It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

Comparative analysis of antibiotic prophylaxis guidelines in cardiac surgery: a survey in Czechia and Slovakia

BACKGROUND

Surgical site infections (SSIs) in cardiac surgery significantly impact patient outcomes. This study examines cardiac antimicrobial prophylaxis guidelines in Czech and Slovak hospitals, crucial for reducing SSI incidence.

METHODS

An electronic survey was conducted across cardiac surgery departments in both countries, focusing on surgical antibiotic prophylaxis (SAP) protocols, antibiotic choices, dosages, timing and postoperative infection rates. Responses were collected over three months, ensuring a comprehensive overview.

FINDINGS

Most surveyed hospitals (79%) implement SAP, but guidelines exhibit notable variability. Cefazolin dominates as the primary prophylactic choice, with varying dosing regimens. Challenges include timing inconsistencies and prolonged prophylaxis durations, particularly in implant-related procedures. Regular guideline revisions are reported in 18% of hospitals within the last year, emphasizing the need for updated practices.

CONCLUSIONS

This study shows the importance of standardizing SAP practices, aligning them with evolving evidence, and implementing regular guideline revisions. The observed variations highlight opportunities for enhanced SSI prevention strategies in cardiac surgery, ultimately contributing to improved patient outcomes.

Antibiotic Stewardship in Surgical Departments

Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.

A retrospective cohort study of the impact of COVID-19 infection control measures on surgical site infections in an academic hospital setting

Previous studies show that both the frequency of surgeries and incidence of surgical site infections (SSIs) have been lower during the coronavirus disease 2019 (COVID-19) pandemic. This study's purpose is to analyse the possible association of the COVID-19 epidemic-related increased health measures, such as protective equipment and products, increased hand hygiene and restrictions imposed, on the incidence of SSIs in an academic medical centre. We designed a single-centre, retrospective cohort study and collected data on the frequency of surgeries and the incidence of SSIs, among patients who had surgeries pre- and post-COVID-19 pandemic. Besides the intervention and outcome variable, we sought information on patient gender, surgery type, body mass index (BMI), smoking, and type II diabetes mellitus. We used Wald 95% confidence interval (95% CI) and the p values of the odds ratio (OR) to report results. Of the N = 24 098 surgeries performed in this hospital, there were 269 patients who reported post-surgical SSIs in this hospital between March 2019 and March 2021. The OR of developing a post-surgical SSI was 0.40 (95% CI: 0.33-0.57, p < 0.05; adjusted for confounders 0.39 [95% CI: 0.30-0.52, p < 0.05]) among patients who had surgery under post-pandemic infection control measures, as compared to patients who had surgery under pre-pandemic usual care infection control measures. Our significant results conclude that an association may exist between the enhanced infection control measures used during the COVID-19 pandemic and lower incidence of SSIs we observed during this period.

Prevalence and Antimicrobial Resistance Patterns of Hospital Acquired Infections through the COVID-19 Pandemic: Real-Word Data from a Tertiary Urological Centre

BACKGROUND

Antimicrobial resistance (AMR) remains a significant public health concern, closely linked to antibiotic overuse. During the COVID-19 pandemic, broad-spectrum antibiotics were frequently administered, potentially exacerbating AMR. This study aimed to assess AMR patterns in our urology department before and after the pandemic.

METHODS

The study encompassed patients admitted to our urology department from January 2016 to December 2022, with confirmed urinary tract infection, bloodstream infection, or wound infection based on positive culture results. Descriptive statistics, including mean, frequency, and percentage, summarized the data. Trends were analyzed using the Joinpoint Regression program.

RESULTS

A total of 506 patients were included. Escherichia coli and Klebsiella pneumoniae displayed resistance rates of 65% and 62% to ciprofloxacin, respectively. K. pneumoniae showed resistance rates of 41% to piperacillin tazobactam and 3rd generation cephalosporins (3GC). Carbapenem resistance was observed in 38% of K. pneumoniae isolates. Additionally, 26% of E. coli, 26% of K. pneumoniae, and 59% of Proteus mirabilis isolates were ESBL-positive. Among gram+, 72% of Staphylococcus aureus isolates were MRSA, and 23% of Enterococcus faecium isolates were VRE. Trends in antimicrobial susceptibility patterns over the 7-year study period revealed a statistically significant decrease in E. coli resistance to amoxicillin-clavulanic acid (APC: -5.85; C.I. 95% p < 0.05) and a statistically significant increase in K. pneumoniae resistance to 3GC (APC: 9.93; CI (-19.9-14.4 95% p < 0.05). There were no statistically significant differences in AMR incidence pre- and post-COVID-19.

CONCLUSION

The COVID-19 pandemic did not appear to influence the AMR incidence in our urology department. However, the overall prevalence of AMR and MDROs in our department remains high compared to European AMR.

Antibiotic Prophylaxis in the Management of Distal Fingertip Amputation and Crush Injury

Purpose

We sought to investigate the role of prophylactic antibiotics for distal fingertip crush injury or transphalangeal amputation treated outside of an operating room and better understand the factors that contribute to antibiotic-prescribing decisions. We hypothesized that prophylactic antibiotics do not meaningfully reduce the incidence of infection and that antibiotics are prescribed in a predictable way.

Methods

This is a retrospective review of all patients treated in a MedStar-affiliated emergency department or urgent care for nonsurgical distal fingertip trauma in 2019. Patient demographics, comorbidities, injury characteristics, interventions, and follow-up details were recorded. Exclusion criteria included signs of infection at the time of presentation, minor injuries not requiring intervention, bite wounds, one-time intravenous antibiotic administration without oral course, and surgical intervention. Outcomes included infection and interventions at follow-up. Chi-square analysis was performed, comparing antibiotic and no-antibiotic groups. A stepwise binomial regression was used to evaluate for variables predictive of antibiotic prescription.

Results

We identified eight infections in 323 patients included in the study (2.5% incidence of infection). There was no statistically significant difference in the incidence of infection between patients treated with antibiotics (2.7%) and those who did not receive antibiotics (2.2%). However, due to the low incidence of infections, we were likely underpowered for this analysis. We also created a model to predict antibiotic prescribing, which achieved an area under the receiver operating characteristic curve of 0.86 (P < .0001) based on age, bleeding disorders, depressive disorders, open wound status, amputation, fractures, and encounter type.

Conclusions

The low incidence of infection (2.5%) and lack of a meaningful difference between the groups call into question prophylactic antibiotic prescribing after these distal fingertip injuries. Our model does predict provider prescribing habits, identifying areas for potential practice pattern change.

Type of study/level of evidence

Therapeutic III.

Predictors of Clostridium difficile infection after stoma reversal following TaTME surgery

BACKGROUND

 The aim of this study was to determine the incidence of Clostridium Difficile infection (CDI) after stoma reversal in patients who underwent transanal Total Mesorectal Excision (TaTME) and to evaluate variables correlated with this post-operative infection.

METHODS

 Patients who underwent stoma reversal surgery following TaTME for rectal cancer between 2015 and 2023 at a high-volume Institution, were retrospectively reviewed for the post-operative occurrence of diarrhea and in-hospital CDI (positive toxin in the stools). Patients were divided into the following subgroups according to the post-operative course: Group A-no clinical symptoms; Group B-mild diarrhea (< 10 evacuations/day); Group C-severe watery diarrhea (> 10 evacuations/day) with CDI negative; and Group D-severe watery diarrhea (> 10 evacuations/day) CDI positive. Clinical and laboratory data were analyzed for their correlation with CDI. A machine learning approach was used to determine predictors of diarrhea following stoma reversal.

RESULTS

 A total of 126 patients were selected, of whom 79 were assessed as Group A, 16 Group B, 25 Group C and 6 (4.8%) Group D. Univariable analysis documented that delayed stoma reversal correlated with CDI (Group A mean interval 44.6 weeks vs. Group D 68.4 weeks, p 0.01). The machine learning analysis confirmed the delay in stoma closure as a probability factor of presenting diarrhea; also, diarrhea probability was 80.5% in males, 77.8% in patients who underwent neoadjuvant therapy, and 63.9% in patients who underwent adjuvant therapy.

CONCLUSIONS

 Stoma reversal surgery can result in moderate rate of in-hospital CDI. Time-to stoma reversal is a crucial variable significantly related with this adverse outcome.

Severe local wound infections after vascular exposure in the groin and other body areas: Prevention, treatment and prognosis

Severe surgical site infections (SSIs) are a frequent nosocomial complication after vascular interventions, an important cause of postoperative morbidity, and a substantial burden to the health care system. Patients undergoing arterial interventions are at elevated risk of SSIs, possibly because of the presence of several risk factors in this patient population. In this review, we examined the available clinical evidence for the prevention, treatment, and prognostication of postoperative severe SSIs after vascular exposure in the groin and other body areas. Results from studies evaluating preoperative, intraoperative, and postoperative preventive strategies and several treatment options are reviewed. In addition, risk factors for surgical wound infections are analyzed in detail and related evidence from the literature is highlighted. Although several measures have been implemented over the time to prevent them, SSIs continue to pose a substantial health care and socioeconomic challenge. Therefore, strategies to decrease the risk and improve the treatment of SSIs for the high-risk vascular patient population should be the focus of continuing improvement and critical review. This review aimed at identifying and reviewing the current evidence for preventing, treating, and performing stratification according to the prognosis of postoperative severe SSIs after vascular exposure in the groin and other body areas.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Association Between the Lockdown for SARS-CoV-2 (COVID-19) and Reduced Surgical Site Infections after Vascular Exposure in the Groin at Two Italian Academic Hospitals

BACKGROUND

The aim of this study was to evaluate whether the scrupulous hygiene rules and the restriction of contacts during the lockdown owing to the COVID-19 pandemic affected the rate and severity of surgical site infections (SSI) after vascular exposure in the groin at two Italian University Hospitals.

METHODS

Starting from March 2020, strict hygiene measures for protection of health care workers (HCW) and patients from COVID-19 infection were implemented, and partly lifted in July 2020. The main exposure for analysis purposes was the period in which patients were operated. Accordingly, study subjects were divided into two groups for subsequent comparisons (preCOVID-19 era: March-June 2018-2019 versus COVID-19 era: March-June 2020). The primary endpoint was the occurrence of superficial and/or deep SSI within 30 days after surgery. The Centers for Disease Control and Prevention definitions were used to classify superficial and deep SSI.

RESULTS

A total of 194 consecutive patients who underwent vascular exposure in the groin were retrospectively analyzed. Of those, 60 underwent surgery from April 1, 2018 to June 30 of the same year; 83 from April 1, 2019 to June 30 of the same year; and 51 from April 1, 2020 to June 30 of the same year. The mean age of the study cohort was 75 years and 140 (72%) were males. Patients who were operated in the COVID-19 era were less likely to develop SSI (10% vs. 28%; P = 0.008), including both deep SSI (4% vs. 13%; P = 0.04) and superficial SSI (6% vs. 15%; P = 0.05). After multivariate adjustments, being operated in the COVID-19 era was found to be a negative predictor for development of an SSI (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.09-0.76; P < 0.001) or deep SSI (OR = 0.21; 95% CI = 0.03-0.98; P < 0.001). Operative time was also found as independent predictor for the development of deep SSI (OR = 1.21; 95%CI = 1.21-1.52; P = 0.02). Using binary logistic regression, there were no independent predictors of superficial SSI that could be identified.

CONCLUSIONS

Vascular exposure in the groin carries a non-negligible risk of SSI. In this study, we provided important insights that are simple and easily viable precautions (such as the universal use of surgical masks both for patients and health care professionals during wound care, the widespread diffusion of hand sanitizers, and the reduction of the number of visitors in the surgical wards) could be promising and safe tools for SSI risk reduction.

Characteristics and impact of postoperative surgical site infection on increased antibiotic duration among patients with laryngocarcinoma: a retrospective cohort study

Background

Whether increased antibiotic duration is necessary for surgical site infection (SSI) in patients after neck surgery is unclear. We investigated the characteristics of SSI, and the impact of SSI on increased antibiotic duration among patients with laryngocarcinoma (LC).

Methods

A retrospective cohort study including consecutive LC patients ≥18 years, undergoing surgery without remote metastasis was conducted from October 2015 to February 2022 in the Department of Otolaryngology-Head and Neck Surgery, Chengdu Second People's Hospital. SSI was defined according to current guidelines. Patients were stratified into 3 groups including no-infection, lower respiratory tract infection (LRTI) and SSI. Patient characteristics was recorded. Patients were followed up until discharge. A multiple linear regression model including SSI and other factors including age, sex, comorbidity and antibiotic treatments was performed to explore the impact of SSI on increased antibiotic duration among LC patients with postoperative infection.

Results

A total of 88 patients were included, with 26 (29.5%) in no-infection group, 38 (43.2%) in LRTI group, and 24 (27.3%) in SSI group. Laryngocutaneous fistula occurred in 8 (33.3%) patients with SSI. Thirteen (34.2%) patients in LRTI group and 9 (37.5%) patients in SSI group experienced postoperative infection within 2 days after surgery, and antibiotic susceptibility tests were performed in 18 (47.4%) and 12 (50.0%) patients in LRTI and SSI group, respectively (P>0.05 for both). Levofloxacin and cefoperazone-sulbactam were the most commonly used antibiotics for postoperative infection in both LRTI and SSI groups (P>0.05 for both), irrespective of antibiotic susceptibility tests or not. The postoperative antibiotic duration in SSI group was significantly longer than that in LRTI group (13.62±4.28 days in SSI vs. 11.22±3.64 days in LRTI, P=0.021). A multiple linear regression analysis including SSI, age, sex, diabetes, antibiotic susceptibility test and hypoalbuminemia showed that, SSI was independently associated with increased antibiotic duration with LRTI as the reference among LC patients diagnosed [regression coefficient β=3.02, 95% confidence interval (CI): 1.01-5.03, P=0.004], whereas antibiotic susceptibility test was not (P=0.467).

Conclusions

SSI may be independently associated with increased postoperative antibiotic duration in patients with LC with or without antibiotic susceptibility test.

Antimicrobial Challenge in Acute Care Surgery

The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.

ACOI Surgical Site Infections Management Academy (ACOISSIMA)

Background:

Surgical site infections (SSIs) are the most common cause of healthcare-associated infections in surgical patients. Many SSIs may be preventable if simple measures are respected. Despite evidence supporting the effectiveness of evidence-based practices in Infection Prevention and Control, many surgeons fail to implement them.

Methods:

To clarify the key issues in the prevention of SSIs, an expert panel designated by the board of directors of Associazione Chirurghi Ospedalieri Italiani—Italian Surgical Association (ACOI) convened in Rome, Italy, on 16 December 2021, for a consensus conference.

Results:

The expert panel approved 11 evidence-based statements regarding the prevention of SSIs. A article was drafted and reviewed by the expert panel, finally obtaining this document that represents the executive summary of the consensus.

Conclusions:

The document aims to disseminate best practices among Italian surgeons and summarizes the ACOI recommendations for the prevention of SSIs.