Epidemiologic characteristics of orthopedic surgical site infections and under-reporting estimation of registries using capture-recapture analysis

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.

High Rate of Undetected Infections in Failed Osteosynthesis of Pertrochanteric Fractures

OBJECTIVE

The objective of this study was to assess the incidence of infection in patients with cutout after proximal femur fracture (PFF) osteosynthesis.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Third-level trauma center.

PATIENT SELECTION CRITERIA

Patients presenting with a cutout following PFF (OTA/AO 31A) osteosynthesis, between January 2007 and December 2020.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome was infection according to the European Bone and Joint Infection Society criteria.

RESULTS

Sixty-seven patients presenting with a cutout were included, with mean age of 83.3 years (range 63-96), and 51 (76.1%) were women. Of all cases, 16 (24.7%) presented a concomitant infection. The presence of concomitant infection was suspected preoperatively in only 3 of the cases. A subgroup analysis was performed between the cases with infection and those without infection, the groups being comparable in terms of demographic data and postoperative radiological criteria. Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs. 22%, P = 0.014) and higher rates of leukocytosis (11.560 vs. 7.890, P = 0.023).

CONCLUSION

Faced with a cutout after osteosynthesis of a PFF, underlying infection should be considered as a possible etiological factor.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of topical vancomycin powder on surgical site infection prevention in major orthopaedic surgery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

Evidence has been mixed regarding the effect of topical vancomycin (VCM) powder in reducing surgical site infection (SSI).

AIM

To clarify the effect of topical VCM powder for the prevention of SSI in major orthopaedic surgeries.

METHODS

The MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov databases were searched from their inception to September 25th, 2023. Randomized controlled trials comparing topical VCM powder and controls for the prevention of SSI in major orthopaedic surgeries were included. Two reviewers independently screened the title and abstract and extracted relevant data, followed by the assessment of the risk of bias and the certainty of the evidence. Main outcome measures were overall SSI, reoperation, and adverse events. Summary results were obtained using random-effects meta-analysis. Trial sequential analysis (TSA) was performed.

FINDINGS

Eight randomized controlled trials yielded data on 4307 participants. VCM powder showed no difference in reducing overall SSI. The cumulative number of patients did not exceed the required information size of 19,233 in our TSA, and the Z-curves did not cross the trial sequential monitoring or futility boundary, suggesting an inconclusive result of the meta-analysis. No difference was found for reoperation. Among SSIs, VCM powder showed a statistically significant difference in reducing Gram-positive cocci SSI. However, the certainty of this evidence was very low.

CONCLUSION

This systematic review and meta-analysis suggests inconclusive results regarding the effect of VCM powder in reducing SSI in major orthopaedic surgeries. Further trials using rigorous methodologies are required to elucidate the effect of this intervention.

Construction of a postoperative infection outbreak investigation form: A tool for early detection and control measures

BACKGROUND

To develop an investigation form for postoperative infection outbreak (PIO), and to identify sources of the outbreak in the early stage.

METHODS

After an exhaustive literature review, we used the Delphi method to determine the indicators and relative risk scores of the assessment tools through 2 rounds of specialist consultation and overall consideration of the opinions and suggestions of 20 specialists.

RESULTS

A total of 203 studies of PIO were eligible for inclusion. The mean authority coefficient (Cr) was 0.87. Kendall's W coefficient of the specialist consultation was 0.704 after 2 rounds of consultation (P < .005), suggesting that the specialists had similar opinions. Based on 4 primary items and 19 secondary items of the source of PIO, and tripartite distribution characteristics of infected patients, we constructed the PIO investigation form.

CONCLUSIONS

The PIO investigation form can be used in the investigation of the early-stage cluster of cases, it's a prerequisite for taking effective control measures, avoiding PIO occurrence. However, the effect of the investigation form needs to be further evaluated.

Factors Contributing to Surgical Site Infections: A Comprehensive Systematic Review of Etiology and Risk Factors

Surgical site infections persist as a substantial concern within the realm of hospital-acquired infections. This enduring issue is further compounded by the mounting challenge of antibiotic resistance, a surge in surgical interventions, and the presence of comorbidities among patients. Thus, a comprehensive exploration of all discernible risk factors, as well as proactive preventive and prophylactic strategies, becomes imperative. Moreover, the prevalence of multidrug-resistant microorganisms has reached alarming proportions. Consequently, there is an acute need to investigate and scrutinize all potential therapeutic interventions to counter this burgeoning threat. Consequently, the primary objective of this review is to meticulously assess the origins and risk elements intertwined with surgical site infections across a diverse spectrum of surgical procedures. As the medical landscape continues to evolve, this critical analysis seeks to provide a nuanced understanding of the multi-faceted factors contributing to surgical site infections, with the overarching aim of facilitating more effective management and mitigation strategies. By exploring these dimensions comprehensively, we endeavor to enhance patient safety and the quality of surgical care in this era of evolving healthcare challenges.

Predictors of in-hospital surgical site infections in surgically managed acetabular fractures: A nationwide analysis

Background

A surgical site infection (SSI) rate of 4%-8% has been reported in patients who undergo open reduction and internal fixation (ORIF) for acetabular fractures. Studies have identified risk factors for SSI, but none have performed a nationwide analysis of SSI in surgically managed acetabular fracture patients.

Methods

The National Inpatient Sample (NIS) database was queried for patients who underwent ORIF for acetabular fractures from 2016 to 2019. Analysis was performed on all patients who underwent ORIF for acetabular fractures, as well as those who only underwent ORIF for isolated acetabular fractures. Clinical characteristics, hospital course, discharge disposition, and hospitalization costs were compared between groups. Multivariate regression analysis was conducted to assess predictors of SSI.

Results

41,725 patients undergoing acetabular fracture repair were identified, of which 490 (1.2%) developed SSI during hospitalization. Age (45.90 vs 49.90, p < 0.001) and Injury Severity Scale (5.99 vs 8.30, p < 0.001) were increased in patients who developed SSI. History of hypertension (HTN) (OR = 2.343, 95% CI 1.96-2.80, p < 0.001), longer hospital length of stay (30.27 days vs 10.00 days, p < 0.001) and total charges ($469,005 vs $193,032, p < 0.001) were associated with SSI. Lower rates of routine discharge were seen in SSI patients (OR = 0.333, 95% CI 0.260-0.426, p < 0.001). Higher rates of inpatient death were associated with SSI (OR = 2.210, 95% CI 1.172-4.17, p = 0.019). Multiple procedures in addition to acetabular fracture repair, iliac artery embolization, substance abuse, later time to internal fixation and HTN were predictive of SSI (p < 0.001).

Conclusions

Severity of injury, time to fixation, and factors associated with compromised cardiovascular integrity were predictors of SSI. Identifying patients at risk for SSI should lead to clinical maneuvers that may optimize outcome.

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.

The Effect of Pharmacist-Led Intervention on Surgical Antibacterial Prophylaxis (SAP) at an Orthopedic Unit

Perioperative antibiotic use is a common reason for antibiotic misuse. Evidence suggests that adherence to SAP guidelines may improve outcomes. The purpose of this study was to analyze the impact of pharmacist-led antibiotic stewardship interventions on SAP guideline compliance. The study was conducted at an Orthopedic Department of a tertiary care medical center. SAP compliance and antibiotic exposure in the pre-intervention and intervention period was compared using chi-square, Fisher exact, and Mann-Whitney tests, as appropriate. Prophylactic antibiotic use in orthopedic joint arthroplasties (overall guideline adherence: agent, dose, frequency, duration), clinical outcomes (length of stay-LOS, number of surgical site infections-SSIs), antibiotic exposure and direct antibiotic costs were compared between pre-intervention and intervention periods. Significant improvement in mean SAP duration (by 42.9%, 4.08 ± 2.08 vs. 2.08 ± 1.90 days, p ˂ 0.001), and overall guideline adherence regarding antibiotic use (by 56.2%, from 2% to 58.2%, p ˂ 0.001) were observed. A significant decrease was observed in antibiotic exposure in SAP (by 41%, from 6.07 ± 0.05 to 3.58 ± 4.33 DDD/patient, p ˂ 0.001), average prophylactic antibiotic cost (by 54.8%, 9278.79 ± 6094.29 vs. 3598.16 ± 3354.55 HUF/patient), and mean LOS (by 37.2%, from 11.22 ± 6.96 to 7.62 ± 3.02 days, p < 0.001); and a slight decrease in the number of confirmed SSIs was found between the two periods (by 1.8%, from 3% to 1.2%, p = 0.21). Continuous presence of the clinical pharmacist led to significant improvement in SAP guideline adherence, which was accompanied by decreased antibiotic exposure and cost.