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

Predictive modeling for identifying infection risk following spinal surgery: Optimizing patient management

Infection is known to occur in a substantial proportion of patients following spinal surgery and predictive modeling may provide a useful means for identifying those at higher risk of complications and poor prognosis, which could help optimize pre- and postoperative management strategies. The outcome measure of the present study was to investigate the occurrence of all-cause infection during hospitalization following scoliosis surgery. To meet this aim, the present study retrospectively analyzed 370 patients who underwent surgery at the Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) between January 2016 and October 2022, and patients who either experienced or did not experience all-cause infection while in hospital were compared in terms of their clinicodemographic characteristics, surgical variables and laboratory test results. Logistic regression was subsequently applied to data from a subset of patients in order to build a model to predict infection, which was validated using another subset of patients. All-cause, in-hospital postoperative infections were found to have occurred in 66/370 patients (17.8%). The following variables were included in a predictive model: Sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), diabetes mellitus, hypertension, preoperative levels of white blood cells and preoperative C-reactive protein (CRP) and duration of surgery. The model exhibited an area under the curve of 0.776 against the internal validation set. In conclusion, dynamic nomograms based on sex, ASA classification, BMI, diabetes mellitus, hypertension, preoperative levels of white blood cells and CRP and duration of surgery may have the potential to be a clinically useful predictor of all-cause infection following scoliosis. The predictive model constructed in the present study may potentially facilitate the real-time visualization of risk factors associated with all-cause infection following surgical procedures.

An explainable long short-term memory network for surgical site infection identification

BACKGROUND

Currently, surgical site infection surveillance relies on labor-intensive manual chart review. Recently suggested solutions involve machine learning to identify surgical site infections directly from the medical record. Deep learning is a form of machine learning that has historically performed better than traditional methods while being harder to interpret. We propose a deep learning model, a long short-term memory network, for the identification of surgical site infection from the medical record with an attention layer for explainability.

METHODS

We retrieved structured data and clinical notes from the University of Utah Health System's electronic health care record for operative events randomly selected for manual chart review from January 2016 to June 2021. Surgical site infection occurring within 30 days of surgery was determined according to the National Surgical Quality Improvement Program definition. We trained the long short-term memory model along with traditional machine learning models for comparison. We calculated several performance metrics from a holdout test set and performed additional analyses to understand the performance of the long short-term memory, including an explainability analysis.

RESULTS

Surgical site infection was present in 4.7% of the total 9,185 operative events. The area under the receiver operating characteristic curve and sensitivity of the long short-term memory was higher (area under the receiver operating characteristic curve: 0.954, sensitivity: 0.920) compared to the top traditional model (area under the receiver operating characteristic curve: 0.937, sensitivity: 0.736). The top 5 features of the long short-term memory included 2 procedure codes and 3 laboratory values.

CONCLUSION

Surgical site infection surveillance is vital for the reduction of surgical site infection rates. Our explainable long short-term memory achieved a comparable area under the receiver operating characteristic curve and greater sensitivity when compared to traditional machine learning methods. With explainable deep learning, automated surgical site infection surveillance could replace burdensome manual chart review processes.

Effects of Postoperative Splinting on Outcomes following Digital Mucous Cyst Excision: A Retrospective Review

Background

Digital mucous cysts (DMCs) are masses on the fingers that can be definitively managed with surgical excision. Though uncommon, surgical site infections can develop into septic arthritis. We sought to determine whether postoperative splinting decreases rates of postoperative infection and the need for postoperative antibiotics. We also explored the effect of age, gender, obesity, and preoperative antibiotic administration on infectious complications.

Methods

Patients who underwent DMC excision between 2011 and 2021 were retrospectively identified. Chi-squared and Fisher's exact tests were used to analyze the complication rates including documented infection, postoperative antibiotic administration, mass recurrence, and return to operating room. Associations were analyzed between both preoperative antibiotic administration and postoperative splinting with respect to postsurgical complications.

Results

The database search identified 373 patients who underwent 394 DMC excisions. Postoperative antibiotics were given in splinted patients at lower rates than their nonsplinted counterparts with a small-to-moderate effect size, but the difference was not statistically significant (2.7 vs. 7.5%). Preoperative antibiotic administration was not found to significantly affect the prescription of postoperative antibiotics. Splinting did not reduce rates of DMC recurrence. Patients who were splinted were more likely to have also received preoperative antibiotics. Males were given postoperative antibiotics more frequently than females (12.6 vs. 4.0%).

Conclusions

Though not statistically significant, splinted patients were prescribed postoperative antibiotics less frequently. Postoperative antibiotics were utilized more frequently than the rate of infections typically reported following this procedure, possibly indicating overcautious prescription habits or underreported suspected infections.

Meta-lasso: new insight on infection prediction after minimally invasive surgery

Surgical site infection (SSI) after minimally invasive lung cancer surgery constitutes an important factor influencing the direct and indirect economic implications, patient prognosis, and the 5-year survival rate for early-stage lung cancer patients. In the realm of predictive healthcare, machine learning algorithms have been instrumental in anticipating various surgical outcomes, including SSI. However, accurately predicting infection after minimally invasive surgery remains a clinical challenge due to the multitude of physiological and surgical factors associated with it. Furthermore, clinical patient data, in addition to being high-dimensional, often exists the long-tail problem, posing difficulties for traditional machine learning algorithms in effectively processing such data. Based on this insight, we propose a novel approach called meta-lasso for infection prediction following minimally invasive surgery. Our approach leverages the sparse learning algorithm lasso regression to select informative features and introduces a meta-learning framework to mitigate bias towards the dominant class. We conducted a retrospective cohort study on patients who had undergone minimally invasive surgery for lung cancer at Shanghai Chest Hospital between 2018 and 2020. The evaluation encompassed key performance metrics, including sensitivity, specificity, precision (PPV), negative predictive value (NPV), and accuracy. Our approach has surpassed the performance of logistic regression, random forest, Naive Bayes classifier, gradient boosting decision tree, ANN, and lasso regression, with sensitivity at 0.798, specificity at 0.779, precision at 0.789, NPV at 0.798, and accuracy at 0.788 and has greatly improved the classification performance of the inferior class.

Risk factors for infection at the saphenous vein harvest site after coronary artery bypass grafting surgery: a retrospective cohort study

INTRODUCTION

Surgical site infection after saphenous vein harvest is common, with reported leg wound infection rates ranging from 2 to 24%. There have been few investigations into sex-related differences in complication rates. Moreover, varied effects of smoking have been reported. The aim of this study was to investigate risk factors such as gender and smoking, associated with surgical site infection after vein graft harvesting in coronary artery bypass grafting surgery.

METHODS

We included 2,188 consecutive patients who underwent coronary artery bypass grafting surgery with at least one vein graft at our centre from 2009 to 2018. All patients were followed up postoperatively. Risk factors for leg wound infection requiring antibiotic treatment and surgical revision were analysed using logistic regression analysis.

RESULTS

In total, 374 patients (17.1%) received antibiotic treatment and 154 (7.0%) underwent surgical revision for leg wound infection at the harvest site. Female sex, high body mass index, diabetes mellitus, longer operation time, peripheral vascular disease and direct oral anticoagulants were independently associated with any leg wound infection at the harvest site. Among surgically revised patients, female sex and insulin or oral treatment for diabetes mellitus as well as longer operation time were independent risk factors. Smoking was not associated with leg wound infection.

CONCLUSION

Female sex is associated with increased risk of leg wound infection. The underlying mechanism is unknown. In the current population, previous or current smoking was not associated with an increased risk of leg wound infection.

Prediction Models for Forecasting Risk of Development of Surgical Site Infection after Lower Limb Revascularization Surgery: A Systematic Review

BACKGROUND

Surgical site infections (SSIs) are a common and potentially preventable complication of lower limb revascularization surgery associated with increased healthcare resource utilization and patient morbidity. We conducted a systematic review to evaluate multivariable prediction models designed to forecast risk of SSI development after these procedures.

METHODS

After protocol registration (CRD42022331292), we searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies describing multivariable prediction models designed to forecast risk of SSI in adults after lower limb revascularization surgery. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risk of bias. A narrative synthesis was performed to summarize predictors included in the models and their calibration and discrimination, validation status, and clinical applicability.

RESULTS

Among the 6,671 citations identified, we included 5 studies (n = 23,063 patients). The included studies described 5 unique multivariable prediction models generated through forward selection, backward selection, or Akaike Information Criterion-based methods. Two models were designed to predict any SSI and 3 Szyilagyi grade II (extending into subcutaneous tissue) SSI. Across the 5 models, 18 adjusted predictors (10 of which were preoperative, 3 intraoperative, and 5 postoperative) significantly predicted any SSI and 14 adjusted predictors significantly predict Szilagyi grade II SSI. Female sex, obesity, and chronic obstructive pulmonary disease significantly predicted SSI in more than one model. All models had a "good fit" according to the Hosmer-Lemeshow test (P > 0.05). Model discrimination was quantified using the area under the curve, which ranged from 0.66 to 0.75 across models. Two models were internally validated using non-exhaustive twofold cross-validation and bootstrap resampling. No model was externally validated. Three studies had a high overall risk of bias according to the Prediction model Risk Of Bias ASsessment Tool (PROBAST).

CONCLUSIONS

Five multivariable prediction models with moderate discrimination have been developed to forecast risk of SSI development after lower limb revascularization surgery. Given the frequency and consequences of SSI after these procedures, development and external validation of novel prediction models and comparison of these models to the existing models evaluated in this systematic review is warranted.

Investigating and Practicing Orthopedics at the Intersection of Sex and Gender: Understanding the Physiological Basis, Pathology, and Treatment Response of Orthopedic Conditions by Adopting a Gender Lens: A Narrative Overview

In the biomedical field, the differentiation between sex and gender is crucial for enhancing the understanding of human health and personalizing medical treatments, particularly within the domain of orthopedics. This distinction, often overlooked or misunderstood, is vital for dissecting and treating musculoskeletal conditions effectively. This review delves into the sex- and gender-specific physiology of bones, cartilage, ligaments, and tendons, highlighting how hormonal differences impact the musculoskeletal system's structure and function, and exploring the physiopathology of orthopedic conditions from an epidemiological, molecular, and clinical perspective, shedding light on the discrepancies in disease manifestation across sexes. Examples such as the higher rates of deformities (adolescent idiopathic and adult degenerative scoliosis and hallux valgus) in females and osteoporosis in postmenopausal women illustrate the critical role of sex and gender in orthopedic health. Additionally, the review addresses the morbidity-mortality paradox, where women, despite appearing less healthy on frailty indexes, show lower mortality rates, highlighting the complex interplay between biological and social determinants of health. Injuries and chronic orthopedic conditions such osteoarthritis exhibit gender- and sex-specific prevalence and progression patterns, necessitating a nuanced approach to treatment that considers these differences to optimize outcomes. Moreover, the review underscores the importance of recognizing the unique needs of sexual minority and gender-diverse individuals in orthopedic care, emphasizing the impact of gender-affirming hormone therapy on aspects like bone health and perioperative risks. To foster advancements in sex- and gender-specific orthopedics, we advocate for the strategic disaggregation of data by sex and gender and the inclusion of "Sexual Orientation and Gender Identity" (SOGI) data in research and clinical practice. Such measures can enrich clinical insights, ensure tailored patient care, and promote inclusivity within orthopedic treatments, ultimately enhancing the precision and effectiveness of care for diverse patient populations. Integrating sex and gender considerations into orthopedic research and practice is paramount for addressing the complex and varied needs of patients. By embracing this comprehensive approach, orthopedic medicine can move towards more personalized, effective, and inclusive treatment strategies, thereby improving patient outcomes and advancing the field.

Risk factors for surgical site infection following cardiac surgery in a region endemic for multidrug resistant organisms

OBJECTIVES

To identify risk factors for surgical site infections following cardiosurgery in an area endemic for multidrug resistant organisms.

DESIGN

Single-center, historical cohort study including patients who underwent cardiosurgery during a 6-year period (2014-2020).

SETTING

Joint Commission International accredited, multiorgan transplant center in Palermo, Italy.

MAIN OUTCOME MEASURES

Surgical site infection was the main outcome.

RESULTS

On a total of 3609 cardiosurgery patients, 184 developed surgical site infection (5.1 %). Intestinal colonization with multidrug resistant organisms was more frequent in patients with surgical site infections (69.6 % vs. 33.3 %; p < 0.001). About half of surgical site infections were caused by Gram-negative bacteria (n = 97; 52.7 %). Fifty surgical site infections were caused by multidrug resistant organisms (27.1 %), with extended-spectrum Beta-lactamase-producing Enterobacterales (n = 16; 8.7 %) and carbapenem-resistant Enterobacterales (n = 26; 14.1 %) being the predominant resistance problem. However, in only 24 of surgical site infections caused by multidrug resistant organisms (48 %), mostly carbapenem-resistant Enterobacterales (n = 22), a pathogen match between the rectal surveillance culture and surgical site infections clinical culture was demonstrated. Nevertheless, multivariate logistic regression analysis identified a rectal swab culture positive for multidrug resistant organisms as an independent risk factor for SSI (odds ratio 3.95, 95 % confidence interval 2.79-5.60). Other independent risk factors were female sex, chronic dialysis, diabetes mellitus, previous cardiosurgery, previous myocardial infarction, being overweight/obese, and longer intubation time.

CONCLUSION

In an area endemic for carbapenem-resistant Enterobacterales, intestinal colonization with multidrug resistant organisms was recognized as independent risk factor for surgical site infections.

IMPLICATIONS FOR CLINICAL PRACTICE

No causal relationship between colonization with resistant pathogens and subsequent infection could be demonstrated. However, from a broader epidemiological perspective, having a positive multidrug resistant organisms colonization status appeared a risk factor for surgical site infections. Therefore, strict infection control measures to prevent cross-transmission remain pivotal (e.g., nasal decolonization, hand hygiene, and skin antisepsis).

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?

Risk Factors for Surgical Site Infection after Lower Limb Revascularisation Surgery: a Systematic Review and Meta-Analysis of Prognostic Studies

OBJECTIVE

To systematically review and meta-analyse adjusted risk factors for surgical site infection (SSI) after lower limb revascularisation surgery.

DATA SOURCES

MEDLINE, Embase, Evidence Based Medicine Reviews, and the Cochrane Central Register of Controlled Trials (inception to 28 April 2022).

REVIEW METHODS

Systematic review and meta-analysis conducted according to PRISMA guidelines. After protocol registration, databases were searched. Studies reporting adjusted risk factors for SSI in adults who underwent lower limb revascularisation surgery for peripheral artery disease were included. Adjusted odds ratios (ORs) were pooled using random effects models. GRADE was used to assess certainty.

RESULTS

Among 6 377 citations identified, 50 studies (n = 271 125 patients) were included. The cumulative incidence of SSI was 12 (95% confidence interval [CI] 10 - 13) per 100 patients. Studies reported 139 potential SSI risk factors adjusted for a median of 12 (range 1 - 69) potential confounding factors. Risk factors that increased the pooled adjusted odds of SSI included: female sex (pooled OR 1.41, 95% CI 1.20 - 1.64; high certainty); dependent functional status (pooled OR 1.18, 95% CI 1.03 - 1.35; low certainty); being overweight (pooled OR 1.82, 95% CI 1.29 - 2.56; moderate certainty), obese (pooled OR 2.20, 95% CI 1.44 - 3.36; high certainty), or morbidly obese (pooled OR 1.65, 95% CI 1.08 - 2.52; moderate certainty); chronic obstructive pulmonary disease (pooled OR 1.42, 95% CI 1.17 - 1.71; high certainty); chronic limb threatening ischaemia (pooled OR 1.67, 95% CI 1.22 - 2.29; moderate certainty); chronic kidney disease (pooled OR 2.13, 95% CI 1.18 - 3.83; moderate certainty); intra-operative (pooled OR 1.23, 95% CI 1.02 - 1.49), peri-operative (pooled OR 1.92, 95% CI 1.27 - 2.90), or post-operative (pooled OR 2.21, 95% CI 1.44 - 3.39) blood transfusion (moderate certainty for all); urgent or emergency surgery (pooled OR 2.12, 95% CI 1.22 - 3.70; moderate certainty); vein bypass and or patch instead of endarterectomy alone (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty); an operation lasting ≥ 3 hours (pooled OR 1.86, 95% CI 1.33 - 2.59; moderate certainty) or ≥ 5 hours (pooled OR 1.60, 95% CI 1.18 - 2.17; moderate certainty); and early or unplanned re-operation (pooled OR 4.50, 95% CI 2.18 - 9.32; low certainty).

CONCLUSION

This systematic review identified evidence informed SSI risk factors following lower limb revascularisation surgery. These may be used to develop improved SSI risk prediction tools and to identify patients who may benefit from evidence informed SSI prevention strategies.

Do We Need Routine Postoperative Prophylactic Oral Antibiotics in Elective Foot and Ankle Surgery?

Background

Previous studies about antibiotic prophylaxis in foot and ankle surgery have focused on perioperative intravenous administration, with few studies reporting on the efficiency of postoperative oral antibiotics. The purpose of this study is to investigate differences in the rate of postoperative infection and wound complications between patients with and without postoperative oral antibiotics and to identify independent risk factors for these complications following foot and ankle surgeries.

Methods

A retrospective review of all elective foot and ankle surgeries with at least a 6-month follow-up was performed over a 2-year time span. Patients were divided into 2 groups based on if they received postoperative oral antibiotics. We compared the rates of postoperative infections and wound complications between the 2 groups. The surgical site, the number of Current Procedural Terminology codes, and the number of surgical incisions were also noted. Multivariable logistic regression analysis was performed to identify independent risk factors of postoperative infection and wound complications.

Results

A total of 366 patients were included in this study-240 with antibiotics and 126 without antibiotics. There was no significant difference in the rates of postoperative infection and wound complications between the 2 groups. The rate of superficial infection, deep infection, and wound complications was 1.7%, 0.8%, and 5.8% in the antibiotic group vs 3.2%, 0.0%, and 4.0% in patients without antibiotics, respectively. Multivariable logistic regression analysis identified independent risk factors of postoperative infection and wound complications as follows: smoking (OR: 4.7), male (OR: 4.0), history of neoplasm (OR: 6.7), and multiple incisions (OR: 4.1).

Conclusion

Our results suggest that routine postoperative prophylactic oral antibiotics are not needed following elective foot and ankle surgeries. However, certain risk factors may increase the risk for postoperative infection and wound complications in foot and ankle surgery.

Level of Evidence

Level III, case-control study.

Prevalence of surgical wound infection and related factors in patients after long bone surgery: A systematic review and meta-analysis

The goal of this systematic review and meta-analysis is to provide an overview of the prevalence of surgical wound infection and related factors in patients after long bone surgery. A comprehensive, systematic search was conducted in different international electronic databases, such as Scopus, PubMed, Web of Science and Persian electronic databases such as Iranmedex and Scientific Information Database using keywords extracted from Medical Subject Headings such as "Prevalence", "Surgical wound infection", "Surgical site infection" and "Orthopedics" from the earliest to the May 1, 2023. The appraisal tool for cross-sectional studies (AXIS tool) evaluates the quality of the included studies. A total of 71 854 patients undergoing long bone surgery participated in 12 studies. The pooled prevalence of surgical wound infection in patients who underwent long bone surgery reported in the 12 studies was 3.3% (95% CI: 1.5%-7.2%; I2  = 99.39%; p < 0.001). The pooled prevalence of surgical wound infection in male and female patients who underwent long bone surgery was 4.6% (95% CI: 1.7%-11.7%; p < 0.001; I2  = 99.34%) and 2.6% (95% CI: 1.0%-6.3%; I2  = 98.84%; p < 0.001), respectively. The pooled prevalence of surgical wound infection in patients with femur surgery sites reported in nine studies was 3.7% (95% CI: 2.1-6.4%; I2  = 93.43%; p < 0.001). The pooled prevalence of surgical wound infection in open and close fractures was 16.4% (95% CI: 8.2%-30.2%; I2  = 95.83%; p < 0.001) and 2.9% (95% CI: 1.5%-5.5%; I2  = 96.40%; p < 0.001), respectively. The pooled prevalence of surgical wound infection in patients with diabetes mellitus (DM), hypertension (HTN) and cardiovascular disease (CVD) was 4.6% (95% CI: 2.3%-8.9%; I2  = 81.50%; p < 0.001), 2.7% (95% CI: 1.2%-6.0%; I2  = 83.82%; p < 0.001) and 3.0% (95% CI: 1.4%-6.4%; I2  = 69.12%; p = 0.006), respectively. In general, the different prevalence of surgical wound infection in patients undergoing surgical treatment after long bone fracture may be caused by underlying factors (gender and co-morbidity) and fracture-related factors (surgery site and type of fracture).

Social Vulnerability and Surgery Outcomes: A Cross-sectional Analysis

Background

Post-operative complications present a challenge to the healthcare system due to the high unpredictability of their incidence. However, the socioeconomic factors that relate to postoperative complications are still unclear as they can be heterogeneous based on communities, types of surgical services, and sex and gender.

Methods

In this study, we conducted a large population cross-sectional analysis of social vulnerability and the odds of various post-surgical complications. We built statistical logistic regression models of postsurgical complications with social vulnerability index as the independent variable along with sex interaction.

Results

We found that social vulnerability was associated with abnormal heart rhythm with socioeconomic status and housing status being the main association factors. We also found associations of the interaction of social vulnerability and female sex with an increase in odds of heart attack and surgical wound infection.

Conclusions

Our results indicate that social vulnerability measures such as socioeconomic status and housing conditions could be related to health outcomes. This suggests that the domain of preventive medicine should place social vulnerability as a priority to achieve its goals.

Risk factors for fracture-related infection after ankle fracture surgery

INTRODUCTION

Ankle fracture surgery comes with a risk of fracture-related infection (FRI). Identifying risk factors are important in preoperative planning, in management of patients, and for information to the individual patient about their risk of complications. In addition, modifiable factors can be addressed prior to surgery. The aim of the current paper was to identify risk factors for FRI in patients operated for ankle fractures.

METHODS

A cohort of 1004 patients surgically treated for ankle fractures at Haukeland University Hospital in the period of 2015-2019 was studied retrospectively. Patient charts and radiographs were assessed for the diagnosis of FRI. Binary logistic regression was used in analyses of risk factors. Regression coefficients were used to calculate the probability for FRI based on the patients' age and presence of one or more risk factors.

RESULTS

FRI was confirmed in 87 (9%) of 1004 patients. Higher age at operation (p < .001), congestive heart failure (CHF), p = 0.006), peripheral artery disease (PAD, p = 0.001), and current smoking (p = .006) were identified as risk factors for FRI. PAD and CHF were the risk factors displaying the strongest association with FRI with an adjusted odds ratio of 4.2 (95% CI 1.8-10.1) and 4.7 (95% CI 1.6-14.1) respectively.

CONCLUSION

The prevalence of FRI was 9% after surgical treatment of ankle fractures. The combination of risk factors found in this study demonstrate the need for a thorough, multidisciplinary, and careful approach when faced with an elderly or frail patient with an ankle fracture. The results of this study help the treating surgeons to inform their patients of the risk of FRI prior to ankle fracture surgery.

LEVEL OF EVIDENCE

Level III retrospective case-control study.

Post-discharge occurrence of surgical site infections after hip or knee arthroplasty surgery in Poland, a population-based study

Arthroplasty is a common procedure improving functioning of patients and their quality of life. Infection is a serious complication that determines subsequent management of the prosthesis and the patient. The aim of the study was to investigate the incidence of post-discharge surgical site infections (SSI) and their risk factors. A retrospective analysis of an anonymized database from the National Health Found for 2017 of 56,068 adult patients undergoing hip replacement surgery (HPRO) and 27,457 patients undergoing knee replacement surgery (KPRO). The cumulative incidence of post-discharge SSI was 0.92% for HPRO and 0.95% for KPRO. The main risk factors for hip SSI were male gender, diseases of hematopoietic, musculoskeletal and nervous system. The risk factor for knee SSI was male gender. All comorbidities significantly increased the risk of SSI. The ICU stay and antibiotics administered at discharge in studied population increased the risk of detection of SSI after HPRO and KPRO by up to four and seven times, respectively. For both procedures rehabilitation after surgery and total endoprosthesis decreased incidence of SSIs. The lower experience of the center was related to higher SSI incidence in HPRO in primary (1.5% vs. 0.9%) and in revision surgeries (3.8% vs. 2.1%), but in KPRO, lower experience only in primary surgeries was significantly associated with SSI. The cumulative incidence of post-discharge SSI in Poland is higher than in other European countries. Special attention should be paid to patients with chronic diseases.

Retrospective Analysis of Bone Substitute Material for Traumatic Long Bone Fractures: Sex-Specific Outcomes

Male patients often experience increased bone and muscle loss after traumatic fractures. This study aims to compare the treatment outcomes of male and female patients with large bone defects. A total of 345 trauma patients underwent surgery, with participants divided into two groups: one receiving bone substitute material (BSM) for augmented defects (n = 192) and the other without augmentation (empty defects = ED, n = 153). Outcome parameters were assessed among female (n = 184) and male (n = 161) patients. Descriptive statistics revealed no significant differences between male and female patients. Approximately one-half of the fractures resulted from high-energy trauma (n = 187). The BSM group experienced fewer complications (p = 0.004), including pseudarthrosis (BSM: n = 1, ED: n = 7; p = 0.02). Among female patients over 65, the incidence of pseudarthrosis was lower in the BSM group (p = 0.01), while younger females showed no significant differences (p = 0.4). Radiologically, we observed premature bone healing with subsequent harmonization. Post hoc power analysis demonstrated a power of 0.99. Augmenting bone defects, especially with bone substitute material, may reduce complications, including pseudarthrosis, in female patients. Additionally, this material accelerates bone healing. Further prospective studies are necessary for confirmation.

Antimicrobial Stewardship for Outpatients with Chronic Bone and Joint Infections in the Orthopaedic Clinic of an Academic Tertiary Hospital, South Africa

Bone and joint infections are associated with prolonged hospitalizations, high morbidity and complexity of care. They are difficult to treat, and successful therapy requires organism-specific antimicrobial therapy at high doses for a prolonged duration as recommended in standard treatment guidelines (STGs). Adherence to the treatment plan is equally important, which is enhanced with knowledge of the condition as well as appropriate antibiotics. Consequently, the aim of this study was to provide antimicrobial stewardship (AMS) services to outpatients with chronic bone and joint infections presenting to the orthopaedic clinic at a public South African tertiary hospital. A total of 44 patients participated in this study. Chronic osteomyelitis was diagnosed in 39 (89%) patients and septic arthritis in 5 (11%). The majority (43%) of infections were caused by Staphylococcus aureus followed by Pseudomonas aeruginosa (14%). Seventy-one antibiotics were prescribed at baseline with rifampicin prescribed the most (39%), followed by ciprofloxacin (23%). The majority (96%) of the antibiotics were not prescribed according to the South African STG; however, interventions were only needed in 31% of prescribed antibiotics (n = 71) since the STG only recommends empiric therapy directed against Staphylococcus aureus. Seventy-seven percent of the patients obtained a high self-reported adherence score at baseline. Consequently, there is a need to improve AMS in bone and joint infections to improve future care.

Time to development of surgical site infection and its predictors among general surgery patients admitted at specialized hospitals in Amhara region, northwest Ethiopia: a prospective follow-up study

BACKGROUND

Surgical site infection is an infection occurring within 30 days after surgery. It is recently reported that evidence-based information on the specific time when the majority of surgical site infections would develop is a key to early detect the infection as well as to preventing and early intervene against their pressing and fatal complications. Therefore, the current study aimed to determine the incidence, predictors, and time to development of surgical site infection among general surgery patients at specialized hospitals in the Amhara region.

METHOD

An institution-based prospective follow-up study was conducted. The two-stage cluster sampling procedure was used. A systematic sampling technique with a K interval of 2 was applied to prospectively recruit 454 surgical patients. Patients were followed up for 30 days. Data were collected using Epicollect5 v 3.0.5 software. Post-discharge follow-up and diagnosis were done by telephone call follow-up. Data were analyzed using STATA™ version 14.0. Kaplan-Meier curve was used to estimate survival time. Cox proportional regression model was used to determine significant predictors. Variables with a P-value less than 0.05 in the multiple Cox regression models were independent predictors.

RESULT

The incidence density was 17.59 per 1000 person-day-observation. The incidence of post-discharge Surgical site infection was 70.3%. The majority of surgical site infections were discovered after discharge between postoperative days 9 to 16. Being male (AHR: 1.98, 95% CI: 1.201 - 3.277, diabetes Mellitus (AHR: 1.819, 95% CI: 1.097 - 3.016), surgical history (AHR: 2.078, 95% CI: 1.345, 3.211), early antimicrobial prophylaxis (AHR: 2.60, 95% CI: 1.676, 4.039), American Society of Anesthesiologists score ≥ III AHR: 6.710, 95% CI: 4.108, 10.960), duration of the surgery (AHR: 1.035 95% CI: 1.001, 1.070), Age (AHR: 1.022 95% CI: 1.000, 1.043), and the number of professionals in the Operation Room (AHR: 1.085 95% CI: 1.037, 1.134) were found to be the predictors of time to development of Surgical site infection.

CONCLUSION

The incidence of surgical site infection was higher than the acceptable international range. The majority of infections were detected after hospital discharge between 9 to 16 postoperative days. The main predictors of Surgical site infection were Age, Sex, Diabetes Mellitus, previous surgical history, the timing of Antimicrobial prophylaxis, American Society of Anesthesiologists score, pre-operative hospital stay, duration of surgery, and the number of professionals in the operation room. Hence, hospitals should give great emphasis on pre-operative preparation, post-discharge surveillance, modifiable predictors, and high-risk patients, as they found in this study.

Association between the proportion of laparoscopic approaches for digestive surgeries and the incidence of consequent surgical site infections, 2009-2019: A retrospective observational study based on national surveillance data in Japan

BACKGROUND

Surgical site infections (SSIs) are among the most common healthcare-associated infections. Laparoscopy is increasingly being used in various surgical procedures. However, no study has examined the association between the proportion of laparoscopic procedures and the incidence of SSIs in digestive surgery using nationwide surveillance data.

METHODS

We retrospectively investigated national SSI surveillance data from the Japan Nosocomial Infections Surveillance between 2009 and 2019. The annual trend of the SSI rate and the proportion of laparoscopic procedures were assessed, focusing on five major digestive surgeries. This was based on data from 109,544 (appendix surgery), 206,459 (gallbladder surgery), 60,225 (small bowel surgery), 363,677 (colon surgery), and 134,695 (rectal surgery) procedures. The effect of a 10% increase in the proportion of laparoscopic procedures on the reduction of the SSI rate was estimated using mixed-effect logistic regression.

FINDINGS

The average SSI rate of the five digestive surgeries decreased from 11.8% in 2009 to 8.1% in 2019. The proportion of laparoscopic procedures in each of the five digestive surgeries increased continuously (p<0.001). The SSI rate for laparoscopic procedures was always lower than that for open procedures. The results were consistent between all and core hospitals participating in the surveillance. The odds ratios of the 10% increase in the proportion of laparoscopic procedures for five digestive surgeries were always <0.950 (p<0.001).

CONCLUSION

An increase in the proportion of laparoscopic procedures was associated with a reduction in the SSI rate in digestive surgeries.

Sex differences in diabetic foot ulcer severity and outcome in Belgium

BACKGROUND

Sex differences are increasingly recognized to play an important role in the epidemiology, treatment and outcomes of many diseases. This study aims to describe differences between sexes in patient characteristics, ulcer severity and outcome after 6 months in individuals with a diabetic foot ulcer (DFU).

METHODS

A total of 1,771 patients with moderate to severe DFU participated in a national prospective, multicenter cohort study. Data were collected on demographics, medical history, current DFU and outcome. For data analysis, a Generalized Estimating Equation model and an adjusted Cox proportional hazards regression were used.

RESULTS

The vast majority of patients included were male (72%). Ulcers in men were deeper, more frequently displaying probe to bone, and more frequently deeply infected. Twice as many men presented with systemic infection as women. Men demonstrated a higher prevalence of previous lower limb revascularization, while women presented more frequently with renal insufficiency. Smoking was more common in men than in women. No differences in presentation delay were observed. In the Cox regression analysis, women had a 26% higher chance of healing without major amputation as a first event (hazard ratio 1.258 (95% confidence interval 1.048-1.509)).

CONCLUSIONS

Men presented with more severe DFU than women, although no increase in presentation delay was observed. Moreover, female sex was significantly associated with a higher probability of ulcer healing as a first event. Among many possible contributing factors, a worse vascular state associated with a higher rate of (previous) smoking in men stands out.

Surgical Site Infection Prevention: A Review

IMPORTANCE

Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer.

OBSERVATIONS

Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis.

CONCLUSIONS AND RELEVANCE

Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.

Infections and Colon Surgery: Preliminary Results from a Surveillance Program in an Italian Hospital

Surgical site infections (SSIs) represent a valid indicator of the healthcare quality. This study described the preliminary results of one-year active surveillance program on colon surgeries in a hospital in Molise region, central Italy. Patients who had undergone colon surgery according to National Healthcare Safety Network were included. Data on intervention, perioperative antibiotic prophylaxis, and SSIs occurrence were collected. Chi-square and Fisher's Exact test were used to evaluate any association between risk factors and SSIs. Sixty-eight patients (mean age 70.6 years) were included, and 44 (64.7%) were males. The most frequent interventions were right (n = 17, 25.0%) and left (n = 15, 22.0%) hemicolectomy. Surgical interventions were largely elective (n = 43, 63.2%) and with laparotomy (n = 56, 82.4%). During hospital stay, 10 (14.7%) SSIs were detected, including five superficial, three deep and two organ/space infections. Three (4.4%) additional SSIs were detected at post-discharge follow-up, for 13 (19.1%; CI95%: 9.7%-28.5%) total cases detected. Metronidazole plus Ceftriaxone (third generation cephalosporin) was the antibiotics combination mostly used (n = 36, 52.9%) for the perioperative antibiotic prophylaxis within 60 minutes of incision. The study underlines the need of improvements of the practices currently adopted, since SSIs could be significantly reduced through a multimodal strategy generating bundles. As third generation cephalosporins may facilitate resistant strains emergence, for perioperative prophylaxis in clean-contaminated interventions with entry into gastrointestinal tract, Cefazolin plus Metronidazole or only second generation cephalosporin are recommended. Due to the large variability of post-intervention antibiotic therapy, antimicrobial stewardship approach is strictly necessary.

Clinical and economic burden of surgical site infections in inpatient care in Germany: A retrospective, cross-sectional analysis from 79 hospitals

BACKGROUND

Surgical site infections (SSI) present a substantial burden to patients and healthcare systems. This study aimed to elucidate the prevalence of SSIs in German hospitals and to quantify their clinical and economic burden based on German hospital reimbursement data (G-DRG).

METHODS

This retrospective, cross-sectional study used a 2010-2016 G-DRG dataset to determine the prevalence of SSIs in hospital, using ICD-10-GM codes, after surgical procedures. The captured economic and clinical outcomes were used to quantify and compare resource use, reimbursement and clinical parameters for patients who had or did not have an SSI.

FINDINGS

Of the 4,830,083 patients from 79 hospitals, 221,113 were eligible. The overall SSI prevalence for the study period was 4.9%. After propensity-score matching, procedure type, immunosuppression and BMI ≥30 were found to significantly affect the risk of SSI (p<0.001). Mortality and length of stay (LOS) were significantly higher in patients who had an SSI (mortality: 9.3% compared with 4.5% [p<0.001]; LOS (median [interquartile range, IQR]): 28 [27] days compared with 12 [8] days [p<0.001]). Case costs were significantly higher for the SSI group (median [IQR]) €19,008 [25,162] compared with € 9,040 [7,376] [p<0.001]). A median underfunding of SSI was identified at €1,534 per patient.

INTERPRETATION

The dataset offers robust information about the "real-world" clinical and economic burden of SSI in hospitals in Germany. The significantly increased mortality of patients with SSI, and their underfunding, calls for a maximization of efforts to prevent SSI through the use of evidence-based SSI-reduction care bundles.

Risk Stratification of Local Flaps and Skin Grafting in Skin Cancer-Related Facial Reconstruction: A Retrospective Single-Center Study of 607 Patients

Background: Non-melanoma skin cancer (NMSC) takes up a substantial fraction of dermatological and plastic surgical outpatient visits and surgeries. NMSC develops as an accumulated exposure to UV light with the face most frequently diagnosed. Method: This retrospective study investigated the risk of complications in relation to full-thickness skin grafts (FTSG) or local flaps in 607 patients who underwent facial surgery and reconstruction at a high-volume center for facial cancer surgery at a tertiary university hospital. Results: Between 01.12.2017 and 30.11.2020, 304 patients received reconstructive flap surgery and 303 received FTSG following skin cancer removal in the face. Flap reconstruction was predominantly performed in the nasal region (78%, n = 237), whereas FTSG reconstruction was performed in the nasal (41,6%, n = 126), frontal (19.8%, n = 60), and temporal areas (19.8%, n = 60), respectively. Patients undergoing FTSGs had a significantly higher risk of hematoma (p = 0.003), partial necroses (p < 0.001), and total necroses (p < 0.001) compared to flap reconstruction. Age and sex increased the risk of major complications (hematoma, partial or total necrosis, wound dehiscence, or infection) for FTSG, revealing that men exhibited 3.72 times increased risk of major complications compared to women reconstructed with FTSG. A tumor size above 15 mm increased the risk of hematoma and necrosis significantly. In summary, local flaps for facial reconstruction after skin cancer provide lower complication rate compared with FTSGs, especially in elderly and/or male patients. The indication for FTSG should be considered critically if the patient’s tumor size and location allow for both procedures.

Incidence and risk factors of surgical site infections after coronary artery bypass grafting surgery in Oman

Background

There is limited information about the incidence and risk factors of surgical site infections (SSIs) after coronary artery bypass (CABG) surgeries in the Omani population.

Aim

To estimate the prevalence and describe possible risk factors of SSIs after CABG surgeries in Oman.

Method

A retrospective nested case-control design was used to screen 596 patients who underwent CABG surgeries over 2 years (2016-2017) in two tertiary hospitals in Oman. The CDC definition for SSIs was used to identify the infected cases.

Results

Prevalence rate of SSIs was 17.4% and 17.5% in 2016 and 2017, respectively. The most isolated microorganism was Gram-positive bacteria (45.2%). Risk factors of SSIs include female gender (OR = 3.2, p < 0.001), diabetes (OR = 5.83, p < 0.001), overweight or obese (OR = 2.14, p < 0.05) and shaving technique [using razor shaving] (OR = 8.4, p < 0.001). Readmission rate for the case group was 44.2%.

Conclusion

The infection rate of SSIs after CABG surgeries in developing countries, such as Oman, is considerably high. There is an urgent need to establish SSIs preventive program at the national level. Frequent and systematic assessment of infection control practices before and after CABG surgeries is fundamental and priority strategy to prevent SSIs.

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.

Efficacy of Postoperative Oral Antibiotics in Foot and Ankle Surgery

BACKGROUND

Preoperative oral antibiotic use in patients undergoing foot and ankle surgery is standard practice, but no consensus has been reached regarding the efficacy of postoperative oral antibiotics. The purpose of this study was to determine whether postoperative oral antibiotics reduce the rate of surgical site infections (SSIs) in patients, with and without comorbidities, undergoing foot and ankle surgery.

METHODS

A retrospective chart review was conducted identifying patients who underwent foot and ankle surgery by 4 fellowship-trained, foot and ankle orthopaedic surgeons between January 1, 2015, and January 1, 2019. Patients were divided into 2 groups: those who received postoperative oral antibiotics (group 1) and those who did not (group 2). Two surgeons routinely prescribed postoperative oral antibiotics, and 2 did not. Demographics, comorbidities, and procedure complexity based on surgical site and Current Procedural Terminology code were recorded from the charts. The primary outcome was postoperative infection (superficial or deep) within 6 months after surgery. Patients with antibiotic use prior to surgery, preoperative infection, or lack of follow-up >6 weeks were excluded. Multivariate logistic regression modeling was used to analyze differences in infection rate and severity.

RESULTS

Chart review identified 3631 patients, 1227 of whom did not receive postoperative oral antibiotics whereas 2394 patients did. Routine postoperative oral antibiotic use did not significantly affect postoperative infection rates or severity. However, all covariates studied (diabetes, hypertension, obesity, tobacco use, alcohol use, rheumatoid conditions, and age) influenced postoperative infection rates and severity.

CONCLUSION

The results of this study indicate that postoperative oral antibiotics are not associated with differences in infection rates or severity. We do not recommend routine use in foot and ankle surgery.

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.

Antibiotic Use, Incidence and Risk Factors for Orthopedic Surgical Site Infections in a Teaching Hospital in Madhya Pradesh, India

Orthopedic surgeries contribute to the overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably (1.6−38%); however, there is a lack of a national SSI surveillance system. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the European Centre for Disease Prevention and Control guidelines. The American Society for Anesthesiologists classification system was used to predict patients’ operative risk. Univariable and multivariable backward stepwise logistic regressions were performed. Overall, 7.6% of patients developed SSIs over three years. The most common SSIs causative microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32−5.30), previous hospitalization (OR 2.15; 95%CI 1.25−3.69), antibiotic prescription during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51−7.00) and postoperative length of stay > 15 days (OR 3.30; 95%CI 1.83−5.95) were identified as significant risk factors. Additionally, preoperative shower significantly increased the SSI risk (OR 4.73; 95%CI 2.72−8.22), which is unconfirmed in the literature so far.

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.

Effectiveness of Oral Antibiotic Therapy in Prevention of Postoperative Wound Infection Requiring Surgical Washout In Spine Surgery

BACKGROUND

Surgical site infections (SSIs) after spine surgery are a significant cause of morbidity. Surgeons often prescribe oral antibiotics in the postoperative setting for infected-appearing wounds to prevent reoperation for infection; however, the efficacy of this practice has not been well studied.

METHODS

Neurosurgical spine patients with clinical concerns for SSI at the University of Pennsylvania were retrospectively studied from 2014 to 2018. Clinical predictors of 90-day reoperation for infection despite antibiotic treatment and variables that influenced antibiotic prescription were analyzed.

RESULTS

Three hundred and ninety-two patients were included in the study. Preoperative albumin level, days elapsed to antibiotic prescription from index surgery, preoperative hemoglobin level, surgical location, gender, discharge disposition, and level of wound concern were significant predictors of reoperation for infection on bivariate analysis. Days elapsed to antibiotic prescription, surgical location, and level of wound concern remained significant after multivariable logistic regression. Variables that significantly predicted prescription of an antibiotic include length of stay, cerebrospinal fluid leak, race, and level of wound concern. Length of stay, race, and level of wound concern remained significant after multivariable analysis.

CONCLUSIONS

Wound infection remains a challenging problem in spine surgery and it is reasonable to perform early reoperation in patients with high clinical concerns for infection, because bacterial isolates are often resistant to common oral antibiotics. Patients with wounds with low clinical concerns for infection may undergo a trial of oral antibiotics; however, duration of treatment should not be prolonged.

Male Sex, Cartilage Surgery, Tobacco Use, and Opioid Disorders are Associated with an Increased Risk of Infection After Anterior Cruciate Ligament Reconstruction

PURPOSE

To identify patient-related risk factors for infection following anterior cruciate ligament reconstruction (ACLR).

METHODS

The Mariner database within PearlDiver was queried for patients from 2010 to 2019 undergoing primary arthroscopic ACLR. Patients undergoing ACLR with concomitant open surgery or additional ligament reconstructions were excluded. Postoperative diagnoses or procedures for superficial or deep infection within 6 months were assessed. A multivariable logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

In total, 217,541 patients underwent ACLR and 1779 (0.8%) patients had a postoperative infection within 6 months. Significant independent risk factors included male sex (OR 1.58, 95% CI 1.43-1.75, P < .001), obesity (OR 1.22, 95% CI 1.05-1.43, P = .020), morbid obesity (OR 2.54, 95% CI 2.11-3.06, P = .002), tobacco use (OR 1.36, 95% CI 1.19-1.55, P < .001), age younger than 40 years (OR 1.21, 95% CI 1.07-1.37, P = .033), depression (OR 1.18, 95% CI 1.04-1.34, P = .012), opioid disorder (OR 1.50, 95% CI 1.22-1.85, P < .001), concomitant simple cartilage surgery (OR 1.63, 95% CI 1.43-1.86, P < .001), and complex cartilage surgery (OR 1.67, 95% CI 1.20-2.32, P = .002). Partial meniscectomy and meniscal repair at the time of ACLR were not associated with an increased risk of infection.

CONCLUSIONS

In a large national sample, male sex, obesity, tobacco use, older age, depression, opioid disorders and concomitant cartilage surgery were significant risk factors for infection following ACLR.

LEVEL OF EVIDENCE

Therapeutic Level IV, retrospective case series.

Surgical site infection following minimally invasive lobectomy: Is robotic surgery superior?

Background

Surgical site infection (SSI) in thoracic surgery remains a significant cause of morbidity and prolonged hospitalization. Minimally invasive surgery (MIS) has significantly reduced the risk of SSI. We intended to compare whether there was difference between video‐assisted thoracic surgery (VATS) and robotic‐assisted thoracic surgery (RATS) in SSI and highlight possible factors influencing SSI in lobectomy.

Methods

This retrospective study analyzed patients who underwent minimally invasive lobectomy from January 2018 to December 2019. All patients' clinical characteristics and surgery‐related information which may be related to the likelihood of SSI were recorded.

Results

A total of 1231 patients' records were reviewed with 806 VATS and 425 RATS. SSI was classified as deep or superficial SSI. Eighty‐six (7.0%) patients were found to develop an SSI with 62 patients having deep infections and 24 had superficial infection. No statistical difference in the incidence rate and category of SSI was observed between patients undergoing VATS and RATS.

Conclusions

There was no difference in the incidence of SSI between VATS and RATS lobectomy. Male gender, heavy smoking, uncontrolled diabetes mellitus, body mass index (BMI) > 27.9, more blood loss, and the higher National Healthcare Safety Network (NHSN) risk index score (1 or 2) were the independent risk factors of SSI following minimally invasive lobectomy, while male gender, uncontrolled diabetes mellitus, BMI > 27.9, more blood loss and the higher NHSN risk index score (1 or 2) were the main predictors of deep SSI.

Intraoperative Bile Culture in Pancreaticoduodenectomy: Teaching Old Dogma New Tricks

INTRODUCTION

Biliary stents increase surgical site infections (SSIs) following pancreaticoduodenectomy due to bactibilia and contaminated intraoperative bile spillage. Intraoperative bile culture (IOBC) is performed to guide empiric therapy for SSIs; however, its utility is poorly studied. We sought to evaluate IOBC and the interplay between stenting, bactibilia, and SSI following pancreaticoduodenectomy.

METHODS

Patients undergoing pancreaticoduodenectomy from January 2008 to April 2020 were identified through our institutional National Surgical Quality Improvement Project (NSQIP) database; patients without IOBC were excluded. Odds of SSI were analyzed with multivariable logistic regression.

RESULTS

Four-hundred-eighty-three patients were identified. One-hundred-eighty-nine (39%) patients had plastic stents and 154 (32%) had metal stents. Three-hundred-twenty-nine (96%) patients with stents had bactibilia versus 18 (13%) without stents (P < 0.001). The biliary microbiome and antibiotic resistance patterns in patients with metal and plastic stents were nearly identical. Of 159 NSQIP-defined SSIs, most were incisional (n = 92, 58%). Bactibilia and stent presence were associated with incisional (OR 3.69 and 3.39, both P < 0.001) but not organ space SSI (P > 0.1); however, stent type was not (P > 0.5). Of the 73 speciated SSI cultures, an IOBC-identified organism was present in 42 (58%), while at least one organism not found in the IOBC was present in 49 (67%).

CONCLUSION

Bactibilia is associated with incisional but not organ space SSI following pancreaticoduodenectomy and is strongly associated with stent presence. Stent type does not independently influence the biliary microbiome or SSI risk. IOBC has a poor ability to predict causative organisms in SSIs following pancreaticoduodenectomy and is not recommended for routine use.

Impact and Sustainability of Antibiotic Stewardship on Antibiotic Prescribing in Visceral Surgery

BACKGROUND

Antibiotic stewardship (AS) ward rounds are a core element in clinical care for surgical patients. Therefore, we aimed to analyze the impact of surgical AS ward rounds on antibiotic prescribing, and the sustainability of the effect after the AS interventions are no longer provided.

METHODS

On four wards of the department of visceral surgery, we conducted two independent retrospective prescribing analyses (P1, P2) over three months each. During the study periods, the level of AS intervention differed for two of the four wards (ward rounds/no ward rounds).

RESULTS

AS ward rounds were associated with a decrease in overall antibiotic consumption (91.1 days of therapy (DOT)/100 patient days (PD) (P1), 70.4 DOT/100PD (P2)), and improved de-escalation rates of antibiotic therapy (W1/2: 25.7% (P1), 40.0% (P2), p = 0.030; W3: 15.4 (P1), 24.2 (P2), p = 0.081). On the ward where AS measures were no longer provided, overall antibiotic usage remained stable (71.3 DOT/100PD (P1), 74.4 DOT/100PD (P2)), showing the sustainability of AS measures. However, the application of last-resort compounds increased from 6.4 DOT/100PD to 12.1 DOT/100PD (oxazolidinones) and from 10.8 DOT/100PD to 13.2 DOT/100PD (carbapenems).

CONCLUSIONS

Antibiotic consumption can be reduced without negatively affecting patient outcomes. However, achieving lasting positive changes in antibiotic prescribing habits remains a challenge.

Risk of surgical site infection in hand trauma, and the impact of the SARS-CoV-2 pandemic: A cohort study

BACKGROUND

Despite the ubiquity of hand trauma, there remains insufficient published data to reliably inform these patients of surgical site infection (SSI) risk. We describe the risk of SSI in a single-centre cohort of patients with hand trauma, with an analysis of the impact of the coronavirus disease-2019 (COVID-19) pandemic.

METHODS

Retrospective data collection of consecutive patients who underwent surgery for hand and wrist trauma in a single plastic surgery centre over two, three-month periods. Demographic, injury and operative details, alongside prophylactic antibiotic use, were recorded. Burn injuries and wounds infected at presentation were excluded. Presence of SSI at 30 days (90 days if a surgical implant was used) was assessed.

RESULTS

Overall, 556 patients - 'Pre-COVID-19' (n = 310) and 'During COVID-19' (n = 246) - were included. Risk of SSI was 3.6% in the aggregated cohort. Female patients were more likely to develop an SSI, even when adjusted for their greater prevalence of bite aetiologies (adj OR 2.5; 95% CI, 1.00-6.37 and p < 0.05). The absolute risk of SSI in the 'Pre-COVID-19' group was 2.3% and 5.3% in the 'During COVID-19' group. The relative risk of developing an SSI in the 'During COVID-19' group was 2.34 (95% CI, 0.95-5.78 and p = 0.06). Baseline characteristics were equivalent between the two groups.

CONCLUSION

The risk of SSI in hand trauma is the same as the nationally estimated risk for all surgeries; 3-5%. Changes in presentation and practice associated with the first wave of the COVID-19 pandemic did not appear to alter the risk of SSI in patients undergoing surgery for hand trauma.

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.

Retrospective Study of Nosocomial Infections in the Orthopaedic and Rehabilitation Clinic of the Medical University of Lublin in the Years 2018-2020

Nosocomial infections appear in patients treated in hospital, which are not the initial cause of admission. A retrospective study concerning nosocomial infections was conducted to provide data about the amount, frequency and types of nosocomial infections in the rehabilitation ward in the Orthopaedics and Rehabilitation Clinic of Lublin. The study was conducted on a group of 49 patients that were admitted or transferred to the ward over a period of 20 months in the years 2018–2020. The patients and therefore the infections were divided by age, sex, time of hospitalization and the underlying disease. The study also provided data about the most frequent infection types in these patients, as well as the most commonly used drugs to treat those infections. The results showed that in fact all of the examined factors have an impact on the frequency of nosocomial infections appearance rates. Furthermore, results in the study showed that factors examined by the study also have an impact on what type of infection was present in these groups of patients.

Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure

INTRODUCTION

Most surgical site infections after shoulder surgery are caused by Cutibacterium acnes. Topically applied benzoyl peroxide (BPO) has for years been used to decrease the skin load of C acnes in treatment of acne vulgaris. The purpose of this study was to examine this effect on bacterial colonization in patients subjected to elective shoulder surgery at different stages of the procedure.

METHODS

A total of 100 patients scheduled for primary elective open shoulder surgery were randomized to prepare either with BPO or according to local guidelines-with soap (control group). Four skin swabs were taken in a standardized manner at different times, before and after surgical skin preparation, 1 in dermis, and finally after the skin was sutured. Before skin incision, 5 punch biopsies (3 mm in diameter and maximum 4 mm deep) were retrieved spaced 2 cm apart in the planned skin incision. On culturing, quantification of C acnes was made by serial dilutions.

RESULTS

Men had a 5-fold higher amount of C acnes on untreated skin. Treatment with BPO considerably lowered this count (P = .0001) both before and after skin disinfection compared to the control group. This positive effect of BPO persisted until skin closure, the point at which some recolonization of C acnes had occurred, but to a higher degree in the control group (P = .040).

CONCLUSION

Preoperative BPO treatment of the shoulder may be an effective method to decrease bacterial skin load of C acnes from skin incision until wound closure.

Web-Based Calculator Predicts Surgical-Site Infection After Thoracolumbar Spine Surgery

BACKGROUND

Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an individual's risk of a wound infection following thoracolumbar spine surgery.

METHODS

We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer-Lemeshow test was employed to evaluate goodness-of-fit and model calibration.

RESULTS

In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio [OR] 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound_Infection_Calculator/.

CONCLUSIONS

In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs.

Association between the frequency of surgeries for video-assisted thoracic surgery and the incidence of consequent surgical site infections: a retrospective observational study based on national surveillance data

Background

The association between the frequency of surgeries and the incidence of surgical site infections (SSIs) has been reported for various surgeries. However, no previous study has explored this association among video-assisted thoracic surgeries (VATS). Hence, we aimed to investigate the association between the frequency of surgeries and SSI in video-assisted thoracic surgeries.

Methods

We analyzed the data of 26,878 thoracic surgeries, including 21,154 VATS, which were collected during a national surveillance in Japan between 2014 and 2018. The frequency of surgeries per hospital department was categorized into low (< 50/year), moderate (50–100/ year), and high (> 100/year). Chi-squared test or Fisher’s exact test was used for discrete explanatory variables, whereas Wilcoxon’s rank-sum test or Kruskal-Wallis test was used for continuous explanatory variables. Univariate analysis of the department groups was conducted to explore confounding factors associated with both SSIs and the department groups. We used a multiple logistic regression model focusing on VATS and stratified by the National Nosocomial Infections Surveillance System (NNIS) risk index.

Results

The rates of SSIs in the hospital groups with low, moderate, and high frequency of surgeries were 1.39, 1.05, and 1.28%, respectively. In the NNIS risk index 1 stratum, the incidence of SSIs was significantly lower in the moderate-frequency of surgeries group than that in the other groups (odds ratio [OR]: vs. low-frequency of surgeries: 2.48 [95% confidence interval [CI]: 1.20–5.13], P = 0.0143; vs. high-frequency of surgeries: 2.43 [95% CI: 1.44–4.11], P = 0.0009). In the stratum of NNIS risk indices 2 and 3, the incidence of SSI was significantly higher in the low-frequency of surgeries group (OR: 4.83, 95% CI: 1.47–15.93; P = 0.0095).

Conclusion

The result suggests that for departments with low-frequency of surgeries, an increase in the frequency of surgeries to > 50 per department annually potentially leads to a decrease in the incidence of SSIs. This occurs through an increase in the experience of the departmental surgeons and contributes to the improvement of VATS outcomes in thoracic surgeries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06050-6.

Risk Factor Analysis for Infection after Medial Open Wedge High Tibial Osteotomy

Background: Medial open wedge high tibial osteotomy (MOWHTO) is a well-established treatment for osteoarthritis of the medial tibiofemoral compartment. Surgical site infection (SSI) after MOWHTO is a devastating complication that may require further surgery. In this study, we aimed to identify the risk factors for infection after MOWHTO over 1 to 4 years of follow-up. Methods: Fifty-nine patients who underwent MOWHTO combined with knee arthroscopic surgery were included in this prospective study. Artificial bone grafts were used in all cases. Possible risk factors, including sex, age, body mass index (BMI), underlying disease, hospitalization length, correction angle, and surgery time, were recorded. Both univariate and multivariate analysis were used. Results: A total of 59 patients who underwent 61 operations were included. Eleven patients (18.0%) were reported to have SSI. Univariate analysis showed that smoking and diabetes mellitus were positively associated with SSI. Multivariate analysis showed that smoking and age were positively associated with SSI. Three patients (4.9%) were reported to suffer from deep SSI, requiring surgical debridement, all of whom were male smokers. Conclusion: Smoking, diabetes mellitus, and old age were identified to be possible risk factors of SSI after MOWHTO. These findings are common risk factors of SSI after orthopedic surgery according to the literature. Patient selection should be performed cautiously, and postoperative prognosis for MOWHTO should be carefully explained to patients who smoke.

Prospective multicenter study on the incidence of surgical site infection after emergency abdominal surgery in China

There is still a lack of relevant studies on surgical site infection (SSI) after emergency abdominal surgery (EAS) in China. This study aims to understand the incidence of SSI after EAS in China and discuss its risk factors. All adult patients who underwent EAS in 47 hospitals in China from May 1 to 31, 2018, and from May 1 to June 7, 2019, were enrolled in this study. The basic information, perioperative data, and microbial culture results of infected incision were prospectively collected. The primary outcome measure was the incidence of SSI after EAS, and the secondary outcome variables were postoperative length of stay, ICU admission rate, ICU length of stay, 30-day postoperative mortality, and hospitalization cost. Univariate and multivariate logistic regression were used to analyze the risk factors. The results were expressed as the odds ratio and 95% confidence interval. A total of 953 patients [age 48.8 (SD: 17.9), male 51.9%] with EAS were included in this study: 71 patients (7.5%) developed SSI after surgery. The main pathogen of SSI was Escherichia coli (culture positive rate 29.6%). Patients with SSI had significantly longer overall hospital (p < 0.001) and ICU stays (p < 0.001), significantly higher ICU admissions (p < 0.001), and medical costs (p < 0.001) than patients without SSI. Multivariate logistic regression analysis showed that male (P = 0.010), high blood glucose level (P < 0.001), colorectal surgery (P < 0.001), intestinal obstruction (P = 0.045) and surgical duration (P = 0.007) were risk factors for SSI, whereas laparoscopic surgery (P < 0.001) was a protective factor. This study found a high incidence of SSI after EAS in China. The occurrence of SSI prolongs the patient's hospital stay and increases the medical burden. The study also revealed predictors of SSI after EAS and provides a basis for the development of norms for the prevention of surgical site infection after emergency abdominal surgery.

Risk factors for deep surgical site infection after posterior cervical spine surgery in adults: a multicentre observational cohort study

Surgical site infection (SSI) is a serious complication following spine surgery and is correlated with significant morbidities, poor clinical outcomes, and increased healthcare costs. Accurately identifying risk factors can help develop strategies to reduce this devastating consequence; however, few multicentre studies have investigated risk factors for SSI following posterior cervical spine surgeries. Between July 2010 and June 2015, we performed an observational cohort study on deep SSI in adult patients who underwent posterior cervical spine surgery at 10 research hospitals. Detailed patient- and procedure-specific potential risk variables were prospectively recorded using a standardised data collection chart and were reviewed retrospectively. Among the 2184 consecutive adult patients enrolled, 28 (1.3%) developed postoperative deep SSI. Multivariable regression analysis revealed 2 statistically significant independent risk factors: occipitocervical surgery (P < 0.001) and male sex (P = 0.024). Subgroup analysis demonstrated that occipitocervical surgery (P = 0.001) was the sole independent risk factor for deep SSI in patients with instrumented fusion. Occipitocervical surgery is a relatively rare procedure; therefore, our findings were based on a large cohort acquired using a multicentre study. To the best of our knowledge, this is the first study to identify occipitocervical procedure as an independent risk variable for deep SSI after spinal surgery.

A retrospective analysis of factors affecting surgical site infection in orthopaedic patients

Objective

To investigate the factors affecting surgical site infections (SSI) in patients undergoing orthopaedic surgery.

Methods

The electronic medical records of patients undergoing orthopaedic surgery between September 2010 and July 2018 were retrospectively retrieved and reviewed. Logistic regression analyses were used to analyse the correlation between surgery-related variables and SSI. The odds ratio (OR) and 95% confidence interval (CI) were estimated for the risk factors.

Results

Clinical data from 25 954 patients were reviewed and 804 (3.1%) were found to have become infected at the surgical site. Older age (≥60 years) was a risk factor (OR 2.218) and younger age (<18 years) was a protective factor (OR 0.258). Diabetes mellitus (OR 6.560) and hypertension (OR 3.991) were independent risk factors. Compared with type II incisions, type I incisions had a lower risk for SSI (OR 0.031), while type III incisions had a greater risk of SSI (OR 2.599). Compared with upper limbs and hands, the feet had a lower risk of infection, while surgery performed at the spine and joints did not increase the risk as compared with foot surgery.

Conclusion

Older age, hypertension, diabetes mellitus and type III incisions were risk factors for SSI following orthopaedic surgery.

Risk factors for deep surgical site infection following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine: a multicenter, observational cohort study of 2913 consecutive cases

PURPOSE

Surgical site infection (SSI) is one of the most devastating complications following spinal instrumented fusion surgeries because it may lead to a significant increase in morbidity, mortality, and poor clinical outcomes. Identifying the risk factors for SSI can help in developing strategies to reduce its occurrence. However, data on the risk factors for SSI in degenerative diseases are limited. This study aimed to identify risk factors for deep SSI following posterior instrumented fusion for degenerative diseases in the thoracic and/or lumbar spine in adult patients.

METHODS

This was a multicenter, observational cohort study conducted at 10 study hospitals between July 2010 and June 2015. The subjects were consecutive adult patients who underwent posterior instrumented fusion surgery for degenerative diseases in the thoracic and/or lumbar spine and developed SSI. Detailed patient-specific and procedure-specific potential risk variables were prospectively recorded using a standardized data collection chart and retrospectively reviewed.

RESULTS

Of the 2913 enrolled patients, 35 developed postoperative deep SSI (1.2%). Multivariable regression analysis identified three independent risk factors: male sex (P = 0.002) and American Society of Anesthesiologists (ASA) score of ≥ 3 (P = 0.003) as patient-specific risk factors, and operation including the thoracic spine (P = 0.018) as a procedure-specific risk factor.

CONCLUSION

Thoracic spinal surgery, an ASA score of ≥ 3, and male sex were risk factors for deep SSI after routine thoracolumbar instrumented fusion surgeries for degenerative diseases. Awareness of these risk factors can enable surgeons to develop a more appropriate management plan and provide better patient counseling.

Epidemiology of surgical site infection following abdominal surgeries at a reference hospital in North-West Cameroon

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Increase in surgical site infections caused by gram-negative bacteria in warmer temperatures: Results from a retrospective observational study

OBJECTIVE

Surgical site infections (SSIs) occur more frequently during periods of warmer temperatures. We aimed to investigate for which pathogens this association is particularly strong.

DESIGN

A retrospective observational study was conducted.

METHODS

Data from the SSI-module of the German nosocomial infection surveillance system between 2000 and 2016 were linked with data from the German Meteorological Service. Patient- and procedure-related data were associated with monthly aggregated meteorological data. Due to high correlation with other meteorological parameters, we focused on the outside temperature. Adjusted odds ratios were calculated for SSI rates relating to temperature. SSIs were stratified by pathogen. A P value of <.05 was considered significant.

RESULTS

Altogether, 2,004,793 procedures resulting in 32,118 SSIs were included. Generally, warmer temperatures were associated with a higher SSI risk, especially for SSIs with gram-negative pathogens. This association was particularly prominent for Acinetobacter spp, Pseudomonas aeruginosa, and certain Enterobacteriaceae. Per additional 1°C, we observed a 6% increase in the SSI risk for Acinetobacter spp and a 4% increase for Enterobacter spp. Superficial SSIs with Acinetobacter spp were 10 times more likely to occur when comparing surgeries in months with mean temperatures of ≥20°C to mean temperatures of <5°C.

CONCLUSIONS

Higher temperatures were associated with increased SSI rates caused by gram-negative bacteria. Future SSI prevention measures should consider this aspect. Underlying shifts in microbiome composition due to climate factors should be included in further analyses. Given the expected rise of global temperatures until the end of the century, this topic has relevance from multiple perspectives.