SPB was €4274.32 per patient, €98.27, or 2.25%, lower than that of the standard of care (€4372.59). Sensitivity analyses confirmed these findings, indicating a median saving of 2.22% (95% credible interval: 1.00%-3.79%]). The SPB also reduced inpatient SSI incidence from 2.96% to 0.91%. The break-even point for the SPB was found when the standard of care had an SSI incidence of 0.938%. Major cost drivers were the cost of inpatient SSI care, general ward, and operating room, and the increased risk of an SSI associated with unintended, intraoperative hypothermia. Varying the effectiveness factor from 10% to 130% did not substantially impact model outcomes.

Conclusions

Introducing the SPB is expected to reduce care costs if the inpatient SSI rate (superficial and deep combined) in THKA procedures exceeds 1%. Research into how bundles of measures perform together is required to further inform the results of this computational analysis.

A clinical prediction model for predicting the surgical site infection after an open reduction and internal fixation procedure considering the NHSN/SIR risk model: a multicenter case-control study

Introduction

Surgical site infection (SSI) is one of the most common surgical-related complications worldwide, particularly in developing countries. SSI is responsible for mortality, long hospitalization period, and a high economic burden.

Method

This hospital-based case-control study was conducted in six educational hospitals in Tehran, Iran. A total of 244 patients at the age of 18-85 years who had undergone open reduction and internal fixation (ORIF) surgery were included in this study. Among the 244 patients, 122 patients who developed SSIs were selected to be compared with 122 non-infected patients used as controls. At the second stage, all patients (n = 350) who underwent ORIF surgery in a hospital were selected for an estimation of the standardized infection ratio (SIR). A logistic regression model was used for predicting the most important factors associated with the occurrence of SSIs. Finally, the performance of the ORIF prediction model was evaluated using discrimination and calibration indices. Data were analyzed using R.3.6.2 and STATA.14 software.

Results

Klebsiella (14.75%) was the most frequently detected bacterium in SSIs following ORIF surgery. The results revealed that the most important factors associated with SSI following an ORIF procedure were found to be elder age, elective surgery, prolonged operation time, American Society of Anesthesiologists score of ≥2, class 3 and 4 wound, and preoperative blood glucose levels of >200 mg/dl; while preoperative higher hemoglobin level (g/dl) was found to be a protective factor. The evidence for the interaction effect between age and gender, body mass index and gender, and age and elective surgery were also observed. After assessing the internal validity of the model, the overall performance of the models was found to be good with an area under the curve of 95%. The SIR of SSI for ORIF surgery in the selected hospital was 0.66 among the patients aged 18-85 years old.

Conclusion

New risk prediction models can help in detecting high-risk patients and monitoring the infection rate in hospitals based on their infection prevention and control programs. Physicians using prediction models can identify high-risk patients with these factors prior to ORIF procedure.

Assessment of risk factors associated with surgical site infection following abdominal surgery: a systematic review

Objective

Surgical site infections (SSIs) are among the most common healthcare-associated infections occurring following 1%-3% of all surgical procedures. Their rates are the highest following abdominal surgery. They are still associated with increased morbidity and healthcare costs despite the advancement in the medical field. Many risk factors for SSIs following abdominal surgery have been identified. The aim of this study is to comprehensively assess these risk factors as published in peer-reviewed journals.

Design

A systematic review was conducted with accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

Setting

The databases for search were PubMed and Cochrane Library, in addition to reference lists. Studies were retrieved and assessed for their quality. Data were extracted in a designed form, and a stratified synthesis of data was conducted to report the significant risk factors.

Participants

Patients undergoing general abdominal surgery.

Intervention

The intervention of general abdominal surgery.

Main outcome measures

To identify and assess the risk factors for SSI following abdominal surgery.

Results

Literature search yielded 813 articles, and the final screening process identified 11 eligible studies. The total number of patients is 11 996. The rates of SSI ranged from 4.09% to 26.7%. Nine studies were assessed to be of high quality, the remaining two studies have moderate quality. Stratified synthesis of data was performed for risk factors using summary measures (OR/risk ratio, 95% CI, and p value). Male sex and increased body mass index (BMI) were identified as significant demographic risk factors, and long operative time was among the major significant procedure-related risk factors.

Conclusions

Male sex, increased BMI, diabetes, smoking, American Society of Anesthesiologists classification of >2, low albumin level, low haemoglobin level, preoperative hospital stay, long operative time, emergency procedure, open surgical approach, increased wound class, intraoperative blood loss, perioperative infection, perioperative blood transfusion, and use of drains are potential independent risk factors for SSI following abdominal surgery.

No impact of sex on surgical site infections in abdominal surgery: a multi-center study

OBJECTIVE

Male sex is controversially discussed as a risk factor for surgical site infections (SSI). The aim of the present study was to evaluate the impact of sex on SSI in abdominal surgery under elimination of relevant confounders.

METHODS

Clinicopathological data of 6603 patients undergoing abdominal surgery from a multi-center prospective database of four Swiss hospitals including patients between 2015 and 2018 were assessed. Patients were stratified according to postoperative SSI and risk factors for SSI were identified using univariate and multivariate analysis.

RESULTS

In 649 of 6603 patients, SSI was reported (9.8%). SSI was significantly associated with reoperation (22.7% vs. 3.4%, p < 0.001), increased mortality rate (4.6% vs. 0.9%, p < 0.001), and increased rate of length of hospital stay > 75th percentile (57.0% vs. 17.9%, p < 0.001). In univariate analysis, male sex was a significant risk factor for SSI (p = 0.01). In multivariate analysis including multiple confounders' such as comorbidities and perioperative factors, there was no association between male sex and risk of SSI (odds ratio (OR) 1.1 [CI 0.8-1.4]). Independent risk factors for SSI in multivariate analysis were BMI ≥ 30 kg/m² (OR 1.8 [CI 1.3-2.3]), duration of surgery > 75th percentile (OR 2.3 [1.8-2.9]), high contamination level (OR 1.3 [1.0-1.6]), laparotomy (OR 1.3 [1.0-1.7]), previous laparotomy (OR 1.4 [1.1-1.7]), blood transfusion (OR 1.7 [1.2-2.4]), cancer (OR 1.3 [1.0-1.8] and malnutrition (OR 2.5 [1.8-3.4]).

CONCLUSION

Under elimination of relevant confounders, there is no significant correlation between sex and risk of SSI after abdominal surgery.

Development of a Nomogram for Predicting Surgical Site Infection in Patients with Resected Lung Neoplasm Undergoing Minimally Invasive Surgery

Background: Predictive models are necessary to target high-risk populations and provide precision interventions for patients with lung neoplasm who suffer from surgical site infections (SSI). Patients and Methods: This case control study included patients with lung neoplasm who underwent minimally invasive surgeries (MIS). Logistic regression was used to generate the prediction model of SSI, and a nomogram was created. A receiver operator characteristic (ROC) curve was used to examine the predictive value of the model. Results: A total of 151 patients with SSI were included, and 604 patients were randomly selected among the patients without SSI (ratio 4:1). Male gender (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.57-4.15; p < 0.001), age >60 years (OR, 2.10; 95% CI, 1.29-3.44, p = 0.003), operation time >60 minutes (all categories, p < 0.05), treatments for diabetes mellitus (OR, 2.96; 95% CI, 1.75-4.98l; p < 0.001), and best forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC; OR, 0.96; 95% CI, 0.94-0.99; p = 0.008) were independently associated with SSI. The model based on these variables showed an area under the curve (AUC) of 0.813 for predicting SSI. Conclusions: A nomogram predictive model was successfully established for predicting SSI in patients receiving MIS, with good predictive value.

Risk factors of surgical site infection in elective laparotomy in a tertiary care center: an observational study

INTRODUCTION

Surgical site infections (SSI) encompass 20-25% of all hospital-acquired infections with their prevalence ranging from 2.5 to 41.9% across the world. Prevalence and risk factors of SSI vary greatly between countries and between healthcare institutions within a country. There is limited data on the pattern and risk factors of SSI in the Indian healthcare scenario. This study is an attempt to identify risk factors of SSI in patients who underwent elective laparotomy in the general surgery department of a tertiary care hospital in India.

METHODOLOGY

This is an observational cross-sectional retrospective study, conducted over 5 years from January 1, 2015, to December 31, 2019. A total of 112 patients who underwent elective laparotomy in the department of general surgery, were enrolled in the study. Data collection was done from hospital case records and discharge summaries of patients.

RESULTS AND DISCUSSION

Out of the 112 patients, a total of 16 patients (14.29%) developed surgical site infections. Preoperative serum total protein (W-465.500, P 0.012) and length of hospital stay (W=1235.000, P≤0.001) were found to have a significant association with surgical site infection. Age, gender, smoking, comorbidity, class of surgical wound and, preoperative albumin did not show any significant association with the development of SSI. Escherichia coli was the predominant organism isolated in culture.

CONCLUSION

Measures to curtail SSI can only be adopted after a thorough understanding of its prevalence and predictors. The characteristics and pattern of SSI will help identify prevalent organisms, their resistance pattern and will aid in formulating antibiotic policy tailor-made for the healthcare institution.

Use of prophylactic antibiotics on surgical site infections in arthroplasty patients (Scoping Review)

Background

Increased demand for arthroplasty also increases the number of complications of arthroplasty, especially surgical site infection (SSI). One of the effective strategies in preventing surgical site infection is the use of appropriate prophylactic antibiotics.

Objective

To identify and analyse information from clinical studies regarding factors affecting the effectiveness of prophylactic antibiotics in arthroplasty patients.

Methods

A scoping review was conducted through the PubMed, Scopus, and Google Scholar databases within a publication range from January 2004 to August 2020. Study data are extracted and analysed by a minimum of two reviewers.

Results

The search results found 2.419 articles, with 39 articles were included for further analysis. Cefazolin monotherapy was the most frequently studied antibiotic (15 articles) followed by vancomycin monotherapy (8 articles). Most widely used antibiotics in arthroplasty were cefazolin mono-therapy (997.599 procedures with SSI incidence range: 0,20–16,05%) followed by vancomycin mono-therapy (125.170 procedures with SSI incidence range: 0.27–3,88%) The correct antibiotic dose has a lower percentage of the SSI than the wrong antibiotic dose. Meanwhile, administration of antibiotics within single dose or <24 h had a lower SSI percentage than administration of antibiotics >24 h. Administration antibiotics before incision also have a lower SSI percentage than after incision. There were no studies that discussed re-dosing of antibiotics in this scoping review.

Conclusions

There is still a need for further research related to the duration and specific timing of first dose of prophylactic antibiotics, especially regarding single dose or multiple dose antibiotics to obtain maximum effectiveness of antibiotic prophylaxis

Rates of Infection After ACL Reconstruction in Pediatric and Adolescent Patients: A MarketScan Database Study of 44,501 Patients

BACKGROUND

Numerous studies have demonstrated an increase in the number of anterior cruciate ligament (ACL) reconstruction procedures performed in pediatric patients. Despite this, most knowledge of surgical site infection rates after these procedures are based on adult studies and data is currently limited in pediatric patients. The purpose of this study was to describe and analyze the rates of infection after ACL reconstruction among pediatric patients and adolescent patients (compared with young adult patients) utilizing the MarketScan Commercial Claims and Encounters Database.

METHODS

The Truven Health Analytics MarketScan Commercial Claims and Encounters database was assessed to access health care utilization data for privately insured individuals aged 5 to 30 years old. ACL reconstruction records performed between 2006 and 2018 were identified using Current Procedures Terminology (CPT) codes. International Classification of Diseases Ninth Revision (ICD-9), Tenth (ICD-10) codes and CPT codes were used to identify patients requiring treatment for infection. All patients had at least 180 days of insurance coverage after intervention.

RESULTS

A total of 44,501 individuals aged below 18 years old and 63,495 individuals aged 18 to 30 years old that underwent arthroscopic ACL reconstruction were identified. There were no differences in infection rates between those below 18 years old (0.52%) and those above 18 years old (0.46%, P=0.227). However, among patients below 18 years old, patients below 15 years old had a significantly lower rate of infection at 0.37% compared with adolescents (15 to 17 y old) at 0.55% (P=0.039). Among young adults, males had higher rates of infection than females (0.52% vs. 0.37%), while no difference was observed in the pediatric and adolescent population (0.58% vs. 0.47%, P=0.109).

CONCLUSION

Utilizing an insurance database, this study demonstrated that rates of infection after ACL Reconstruction in a pediatric/adolescent population are low (0.52%) and similar to rates in young adults. Infection rates after ACLR reconstruction appear to be slightly lower in patients under 15 years of age (0.37%).

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

Impact of patients' gender on microvascular lower extremity reconstruction

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.

Surgical Site Infection Post-appendectomy in a Tertiary Hospital, Jeddah, Saudi Arabia

BACKGROUND AND PURPOSE

Appendectomy considered at the top of emergency surgical procedures worldwide, and surgical site infection (SSI) is not an uncommon complication postoperatively. Many factors may be contributed to SSI occurrence; either during preoperative, intraoperative, or postoperative periods. No recent studies focusing on SSI post-appendectomy and the related factors in our region. So, we aim to find the prevalence and detect the factors that may lead to SSI in post-appendectomy patients at King Abdulaziz University Hospital (KAUH) between 2013 and 2017.

METHODS

This is a retrospective chart review study. Data were collected by data collection sheet from (KAUH) patient's database, as we include: patients' demographics, blood investigations, operation details, co-morbidities, and hospitalization time. All patients who underwent appendectomy between 2013 and 2017 were included. We used frequencies, Mann-Whitney U test, and binary logistic regression tests for data analysis.

RESULT

SSI post-appendectomy was found in 31 patients out of 433. SSI was statistically significant related more with an open technique of appendectomy (p=0.0001), longer duration of the surgery (p=0.0001), perforated type of appendicitis (p=0.002), more hospitalization time (p=0.0004), postoperative lab results of high WBC count (p=0.004), and low albumin (p=0.011). Other factors including demographics and clinical characteristics, intraoperative, perioperative, and hemoglobin level showed no significant relations.

CONCLUSION

Controlling the high rate of SSI by using the optimal technique of approach, decreasing the duration of the surgery, and early intervention may help more in reducing SSI post-appendectomy. Taking into consideration the other perioperative factors will lead to better outcomes for the patients.

High Prevalence of Antibiotic-Resistant Gram-Negative Bacteria Causing Surgical Site Infection in a Tertiary Care Hospital of Northeast India

Background and objective Surgical site infections (SSI) are the most common healthcare-associated infections in low- and middle-income countries associated with substantial morbidity and mortality and impose heavy demands on healthcare resources. We aimed to study the microbiological profile of SSI pathogens and their antibiotic-resistant patterns in a tertiary care teaching hospital serving mostly rural population Methods A prospective, hospital-based cross-sectional study on pathogen profile and drug resistance was conducted from January 2015 to December 2016. Study subjects were the patients who developed signs of SSI after undergoing surgical procedures at three surgical wards (General Surgery, Orthopedics, and Obstetrics & Gynecology). The selection of the patients was based on CDC Module. Standard bacteriological methods were applied for isolation of pathogens and antibiotic-susceptibility testing based on CLSI (Clinical Laboratory Standard Institute) guidelines. Results Out of 518 enrolled subjects, 197 showed growth after aerobic culture yielding 228 pathogen isolates; 12.2% of samples showed polymicrobial growth. Escherichia coli (22.4%) and Klebsiella species (20.6%) were the predominant isolated bacteria followed by Staphylococcus species (18.4%), Pseudomonas species (12.3%), and Enterococcus species (6.6%). Gram-negative bacteria (GNB) were highly resistant to ampicillin (90.1%) and cefazolin (85.9%). High resistance was also observed to mainstay drugs like ceftriaxone (48.4%), cefepime (61%), amoxycillin-clavulanic acid (43.4%), and ciprofloxacin/levofloxacin (37.7%). Among the Gram-positive cocci, Staphylococcus aureus showed 85-96% resistance to penicillin and 65-74% to ampicillin. But GPCs were relatively less resistant to quinolones (16-18%) and macrolides (21.5%). S. aureus was 100% sensitive to vancomycin and clindamycin but vancomycin-resistant Enterococci was encountered in 3/15 (20%) isolates. Conclusion GNBs were responsible for more than two-thirds of aerobic-culture positive SSI and showed high resistance to the commonly used antibiotics thus leaving clinicians with few choices. This necessitates periodic surveillance of causative organisms and their antibiotic-susceptibility pattern to help in formulating hospital antibiotic policy. The antibiotic stewardship program is yet to be adopted in our hospital.

Burden of Staphylococcus aureus infections after orthopedic surgery in Germany

BACKGROUND

This study assessed incidence, risk factors, and outcomes of Staphylococcus aureus infections (SAI) following endoprosthetic hip or knee, or spine surgeries.

METHODS

Adult patients with at least one of the selected surgeries from 2012 to 2015 captured in a German sickness fund database were included. SAI were identified using S. aureus-specific ICD-10 codes. Patients with certain prior surgeries and infections were excluded. Cumulative incidence and incidence density of post-surgical SAI were assessed. Risk factors, mortality, healthcare resource utilization and direct costs were compared between SAI and non-SAI groups using multivariable analyses over the 1 year follow-up.

RESULTS

Overall, 74,327 patients who underwent a knee (28.6%), hip (39.6%), or spine surgery (31.8%) were included. The majority were female (61.58%), with a mean age of 69.59 years and a mean Charlson Comorbidity Index (CCI) of 2.3. Overall, 1.92% of observed patients (20.20 SAI per 1000 person-years (PY)) experienced a SAI within 1 year of index hospitalization. Knee surgeries were associated with lower SAI risk compared with hip surgeries (Hazard Ratio (HR) = 0.8; p = 0.024), whereas spine surgeries did not differ significantly from hip surgeries. Compared with non-SAI group, the SAI group had on average 4.4 times the number of hospitalizations (3.1 vs. 0.7) and 7.7 times the number of hospital days (53.5 vs. 6.9) excluding the index hospitalization (p < 0.001). One year post-orthopedic mortality was 22.38% in the SAI and 5.31% in the non-SAI group (p < 0.001). The total medical costs were significantly higher in the SAI group compared to non-SAI group (42,834€ vs. 13,781€; p < 0.001). Adjusting for confounders, the SAI group had nearly 2 times the all-cause direct healthcare costs (exp(b) = 1.9; p < 0.001); and 1.72 times higher risk of death (HR = 1.72; p < 0.001).

CONCLUSIONS

SAI risk after orthopedic surgeries persists and is associated with significant economic burden and risk of mortality. Hence, risk reduction and prevention methods are of utmost importance.

Prophylactic surgical drainage is associated with increased infection following intramedullary nailing of diaphyseal long bone fractures: A prospective cohort study in Nigeria

Introduction: Prophylactic surgical drains are commonly used in Nigeria following intramedullary nailing (IMN) of long bone diaphyseal fractures. However, evidence in the literature suggests that drains do not confer any benefit and predispose clean wounds to infection. This study compares outcomes between patients treated with and without prophylactic surgical drainage following diaphyseal long bone fractures treated with IMN. Methods: A prospective cohort study with randomization was conducted at a tertiary referral center in Enugu, Nigeria. Investigators included skeletally mature patients with diaphyseal long bone (femur, tibia, humerus) fractures treated with SIGN IMN. Patients followed-up at 5, 14, and 30 days post-operatively. The primary outcome was surgical site infection (SSI) rate. Secondary outcomes included post-operative pain at 6 and 12 h, need for blood transfusion, wound characteristics (swelling, ecchymosis, and gaping), need for dressing changes, and length of hospital stay. Results: Of the enrolled patients, 76 (96%) of 79 completed 30-day follow-up. SSI rate was associated with patients who received a prophylactic drain versus those who did not (23.7% vs. 10.5%, p = 0.007). There were no significant differences in transfusion need (p = 0.22), wound swelling (p = 0.74), wound ecchymosis (p = 1.00), wound gaping (p = 1.00), dressing change need (p = 0.31), post-operative pain at 6 h (p = 0.25) or 12 h (p = 0.57), or length of stay (p = 0.95). Discussion: Surgical drain placement following IMN of diaphyseal long bone fractures is associated with a significantly higher risk of SSI. Reducing surgical drain use following orthopaedic injuries in lower resource settings may translate to reduced infection rates.

Risk factors for deep surgical site infection following thoracolumbar spinal surgery

OBJECTIVE

Surgical site infection (SSI) following spine surgery causes major morbidity and greatly impedes functional recovery. In the modern era of advanced operative techniques and improved perioperative care, SSI remains a problematic complication that may be reduced with institutional practices. The objectives of this study were to 1) characterize the SSI rate and microbial etiology following spine surgery for various thoracolumbar diseases, and 2) identify risk factors that were associated with SSI despite current perioperative management.

METHODS

All patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.

RESULTS

In total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.

CONCLUSIONS

This institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.

Surgical Site Infections in Aesthetic Surgery

Surgical site infections represent one of the most common postoperative complications in patients undergoing aesthetic surgery. As with other postoperative complications, the incidence of these infections may be influenced by many factors and varies depending on the specific operation performed. Understanding the risk factors for infection development is critical because careful patient selection and appropriate perioperative counseling will set the right expectations and can ultimately improve patient outcomes and satisfaction. Various perioperative prevention measures may also be employed to minimize the incidence of these infections. Once the infection occurs, prompt diagnosis will allow management of the infection and any associated complications in a timely manner to ensure patient safety, optimize the postoperative course, and avoid long-term sequelae.

[Bowel preparation for elective colorectal surgery in Germany 2017 : Results of a survey among members of the German Society of General and Visceral Surgery]

BACKGROUND

The morbidity after colorectal resection is still high. Perioperative i.v. antibiotic administration has become established as the standard to decrease the wound infection rate. An ongoing discussion is the status of preoperative mechanical bowel preparation. There seems to be evidence that mechanical bowel preparation in combination with administration of oral non-resorbable antibiotics significantly decreases the rate of anastomotic leakage and postoperative wound infections.

OBJECTIVE

In order to obtain an overview on the state of preoperative preparation before elective colorectal surgery in Germany, a survey was initiated among the members of the German Society of General and Visceral Surgery.

MATERIAL AND METHODS

In March 2017 the 5200 members of the German Society of General and Visceral Surgery (DGAV) received via email a link to an online survey on bowel preparation before elective colorectal surgery.

RESULTS

A total of 557 colleagues answered the questionnaire online. Mechanical bowel preparation with orthograde lavage was the predominant method for bowel preparation prior to colon resection in over 50%. In rectal surgery with primary anastomosis and planned protective stoma, mechanical bowel preparation with orthograde lavage dominated with 76.5%. An oral antibiotic administration alone and in combination with mechanical bowel preparation for colon resection was used by less than 10% and 2%, respectively and ca. 11 % for rectal surgery both with and without mechanical bowel preparation.

CONCLUSION

In contrast to the evidence in the current literature to carry out preoperative mechanical preparation of the bowel in combination with an oral antibiotic administration prior to colorectal resection, in practice these recommendations have not become established among the participants of this survey.

A Longitudinal Study of S. aureus Infection in a National Cohort of Surgical Patients

BACKGROUND

Postoperative infections are a common and often preventable complication of surgery. S. aureus is a prevalent organism cultured in these infections and is associated with morbidity, mortality, and increased healthcare utilization. However, the long-term burden of S. aureus infection in surgical patients is not well studied. The purpose of this retrospective observational study is to assess the incidence, time trend, and burden of S. aureus infection up to 1 year after surgery.

METHODS

We obtained manually-reviewed data from the VA Surgical Quality Improvement Program (VASQIP) to identify surgeries in all major specialties. These were combined with laboratory microbiology and pharmacy data to identify pneumonia and infections of the urinary tract, surgical site, and blood.

RESULTS

In the study population of 559,550 patients, S. aureus incidence decreased each year, from 2.1% in 2008 to 1.1% in 2015. Among these, incidence of methicillin-resistant S. aureus (MRSA) infection decreased from 0.7% to 0.4%, and methicillin-susceptible S. aureus (MSSA) decreased from 1.4% to 0.7%. S. aureus infection was associated with increased length of stay, ED utilization, inpatient admissions, as well as a 4-fold increase in mortality.

CONCLUSIONS

This is one of the largest studies describing the long-term incidence of S. aureus in the surgical population of a national integrated healthcare system. We conclude that the burden of S. aureus infection extends well beyond the conventional 30-day postoperative window, and late infection should be included in assessing the effects of interventions.

Impact of blood transfusion on major infection after isolated coronary artery bypass surgery: Incidence and risk factors

Background/aim

Cardiac surgery is considered one of the conditions that require a transfusion of blood and blood products in large amount. Infections are one of the most common complications after cardiac surgery. The aim of this study is to assess the impact of blood transfusion on major infections after isolated coronary artery bypass surgery (CABG).

Methods

A retrospective cohort study was conducted at King Abdulaziz Cardiac Center. Eligible adult patients, aged >18 years, who underwent an isolated CABG from 2015 to 2016, were included. Patient demographic information, as well as pre-, intra-, and postoperative data were collected from the electronic hospital information system charts and perfusion records. For data analysis, categorical pre- and postoperative variables were summarized by frequencies and percentages, whereas for continuous variables, means and standard deviation or median and interquartile ranges were used.

Results

The sample size was 459 patients. Red blood cells (RBCs) were transfused in 60.1% of the patients, and the median number of units transfused per patient was 2. The mean hemoglobin threshold for transfusion was 8.2 (standard deviation ± 3.6) g/dL. The mean EuroSCORE of RBC recipients was 3.8 ± 5.9% and that of non-RBC recipients was 2.0 ± 2.0%. In both groups (RBC recipients and non-RBC recipients), the most frequent infections after CABG were pneumonia (12% and 8.7%, respectively), deep surgical site infection (3.6% and 0.5%, respectively), and superficial sternal infection (6.9% and 3.8%, respectively), with a statistically significant difference (all p < 0.05). Patients receiving a blood transfusion at any stage during the intraoperative or postoperative period were 2.6 times more likely to develop an infection compared with those who did not receive a blood transfusion. The recipients of a blood transfusion experienced a longer hospital stay compared with the non-recipients at 11.5 ± 9.8 days versus 8.7 ± 3.4 days, respectively.

Conclusions

Blood transfusion appears to increase the risk of infection post-CABG. However, increased understanding of the role of other potential clinical confounding variables that may impact the infection rate is required. We recommend management strategies that limit RBC transfusion.

Gender-related risk factors for surgical site infections. Results from 10 years of surveillance in Germany

Background

Surgical site infections (SSI) are among the most frequently occurring healthcare-associated infections worldwide. Various analyses to determine risk factors have been conducted in the past, generally attributing a higher SSI-risk to male patients. However, when focusing on specific procedures, this is not always true. Our objective was to identify for which procedures male or female sex represents an independent risk factor for SSI and which parameters may explain these differences.

Methods

We used the database of surgical procedures from the German national nosocomial infection surveillance system. We included procedures conducted between 2008 and 2017. We excluded procedures solely executed for one sex (e.g. mastectomy) and procedures with 20,000 or fewer operations. The observed outcome was the occurrence of SSI. All models were adjusted for confounders, which were eliminated with backward selection. The following factors were included in the analysis: age, ASA score, wound contamination class, duration of surgery, and season. All models contained the investigated factor sex.

Results

Sixteen procedure types with 1,266,782 individual procedures and 18,824 SSI were included. Overall, the incidence rate ratio and the adjusted odds ratio for SSI were significantly higher for male patients. The included individual procedures were grouped into five surgical categories. For orthopedics and traumatology as well as abdominal surgery, SSI-rates were significantly higher for male patients. For heart and vascular surgery, SSI-rates were significantly higher for female patients. Other included surgical categories and individual procedures yielded diverse results. Similar results were found when solely analyzing deep and organ-space SSI. Multivariable analysis for attributable gender-related risk factors revealed differences with regard to underlying risk factors.

Conclusions

SSI-rates differ by sex for certain procedures. When examining underlying risk factors, differences between male and female patients can be demonstrated. Our analysis considered a limited number of parameters, which were not sufficient to fully explain the observed differences. Further studies are required to obtain a more comprehensive understanding of the topic and to include gender-specific aspects into future SSI-prevention strategies.

Relationship between computed tomography-derived body composition, sex, and post-operative complications in patients with colorectal cancer

INTRODUCTION

In the UK, colorectal cancer is the fourth most common cancer and the second most common cause of cancer death. Surgery is the primary modality of treatment, but it is not without complications. Post-operative complications have been linked to preoperative of weight loss and loss of lean tissue, and also to obesity. Given sex differences in body composition, an examination of body composition and post-operative complications may provide valuable information. Therefore, the aim was to examine the relationship between male/female body composition and post-operative complications in patients with operable colorectal cancer.

METHODS

Patients (n = 741) undergoing operation for colorectal cancer were examined. Preoperative CT scans were used to define the muscle mass and quality, visceral obesity, and subcutaneous adiposity. Post-operative complications, in particular, surgical site infection (SSI) and wound infection (WI) were considered as outcome measures.

RESULTS

Male patients with greater subcutaneous adiposity had higher risk of SSI and WI (p < 0.01 and p ≤ 0.001, respectively). On multivariate analysis, Post-operative Glasgow Prognostic Score (poGPS) on Day 4 (OR 2.11, 95% CI 1.53-2.92, P = 0.001) laparoscopic surgery (OR 0.50, 95% CI 0.26-0.98, P = 0.044), and subcutaneous adiposity (OR 2.71, 95% CI 1.26-5.82, P = 0.011) remained significantly independently associated with overall SSI. Subcutaneous adiposity remained significantly independently associated with WI (OR 3.93, 95% CI 1.33-11.57, P = 0.013). In female patients, however, no significant association was found between any body composition measure and complications.

CONCLUSION

This study showed that increased subcutaneous and visceral adiposity were associated with infective complications in male, but not female patients, after colorectal cancer surgery. Therefore, it is important that sex be taken into account when evaluating the potential impact of body composition on post-operative outcomes in patients undergoing surgery for colorectal cancer.

Determinants of superficial surgical site infections in abdominal surgeries at a Rural Teaching Hospital in Central India: A prospective study

Introduction:

Abdominal surgeries have high rate of surgical site infection (SSI), which leads to significant morbidity and financial burden. There is paucity of studies on SSI in rural Indian setup, where there is scarcity of adequate resources. The aim of this study was to determine the incidence and determinants of SSI after abdominal surgeries in a rural setup.

Aim:

To determine the incidence of and associated risk factors for superficial SSIs in abdominal surgery cases at a central Indian rural teaching hospital.

Methods:

This cohort study included 100 patients undergoing abdominal surgery between April 2016 and May 2017 at a central Indian rural teaching hospital. The outcome of interest was superficial SSI and the factors associated with it. Association between risk factors and SSI was calculated using either Chi-square test or odds ratio with 95% CI.

Results:

The cumulative incidence rate of superficial SSI was 39% with 95% CI (29.4%–49.2%). The analysis defined 12 variables significantly associated with superficial SSI: middle or elderly age, male gender, diabetes mellitus, preoperative anemia, preoperative hypoalbuminemia, tobacco smoking, higher ASA score, perioperative blood transfusion, drain placement, surgery duration >2 h, contaminated/dirty wound class and emergency surgery. However, economic status and BMI grade of the study subjects were not associated with development of superficial SSI.

Female radical cystectomy patients have a higher risk of surgical site infections

INTRODUCTION

Surgical site infections (SSI) are common after radical cystectomy. The objectives of this study were to evaluate if female sex is associated with postoperative SSI and if experiencing an SSI was associated with subsequent adverse events.

METHODS

This was a historical cohort study of radical cystectomy patients from the American College of Surgeons' National Surgical Quality Improvement Program database between 2006 and 2016. The primary outcome was development of a SSI (superficial, deep, or organ/abdominal space) within 30 days of surgery. Multivariable logistic regression analyses were performed to determine the association between sex and other patient/procedural factors with SSI. Female patients with SSI were also compared to those without SSI to determine risk of subsequent adverse events.

RESULTS

A total of 9,275 radical cystectomy patients met the inclusion criteria. SSI occurred in 1,277(13.7%) patients, 308 (16.4%) females and 969 (13.1%) males (odds ratio = 1.27; 95% confidence interval 1.10-1.47; P = 0.009). Infections were superficial in 150 (8.0%) females versus 410 (5.5%) males (P < 0.0001), deep in 40 (2.1%) females versus 114 (1.5%) males (P = 0.07), and organ/abdominal space in 118 (6.2%) females versus 445 (6.0%) males (P = 0.66). On multivariable analysis, female sex was independently associated with SSI (odds ratio = 1.21 confidence interval 1.01-1.43 P = 0.03). Females who experience SSI had higher probability of developing other complications including wound dehiscence, septic shock, and need for reoperation (all P < 0.05).

CONCLUSIONS

Female sex is an independent risk factor for SSI following radical cystectomy. More detailed study of patient factors, pathogenic microbes, and treatment factors are needed to prescribe the best measures for infection prophylaxis.

Impact of sex on 30-day complications and long-term functional outcomes following ileal pouch-anal anastomosis for chronic ulcerative colitis

PURPOSE

To determine the impact of patient sex on operative characteristics, short-term complications, and long-term functional outcomes following ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC).

METHODS

A retrospective review was performed on all patients undergoing two- or three-stage IPAA for CUC at our institution between January 2002 and August 2013. Patient demographics, operative characteristics, 30-day postoperative complications, and long-term functional outcomes from annual survey data were analyzed comparing men and women patients.

RESULTS

During the study period, 911 IPAAs (542 men, 369 women) were performed. Men were older and were more often obese (both p < 0.01). Use of a three-stage approach and laparoscopic approach were similar between men and women, but operation length, intraoperative blood loss, and hospital length of stay were all higher in men (all p < 0.05). At 30 days, women had increased rates of superficial surgical site infections and urinary tract infections (both p < 0.05), while men had increased rates of urinary retention (p = 0.03). Five hundred forty-six patients (60%; 307 men, 239 women) responded to the annual post IPAA survey with a median follow-up of 5.1 and 5.0 years in men and women, respectively. Women reported increased frequency of daytime stools in the early follow-up period, but this difference resolved with time. Other functional outcomes were similar.

CONCLUSION

Patient sex impacts intraoperative complexity, postoperative length of stay, 30-day postoperative outcomes, and initial long-term function. These findings underscore the need to adjust preoperative counseling regarding IPAA outcomes based on sex.

Deep brain stimulation hardware-related infections: 10-year experience at a single institution

OBJECTIVE

Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP).

METHODS

The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network's definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher's exact test, or logistic regression, as appropriate for the variables examined.

RESULTS

Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10-1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10-1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations.

CONCLUSIONS

While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.

Effect of Gender on Postoperative Morbidity and Mortality Outcomes: A Retrospective Cohort Study

Full extent of gender differences on postoperative outcomes has never been studied on large scale, specifically postoperative complications. This study aims to assess the effect of gender on 30-day morbidity and mortality after major surgery. A retrospective cohort study was carried out using data of patients undergoing major surgeries from the American College of Surgeons’ National Surgical Quality Improvement Program database between 2008 and 2011. Demographics, pre- and perioperative risk factors, as well as 30-day morbidities, both overall and specific, were reviewed. The 30-day mortality data were also assessed. Multivariate logistic regression analyses, basic (Adj1) and extended (Adj2), were used to assess the association between gender and outcomes. Out of 1,409,131 patients, 57.2 per cent were females. Females had lower prevalence of most system-specific risk variables. Overall morbidities were also lower in females versus males, even after adjustment for variables [total overall morbidity: ORadj2 = 0.9 (0.89–0.92), P < 0.0001] except in some cases such as after cardiac surgeries [ORadj2 = 1.29 (1.14–1.44), P < 0.0001] and vascular surgeries [ORadj2 = 1.14 (1.10–1.18), P < 0.0001], where overall morbidities of females were higher. Specific morbidities were also lower in females than in males in all types of complications except central nervous system-related postoperative complications [ORadj2 = 1.15 (1.08–1.22), P < 0.0001] and return to the operating room [ORadj2 = 1.06 (1.04–1.08), P < 0.0001]. The 30-day mortality rate for females was lower than males [ORadj2 = 0.99 (0.96–1.03), P = 0.94]. Female gender was associated with less perioperative morbidity and mortality versus males, but they did worse after cardiovascular procedures and had more central nervous system-related complications. These outcomes should be taken into consideration by surgeons and should be evaluated further in future studies.

Novel approaches to surgical site infections: what recommendations can be made?

INTRODUCTION

Surgical site infections (SSI) are one of the most frequent healthcare-associated infections worldwide, representing a substantial burden on the healthcare system and the individual patient. Various risk factors for SSI have been identified, which can be separated into patient-related, procedure-related and other risk factors. Areas covered: Other risk factors relevant for SSI are the season in which surgery is performed, the volume of surgeries in a department, the working atmosphere in the operating room and the indications for surgery. Overall, the risk of SSI is higher during summertime. Higher-volume departments appear to be protective against SSI as does a calm working atmosphere. The frequency of certain types of surgery differs greatly among European countries. The decision to perform surgery appears to be dependent on the patient's condition as well as the healthcare system and financial incentives. Expert commentary: When possible, elective surgery should not be executed during summertime but during cooler times of year. Departments with a high volume of surgical procedures should be given preference. The establishment of a calm working atmosphere is beneficial to a surgeon's performance and can reduce SSI rates. The indications for performing surgery should be carefully reevaluated whenever possible.

Staphylococcus aureus Infections in German Patients with Type 2 Diabetes Mellitus after Orthopedic Surgery: Incidence, Risk Factors, and Clinical and Health-Economic Outcomes

BACKGROUND

This study assessed Staphylococcus aureus infection risk in patients with type 2 diabetes mellitus (T2DM) undergoing an orthopedic knee, hip, or spine surgery.

PATIENTS AND METHODS

All patients with a diagnosis of T2DM in the period from 2010 to 2012 were identified from a German claims database. First inpatient knee, hip, or spine surgery was used as index date. Cumulative incidence of S. aureus infections was calculated for several time intervals. Risk factors were identified based on a multi-variable Cox regression analysis. A case control analysis was conducted to assess mortality, healthcare resource utilization, and healthcare costs of S. aureus.

RESULTS

In total, 9,401 patients with T2DM underwent a knee, hip, or spine surgery. Mean age was 72.58 years, 63.32% were female, and 1.08% experienced an S. aureus infection in the 365-day follow-up period. The difference in all-cause direct treatment costs per patient-year between infected and non-infected patients was 24,437.50$. Mortality rates were 25.52% (S. aureus group) versus 5.22% (non-S. aureus group), based on a 365-day follow-up.

CONCLUSIONS

Staphylococcus aureus is associated with a substantial healthcare burden and high mortality. Effective infection control measures should be considered to reduce post-surgical S. aureus infection risk in patients with T2DM.