Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery

Implementation of surgical site infection care bundle in patients undergoing gastrointestinal surgeries

PURPOSE

Surgical site infection (SSI) is one of the frequent healthcare associated infections linked with significant morbidity, prolonged hospitalization, and death. SSI can be reduced by implementation of customized care bundle components as per standard guidelines. Hence this study was undertaken with the objective to implement care bundle in patients undergoing elective gastrointestinal surgeries and assess their impact on SSI rate.

METHODS

The study was an interventional study conducted in the department of surgical gastroenterology for 8 months. Sample size was calculated to be 196 and only elective surgeries are included. CDC NHSN 2023 guidelines are used for surveillance of SSI and global guidelines for prevention of SSI was used for preparation of list of pre-operative, intraoperative and post-operative care bundle components and were implemented before the start of the study.

RESULTS

Overall SSI rate and compliance to SSI care bundle in this study are 13.8% and 28.6%, respectively. When compared with the baseline SSI rate of 19.4%, there is reduction of 28.9% in SSI rate after the implementation of care bundle. Escherichia coli (54.2%) is the most commonly isolated organism. Care bundle non-compliant surgeries are associated with 2.3 times (relative risk-2.3) increased risk of SSI. There is fluctuating trend in compliance of care bundle and SSI rates across months.

CONCLUSION

This study shows the importance of implementation of set of care bundle for prevention of SSI which can be customized and adapted for reducing SSI.

Identifying Risk Factors for Surgical Site Infection After Stoma Closure in Infants for Targeted Implementation of Surgical Site Infection Reduction Bundle

Background: To determine risk factors for surgical site infection (SSI) in infants after stoma closure, to identify at-risk patients, plan timing of surgery, and implement SSI-reduction strategies. Patients and Methods: A single center retrospective comparison study of all children less than one year of age who underwent enterostomy closure (2018-2020) with SSI diagnosed through a prospective surveillance program, using criteria from Public Health England (PHE). Demographics and risk factors, types of SSI, systemic sepsis, mortality and length of stay were compared between SSI and non-SSI. Significant factors associated with SSI were analyzed in a multivariate binomial logistic regression model. Results: Eighty-nine stoma closures were performed, most commonly for necrotizing enterocolitis (NEC) and anorectal malformation. Fourteen had SSI (16%): 12 superficial and two deep; three developed systemic sepsis, but no 30-day mortality. Surgical site infection was associated with NEC (12/14 vs. 32/75; p = 0.003), younger age (median 76 vs. 89 days; p = 0.014), lower corrected gestation (cutoff: 39 weeks gestation; 11/14 vs. 27/75; p = 0.004) and lower weight (cutoff: 2.2 kg; 7/14 vs. 16/75; p = 0.032), compared with non-SSI. After correcting for age, gestation, and weight, logistic regression showed NEC was an independent predictor for SSI (odds ratio [OR], 12; 95% confidence interval [CI],1.2-125). The at-risk cohort (n = 56; 63%) had seven-fold increased risk of SSI and four-fold longer hospital stay, which may be the target for SSI-reduction strategies. Conclusions: Necrotizing enterocolitis-related stoma closure is at increased risk for SSI. Considerations for delaying stoma closure until achieving 39 weeks gestation or 2.2 kg in weight may further reduce SSI. Targeting SSI-reduction strategies using these criteria may improve resource-rationalization.

Post-operative nursing activities to prevent wound complications in patients undergoing colorectal surgeries: A scoping review

AIMS

To identify postoperative interventions and quality improvement initiatives used to prevent wound complications in patients undergoing colorectal surgeries, the types of activities nurses undertake in these interventions/initiatives and how these activities align with nurses' scope of practice.

DESIGN

A scoping review.

DATA SOURCES

Three health databases were searched, and backward and forward citation searching occurred in April 2022. Research and quality improvement initiatives included focussed on adult patients undergoing colorectal surgery, from 2010 onwards. Data were extracted about study characteristics, nursing activities and outcomes. The 'Dimensions of the scope of nursing practice' framework was used to classify nursing activities and then the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework was used to synthesise the review findings.

RESULTS

Thirty-seven studies were included. These studies often reported negative wound pressure therapy and surgical site infection bundle interventions/initiatives. Nurses' scope of practice was most frequently 'Technical procedure and delegated medical care' meaning nurses frequently acted under doctors' orders, with the most common delegated activity being dressing removal.

CONCLUSION

The full extent of possible interventions nurses could undertake independently in the postoperative period requires further exploration to improve wound outcomes and capitalise on nurses' professional role.

IMPACT STATEMENT

Nurses' role in preventing postoperative wound complications is unclear, which may inhibit their ability to influence postoperative outcomes. In the postoperative period, nurses undertake technical activities, under doctors' orders to prevent wound infections. For practice, nurses need to upkeep and audit their technical skills. New avenues for researchers include exploration of independent activities for postoperative nurses and the outcomes of these activities.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

There may be opportunities to broaden nurses' scope of practice to act more autonomously to prevent wound complication.

REPORTING METHOD

Scoping Reviews (PRISMA-ScR) checklist.

PATIENT OR PUBLIC CONTRIBUTION

A health consumer interpreted the data and prepared the manuscript.

Closed-incision negative-pressure wound therapy reduces superficial surgical site infections after open colon surgery: an NSQIP Colectomy Study

BACKGROUND

The use of closed-incision negative-pressure wound therapy (iNPWT) has increased in the last decade across surgical fields, including colectomy.

AIM

To compare postoperative outcomes associated with use of iNPWT following open colectomy from a large national database.

METHODS

A retrospective review of patients who underwent operations from 2015 to 2020 was performed using the National Surgical Quality Improvement Program (NSQIP) Targeted Colectomy Database. Intraoperative placement of iNPWT was identified in patients undergoing open abdominal operations with closure of all wound layers including skin. Propensity score matching was performed to define a control group who underwent closure of all wound layers without iNPWT. Patients were matched in a 1:4 (iNPWT vs control) ratio and postoperative rates of superficial, deep and organ-space surgical site infection (SSI), wound disruption, and readmission.

FINDINGS

A matched cohort of 1884 was selected. Patients with iNPWT had longer median operative time (170 (interquartile range: 129-232) vs 161 (114-226) min; P<0.05). Compared to patients without iNPWT, patients with iNPWT experienced a lower rate of 30-day superficial incisional SSI (3% vs 7%; P<0.05) and readmissions (10% vs 14%; P<0.05). iNPWT did not decrease risk of deep SSI, organ-space SSI, or wound disruption.

CONCLUSION

Although there is a slightly increased operative time, utilization of iNPWT in open colectomy is associated with lower odds of superficial SSI and 30-day readmission. This suggests that iNPWT should be routinely utilized in open colon surgery to improve patient outcomes.

Surgical Site Infection Prevention Using "Strike Teams": The Experience of an Academic Colorectal Surgical Department

ABSTRACT

Surgical site infections (SSIs) are healthcare-acquired infections with substantial morbidity. Surgical site infection persist because of low adherence to prevention bundles comprising multiple infection control elements. We propose the "Strike Team" as an implementation strategy to improve adherence and reduce SSI in colorectal surgery. At an academic medical center, a multidisciplinary Strike Team met monthly to review colorectal SSI cases, audit and discuss barriers to adherence to SSI prevention bundle, and propose actionable feedback. The latter was shared with frontline clinicians by the Strike Team's surgical leaders in everyday practice. Colorectal SSI rates and bundle adherence data were disseminated quarterly via the hospital intranet and reviewed with surgeons at departmental meetings. Trends in adherence and SSI rates were analyzed by regression analysis using a time series model. While the Strike Team was active, adherence to antibiotic prophylaxis, maintenance of normoglycemia, and standardized intraoperative skin preparation significantly increased (p < .05). There was a trend toward statistically significant reduction in SSI (p = .07), although it was not maintained once the Strike Team activity was disrupted by the COVID-19 pandemic. Colorectal SSI prevention requires a resource-intensive, multidisciplinary approach with numerous strategies to improve adherence to infection control bundles, as illustrated by our SSI Strike Team experience.

Analysis of risk factors for surgical site infection after colorectal surgery: a cross-sectional study in the east of China pre-COVID-19

Background

The occurrence of surgical site infection (SSI) can prolong the postoperative hospital stay, increase the economic burden of patients, and even endanger their lives. The purpose of this study was to investigate the incidence, risk factors, and microbiology of SSI after colorectal surgery (CRS) and to provide a basis for the prevention and control of SSI.

Methods

A single-center, prospective, cross-sectional study of adult patients undergoing CRS was conducted from 2010-2019. Univariate and multivariate logistic regression models were used to collect and analyze demographic information, hospital characteristics, and potential perioperative risk factors of SSI.

Results

A total of 3,302 eligible patients were included in this study, with 213 cases experiencing SSIs, resulting in an infection rate of 6.45%. Notably, the incidence of SSI decreased from 13.33% in 2010 to 3.56% in 2019 (Ptrend < 0.001). Escherichia coli accounted for the majority of isolated microorganisms (37.09%), with 49 strains exhibiting resistance to one or more antibiotics (35.25%). Multivariate analysis showed that diabetes, anastomosis leakage, wound classification (contaminated/dirty), operation duration, blood loss greater than 200 ml, and NNIS risk index score for 2 or 3 were independent risk factors. Conversely, laparoscopic approach, preoperative bowel preparation and preoperative albumin levels emerged as protective factors against SSI after CRS. Furthermore, compared to non-SSI patients, SSI patients had a significantly higher 30-day mortality rate following surgery (0.23% vs. 2.35%, p < 0.05).

Conclusion

SSI after CRS was susceptible to many factors, and the pathogen of SSI was mainly Escherichia coli. In clinical practice, measures such as correcting preoperative hypoproteinemia, choosing laparoscopic surgery, preoperative bowel preparation and shortening the duration of surgery should be taken to reduce the incidence of SSI.

Clinical prediction models and risk tools for early detection of patients at risk of surgical site infection and surgical wound dehiscence: a scoping review

OBJECTIVE

Despite advances in surgical techniques, intraoperative practice and a plethora of advanced wound therapies, surgical wound complications (SWCs), such as surgical site infection (SSI) and surgical wound dehiscence (SWD), continue to pose a considerable burden to the patient and healthcare setting. Predicting those patients at risk of a SWC may give patients and healthcare providers the opportunity to implement a tailored prevention plan or potentially ameliorate known risk factors to improve patient postoperative outcomes.

METHOD

A scoping review of the literature for studies which reported predictive power and internal/external validity of risk tools for clinical use in predicting patients at risk of SWCs after surgery was conducted. An electronic search of three databases and two registries was carried out with date restrictions. The search terms included 'prediction surgical site infection' and 'prediction surgical wound dehiscence'.

RESULTS

A total of 73 records were identified from the database search, of which six studies met the inclusion criteria. Of these, the majority of validated risk tools were predominantly within the cardiothoracic domain, and targeted morbidity and mortality outcomes. There were four risk tools specifically targeting SWCs following surgery.

CONCLUSION

The findings of this review have highlighted an absence of well-developed risk tools specifically for SSI and/or SWD in most surgical populations. This review suggests that further research is required for the development and clinical implementation of rigorously validated and fit-for-purpose risk tools for predicting patients at risk of SWCs following surgery. The ability to predict such patients enables the implementation of preventive strategies, such as the use of prophylactic antibiotics, delayed timing of surgery, or advanced wound therapies following a procedure.

Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study

BACKGROUND

Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established.

MATERIALS AND METHODS

Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay.

RESULTS

A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis.

CONCLUSIONS

In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.

Cost-Utility Analysis of the Caresyntax Platform to Identify Patients at Risk of Surgical Site Infection Undergoing Colorectal Surgery

BACKGROUND

Surgical site infections (SSIs) account for up to 18% of all healthcare-associated infections (HAIs). The Caresyntax data-driven surgery platform incorporates the most common risk factors for SSI, to identify high-risk surgical patients before they leave the operating theatre and treat them prophylactically with negative pressure wound therapy (NPWT). An economic analysis was performed to assess the costs and health outcomes associated with introduction of the technology in the English healthcare setting.

METHODS

A hybrid decision tree/Markov model was developed to reflect the treatment pathways that patients undergoing colorectal surgery would typically follow, both over the short term (30-day hospital setting) and long term (lifetime). The analysis considered implementation of Caresyntax's platform-based SSI predictive algorithm in the hospital setting, compared with standard of care, from an English National Health Service (NHS) perspective. The base-case analysis presents results in terms of cost per quality-adjusted life-year (QALY) gained, as well as operational impact.

RESULTS

The base-case analysis indicates that the intervention leads to a cost saving of £55.52m across the total NHS colorectal surgery patient population in 1 year. In addition, the intervention has a 98.36% probability of being cost effective over a lifetime horizon. The intervention results in the avoidance of 19,744 SSI events, as well 191,911 excess hospital bed days saved.

CONCLUSION

Caresyntax's platform-based SSI predictive algorithm has the potential to result in cost savings and improved patient quality of life. Additionally, operational gains for the healthcare provider, including reduced infection rates and hospital bed days saved, have been shown through the economic modeling.

Impact of Surgical Care Bundle on Surgical Site Infection after Non-Reconstructive Breast Cancer Surgery: A Single-Centre Retrospective Comparative Cohort Study

BACKGROUND

Surgical-site infections (SSIs) are the commonest cause of healthcare-related infections. Although a surgical care bundle (SCB), defined as a group of preventative measures, is effective in reducing SSIs, it has not been well documented in breast cancer surgery. We aimed to investigate the impact of SCB on SSI.

METHODS

A single-centre retrospective comparative cohort study between 2016 and 2020 was carried out. An SCB including eight different measures was implemented in October 2018 at Sahlgrenska University Hospital, Sweden. Patients who underwent non-reconstructive breast cancer surgery were included for analysis. The primary endpoint was SSI within 30 days after surgery.

RESULTS

Overall, 10.4% of patients (100/958) developed SSI. After SCB implementation, the overall SSI rate reduced from 11.8% to 8.9% (p = 0.15). The largest SSI rate reduction was seen in the subgroup that underwent breast conservation and sentinel lymph node biopsy (SLNB), from 18.8% to 9.8% (p = 0.01). In this multivariable analysis adjusting for patient and treatment factors, the implementation of SCB resulted in a statistically significant reduction in SSI risk (OR 0.63, 95% CI 0.40-0.99, p = 0.04).

CONCLUSIONS

The implementation of a SCB could reduce the incidence of SSI in breast cancer surgery.

The Impact of Care Bundles on the Incidence of Surgical Site Infections: A Systematic Review

OBJECTIVE

This systematic review assesses the effects of care bundles on the incidence of surgical site infections (SSIs).

DATA SOURCES

The search was conducted between February and May 2021, using PubMed, CINAHL, SCOPUS, Cochrane, and EMBASE databases.

STUDY SELECTION

Studies were included if they used systematic review methodology, were in English, used a quantitative design, and explored the use of care bundles for SSI prevention. A total of 35 studies met the inclusion criteria, and 26 provided data conducive to meta-analysis.

DATA EXTRACTION

Data were extracted using a predesigned extraction tool, and analysis was undertaken using RevMan (Cochrane, London, UK). Quality appraisal was undertaken using evidence-based librarianship.

DATA SYNTHESIS

The mean sample size was 7,982 (median, 840) participants. There was a statistically significant difference in SSI incidence in favor of using a care bundle (SSI incidence 4%, 703/17,549 in the care bundle group vs 7%, 1,157/17,162 in the usual care group). The odds ratio was 0.55 (95% confidence interval, 0.41-0.73; P < .00001), suggesting that there is a 45% reduction in the odds of SSI development for the care bundle group. The mean validity score for all studies was 84% (SD, 0.04%).

CONCLUSIONS

The results indicate that implementing care bundles reduced SSI incidence. However, because there was clinically important variation in the composition of and compliance with care bundles, additional research with standardized care bundles is needed to confirm this finding.

Reducing surgical site infection rates in colorectal surgery - a quality improvement approach to implementing a comprehensive bundle

AIM

Surgical site infections (SSIs) are a preventable cause of morbidity following surgical procedures. Strategies to reduce rates of SSI must address pre-, peri- and postoperative factors and multiple interventions can be combined into 'bundles'. Adoption of these measures can reduce SSIs, but this is dependent on high levels of compliance. The aim of this work is to assess the change in rates of SSI in elective colorectal surgery after implementing a colorectal SSI bundle.

METHOD

This is a single-centre prospective cohort study. All elective colorectal procedures from 2011 until 2018 (inclusive) were included. The primary outcome was inpatient SSI. A multimodal bundle was implemented using quality improvement methodology. The bundle was altered during the timeframe of the study to optimize outcomes. Data were analysed by interrupted time series analysis assessing points at which the bundle was altered.

RESULTS

In the study period, 1075 elective colorectal procedures were performed. Prior to the introduction of the colorectal SSI bundle, the SSI rate was 16.4%. During the implementation period (2013-2015), the overall rate of SSI fell from 15.9% to 9.4%, with the most significant reduction being in superficial SSI, from 8.6% to 4.7%. In the postimplementation period from 2015-2018, there was a further reduction in the overall rate of SSI (5.1%). In 2018, there were 87 consecutive cases without infection.

CONCLUSION

A successful reduction in the rate of SSI following elective colorectal surgery can be achieved by adopting a comprehensive perioperative bundle. This is complemented by a process of continuous measurement and evaluation. The current bundle has achieved a significant reduction in superficial SSI.

Challenges Related to Surgical Site Infection Prevention-Results after Standardized Bundle Implementation

Aim: The aim of this study was to assess the implementation of an intraoperative standardized surgical site infection (SSI) prevention bundle. Methods: The multimodal, evidence-based care bundle included nine intraoperative items (antibiotic type, timing, and re-dosing; disinfection; induction temperature control > 36.5°; glove change; intra-cavity lavage; wound protection; and closure strategy). The bundle was applied to all consecutive patients undergoing colonic resections. The primary outcome, SSI, was independently assessed by the National Infection Surveillance Committee for up to 30 postoperative days. A historical, institutional pre-implementation control group (2012–2017) with an identical methodology was used for comparison. Findings: In total, 1516 patients were included, of which 1256 (82.8%) were in the control group and 260 (17.2%) were in the post-implementation group. After 2:1 propensity score matching, the groups were similar for all items (p > 0.05). Overall compliance with the care bundle was 77% (IQR 77–88). The lowest compliance rates were observed for temperature control (53% overall), intra-cavity lavage (64% overall), and wound protection and closure (68% and 63% in the SSI group, respectively). Surgical site infections were reported in 58 patients (22.2%) vs. 21.4% in the control group (p = 0.79). Infection rates were comparable throughout the Centers for Disease Control and Prevention (CDC) categories: superficial, 12 patients (4.5%) vs. 4.2%, p = 0.82; deep incisional, 10 patients (3.7%) vs. 5.1%, p = 0.34; organ space, 36 (14%) vs. 12.4%, p = 0.48. After propensity score matching, rates remained comparable throughout all comparisons (all p > 0.05). Conclusions: The implementation of an intraoperative standardized care bundle had no impact on SSI rates. This may be explained by insufficient compliance with the individual measures.

Gradually Increasing Surgical Site Infection Prevention Bundle with Monitoring of Potentially Preventable Infections Resulting in Decreasing Overall Surgical Site Infection Rate

Objective: Reduction of surgical site infection. Methods: Retrospective evaluation of a surgical infection prevention program consisting of the gradual introduction of specific infection prevention methods and a surveillance system identifying and reporting on potentially preventable surgical site infections as defined by the omission of a preventive method. Setting: A university tertiary referral medical center. Results: The sequential introduction of infection prevention elements in the bundle resulted in a fluctuating rate of potentially preventable surgical site infections simultaneously with a slow, gradual reduction of the clean wound SSI rate. Conclusions: Change in a complex, multidisciplinary environment such as an inpatient surgical unit happens gradually and requires focused attention and input from all involved professionals.

Healthcare utilization associated with adherence to antibiotics for abdominal surgeries in Japan: cross-sectional analysis of administrative database

BACKGROUND

Since patients receiving surgery may experience surgical site infections, therapeutic guidelines for reducing hospitalization time and cost include appropriate antibiotic use. However, the association between adherence to therapeutic guidelines and healthcare utilization is currently unclear.

OBJECTIVES

This study aimed to confirm the positive association between the adherence to guidelines of antibiotic therapy and a reduction in the length of stay and cost of hospitalization, especially considering the high infection rates in abdominal surgery.

METHODS

This cross-sectional study used administrative data (diagnosis procedure combination data) collected using the case-mix system implemented in acute-care hospitals in Japan. We assessed the length of hospital stay and cost of hospitalization for patients who received prophylactic antibiotic for abdominal surgeries consistent with therapeutic guidelines. The data of patients aged 15 years or older who received appendectomy, laparoscopic cholecystectomy or inguinal hernia repair were extracted. The appropriateness of antibiotic prophylaxis was evaluated in terms of the Japanese guidelines for antibiotic selection and treatment duration. To assess the mean difference in antibiotic costs and length of stay, we performed the propensity score matching by confounding factors. Furthermore, we assessed the progress in healthcare utilization of this therapy over a decade.

RESULTS

Of the 302 233 patients who received single general surgery from April 2014 to March 2016, 198 885 were eligible for analysis after applying the exclusion criteria (143 975 in the adherence and 54 910 in the non-adherence group). Each group comprised 48 439 patients after propensity score matching. Inappropriate antibiotic selection and duration were observed in 9294 (9.8%) and 687 (0.7%) of inguinal hernia repairs, 6431 (25.3%) and 311 (1.2%) of appendectomies and 38 134 (48.5%) and 391 (0.5%) of laparoscopic cholecystectomy cases, respectively. After propensity score matching by operation type, average hospitalization length (6.5 [SD 3.8] and 7.3 [SD 4.8] days) and costs (536 000 [SD 167 000] JPY and 573 000 [SD 213 000] JPY) differed significantly between adherence and non-adherence groups.

CONCLUSION

The results revealed that unnecessary healthcare utilization was associated with failure to adhere to therapeutic guidelines for prophylactic antibiotic therapy in elective general surgeries. We concluded that the progress of reduction in length of hospitalization over the decade was successful. Notably, adherence to treatment duration was better than that was 10 years ago. In this decade, administrators in hospitals have attempted to reduce the duration of hospitalization by developing various clinical pathways for surgical procedures and quality indicators. However, 15 877 patients (8.7%) were prescribed oral antibiotics the day after surgery. These observations should be evaluated further.

Surgeons' mental models of surgical site infection: Insights into adherence with complex prevention bundles

Of 10 surgeons interviewed in a descriptive qualitative study, 6 believed that surgical site infections are inevitable. Bundle adherence was felt to be more likely with strong evidence-based measures developed by surgical leaders. The intrinsic desire to excel was viewed as the main adherence motivator, rather than "pay-for-performance" models.

Implementation of an organ space infection prevention bundle reduces the rate of organ space infection after elective colorectal surgery

BACKGROUND

Surgical site infections (SSIs) are morbid and costly complications after elective colorectal surgery. SSI prevention bundles have been shown to reduce SSI in colorectal surgery, but their impact on organ space infections (OSI) is variable. Adoption of an evidence-based practice without an implementation strategy is often unsuccessful. Our aim was to successfully implement an OSI prevention bundle and to achieve a cost-effective reduction in OSI following elective left-sided colorectal operations.

METHODS

The Translating Research into Practice model was used to implement an OSI prevention bundle in all patients undergoing elective left-sided colorectal resections by a single unit from November 2018 to September 2019. The new components included oral antibiotics with mechanical bowel preparation, when required, and use of impermeable surgical gowns. Other standardised components included alcoholic chlorhexidine skin preparation, glove change after bowel handling prior to wound closure with clean instruments. The primary outcome was OSI. Secondary outcomes included bundle compliance, unintended consequences and total patient costs. Outcomes were compared with all patients undergoing elective left-sided colorectal resections at the same institution in 2017.

RESULTS

Elective colorectal resections were performed in 173 patients across two cohorts. The compliance rate with bundle items was 63% for all items and 93% for one omitted item. There was a reduction in OSI from 12.9% (11 of 85) to 3.4% (3 of 88, p<0.05) after implementation of the OSI prevention bundle. The average cost of an OSI was $A36 900. The estimated savings for preventing eight OSIs by using the OSI bundle in the second cohort was $A295 198.

CONCLUSION

Successful implementation of an OSI prevention bundle was associated with a reduced rate of OSI after elective colorectal surgery. The OSI bundle and its implementation were cost-effective. Further study is required to investigate the sustainability of the OSI prevention bundle.

Implementing a multidisciplinary care bundle to reduce colon surgical site infections

Purpose

The aim of this study was to investigate how rates of surgical site infections (SSI) were changed over 2 years after applying colon SSI bundle in patients who underwent colon surgery.

Methods

The multidisciplinary working group developed a care bundle consisting of 8 components, including several recommendations of Surgical Care Improvement Project and monitoring of medical/surgical hand washing. We implemented the care bundle for each patient who underwent colon surgery from April 2013 to December 2014.

Results

Overall bundle compliance was 87.9% before implementation, 88.2% in 2013, and 90.5% in 2014. In particular, compliance of the following 3 components was substantial improved during the project period; discontinuation of prophylactic antimicrobial agent within 24 hours of surgery (from 88.3% to 100%), surgical hand washing (from 50.0% to 78.9%), and medical hand washing (from 74.7% to 82.8%). The rate of SSI was 8.0% (12/150) during 3 months before implementation, 3.3% (16/480) from April to December in 2013, and 2.3% (14/607) in 2014.

Conclusion

After implementation of multidisciplinary care bundle, the compliance of each component was increased and rates of SSIs were significantly decreased compared to those before the quality improvement project.

The Impact of a Colorectal Care Bundle for Surgical Site Infections at an Academic Disproportionate Share Hospital With a Level I Trauma Center

OBJECTIVES

Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases.

METHODS

A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases.

RESULTS

We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI.

DISCUSSION

While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.

Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis

OBJECTIVE

In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction.

METHODS

We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space).

RESULTS

We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48-0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42-0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46-0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50-0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions.

CONCLUSIONS

Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.

Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review

Background

Surgical site infections (SSIs) are highly prevalent in abdominal surgery despite evidence-based prevention measures. Since guidelines are not self-implementing and SSI-preventive compliance is often insufficient, implementation interventions have been developed to promote compliance. This systematic review aims to identify implementation interventions used in abdominal surgery to prevent SSIs and determine associations with SSI reductions.

Methods

Literature was searched in April 2018 (Medline/PubMed and Web of Science Core Collection). Implementation interventions were classified using the implementation subcategories of the EPOC Taxonomy (Cochrane Review Group Effective Practice and Organisation of Care, EPOC). Additionally, an effectiveness analysis was conducted on the association between the number of implementation interventions, specific compositions thereof, and absolute and relative SSI risk reductions.

Results

Forty studies were included. Implementation interventions used most frequently (“top five”) were audit and feedback (80% of studies), organizational culture (70%), monitoring the performance of healthcare delivery (65%), reminders (53%), and educational meetings (45%). Twenty-nine studies (72.5%) used a multimodal strategy (≥3 interventions). An effectiveness analysis revealed significant absolute and relative SSI risk reductions. E.g., numerically, the largest absolute risk reduction of 10.8% pertained to thirteen studies using 3–5 interventions (p < .001); however, this was from a higher baseline rate than those with fewer or more interventions. The largest relative risk reduction was 52.4% for studies employing the top five interventions, compared to 43.1% for those not including these. Furthermore, neither the differences in risk reduction between studies with different numbers of implementation interventions (bundle size) nor between studies including the top five interventions (vs. not) were significant.

Conclusion

In SSI prevention in abdominal surgery, mostly standard bundles of implementation interventions are applied. While an effectiveness analysis of differences in SSI risk reduction by number and type of interventions did not render conclusive results, use of standard interventions such as audit and feedback, organizational culture, monitoring, reminders, and education at least does not seem to represent preventive malpractice. Further research should determine implementation interventions, or bundles thereof, which are most effective in promoting compliance with SSI-preventive measures in abdominal surgery.

Evaluation of a bundle of care to reduce incisional surgical site infection after gastrointestinal surgery

Background

Surgical site infection (SSI) is associated with morbidity, mortality and increased care costs; many SSIs are considered preventable. The aim of the present study was to test implementation of a pragmatic, evidence-based bundle designed to reduce incisional SSI after emergency laparotomy and elective major lower gastrointestinal surgery.

Method

This was a prospective before-and-after study. Data were collected before the intervention and for two separate subsequent time periods. An evidence-based bundle of care (BOC) was implemented; the primary outcome measure was incisional SSI at 30 days. The secondary outcome measure was 30-day unplanned readmissions. The initial post-intervention group, Group 2, assessed a variable number of potential impacting factors; however, due to funding and staffing levels the second post-bundle group, Group 3, focused on the core aspects of the BOC and rates of incisional SSI and readmission.

Results

In total, 99 patients were included in the 'before' group; and 71 in Group 2 and 92 in Group 3, the post-intervention groups. The incisional SSI rate was 29.3% (29/99) before and 28.2% (20/71) in Group 2 (P=0.873) and 21.7% (20/92) in Group 3 (P=0.234) after the intervention. After adjustment for confounders, the care bundle was associated with a non-significant reduction in SSI (Group 2: odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.45-1.93, P=0.0843). However, it was associated with significantly reduced readmissions 18.1% (18/99) before versus 5.6% (4/71) in Group 2 (OR = 0.236, 95% CI = 0.077-0.72, P=0.012) and 8.7% (8/92) in Group 3 (OR = 0.38, 95% CI = 0.16-0.9, P=0.029). Comparing the pre-bundle group to the post-bundle groups, there was an overall significant reduction in readmissions (P=0.003). This implies a number needed to treat of 8-11 patients to prevent one readmission. Adherence to antibiotic prophylaxis with the Trust guidelines increased from 91% to 99% (1 vs. 2, P=0.047).

Conclusion

Introduction of the bundle was associated with a reduction in the observed rate of incisional SSI from 29.3% to 21.7%; significantly fewer patients required unplanned readmission. Use of the bundle was associated with significantly improved compliance with appropriate antimicrobial prophylaxis.

Understanding determinants of infection control practices in surgery: the role of shared ownership and team hierarchy

Background

Despite a large literature on surgical site infection (SSI), the determinants of prevention behaviours in surgery remain poorly studied. Understanding key social and contextual components of surgical staff behaviour may help to design and implement infection control (IC) improvement interventions in surgery.

Methods

Qualitative semi-structured interviews were conducted with surgeons (n = 8), nurses (n = 5) theatre personnel (n = 3), and other healthcare professionals involved in surgery (n = 4) in a 1500-bed acute care London hospital group. Participants were approached through established mailing lists and snowball sampling. Interviews were recorded and transcribed verbatim. Transcripts were coded and analysed thematically using a constant comparative approach.

Results

IC behaviour of surgical staff was governed by factors at individual, team, and wider hospital level. IC practices were linked to the perceived risk of harm caused by an SSI more than the development of an SSI alone. Many operating room participants saw SSI prevention as a team responsibility. The sense of ownership over SSI occurence was closely tied to how preventable staff perceived infections to be, with differences observed between clean and contaminated surgery. However, senior surgeons claimed personal accountability for rates despite feeling SSIs are often not preventable. Hierarchy impacted on behaviour in different ways depending on whether it was within or between professional categories. One particular knowledge gap highlighted was the lack of awareness regarding criteria for SSI diagnosis.

Conclusions

To influence IC behaviours in surgery, interventions need to consider the social team structure and shared ownership of the clinical outcome in order to increase the awareness in specialties where SSIs are not seen as serious complications.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0565-8) contains supplementary material, which is available to authorized users.

The development of a staphylococcus aureus four antigen vaccine for use prior to elective orthopedic surgery

Staphylococcus aureus (S. aureus) is a challenging bacterial pathogen which can cause a range of diseases, from mild skin infections, to more serious and invasive disease including deep or organ space surgical site infections, life-threatening bacteremia, and sepsis. S. aureus rapidly develops resistance to antibiotic treatments. Despite current infection control measures, the burden of disease remains high. The most advanced vaccine in clinical development is a 4 antigen S. aureus vaccine (SA4Ag) candidate that is being evaluated in a phase 2b/3 efficacy study in patients undergoing elective spinal fusion surgery (STaphylococcus aureus suRgical Inpatient Vaccine Efficacy [STRIVE]). SA4Ag has been shown in early phase clinical trials to be generally safe and well tolerated, and to induce high levels of bactericidal antibodies in healthy adults. In this review we discuss the design of SA4Ag, as well as the proposed clinical development plan supporting licensure of SA4Ag for the prevention of invasive disease caused by S. aureus in elective orthopedic surgical populations. We also explore the rationale for the generalizability of the results of the STRIVE efficacy study (patients undergoing elective open posterior multilevel instrumented spinal fusion surgery) to a broad elective orthopedic surgery population due to the common pathophysiology of invasive S. aureus disease and commonalties of patient and procedural risk factors for developing postoperative S. aureus surgical site infections.

The preventable proportion of healthcare-associated infections 2005-2016: Systematic review and meta-analysis

OBJECTIVE

The preventable proportion of healthcare-associated infections (HAIs) may decrease over time as standards of care improve. We aimed to assess the proportion of HAIs prevented by multifaceted infection control interventions in different economic settings.

METHODS

In this systematic review and meta-analysis, we searched OVID Medline, EMBASE, CINAHL, PubMed, and The Cochrane Library for studies published between 2005 and 2016 assessing multifaceted interventions to reduce catheter-associated urinary tract infections (CAUTIs), central-line-associated bloodstream infections (CLABSIs), surgical site infections (SSIs), ventilator-associated pneumonia (VAP), and hospital-acquired pneumonia not associated with mechanical ventilation (HAP) in acute-care or long-term care settings. For studies reporting raw rates, we extracted data and calculated the natural log of the risk ratio and variance to obtain pooled risk ratio estimates.

RESULTS

Of the 5,226 articles identified by our search, 144 studies were included in the final analysis. Pooled incidence rate ratios associated with multifaceted interventions were 0.543 (95% confidence interval [CI], 0.445-0.662) for CAUTI, 0.459 (95% CI, 0.381-0.554) for CLABSI, and 0.553 (95% CI, 0.465-0.657) for VAP. The pooled rate ratio was 0.461 (95% CI, 0.389-0.546) for interventions aiming at SSI reduction, and for VAP reduction initiatives, the pooled rate ratios were 0.611 (95% CI, 0.414-0.900) for before-and-after studies and 0.509 (95% CI, 0.277-0.937) for randomized controlled trials. Reductions in infection rates were independent of the economic status of the study country. The risk of bias was high in 143 of 144 studies (99.3%).

CONCLUSIONS

Published evidence suggests a sustained potential for the significant reduction of HAI rates in the range of 35%-55% associated with multifaceted interventions irrespective of a country's income level.

Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures

Postoperative wound infections represent an important source of morbidity and mortality in children. Perioperative antibiotic prophylaxis has been shown to decrease the risk of developing infections and hospital guidelines surrounding antibiotic use exist to standardize patient care. Despite supporting evidence, rates of compliance with guidelines vary. Quality improvement initiatives have been introduced to improve compliance with intraoperative antibiotic guidelines. Thorough infection surveillance, including antibiotic provision in presurgical checklists, computerized voice antibiotic administration prompts, and national feedback systems are now increasingly common. Few studies have been conducted investigating the effectiveness of prophylactic antibiotics in children. Outcome measures such as morbidity and mortality and return to the operating room can be used to examine the relationship between antibiotic use and patient outcome but these measures are limited in that they occur infrequently or are subjective and difficult to measure. Metrics such as days alive out of hospital and length of hospital stay may be useful alternatives for ongoing monitoring of infections and identifying improvements in patient outcomes. Guidelines on antibiotic prophylaxis have facilitated an increase in the correct provision of perioperative antibiotics and a reduction in the incidence of postoperative infection. Measures of patient outcome such as days alive out of hospital and length of hospital stay are easy to collect and calculate but further work is needed to confirm the utility of these measures for monitoring infection rates.

Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

BACKGROUND

Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates.

METHODS

Between 2011 and 2016 a total of 1351 patients underwent colorectal operations. Patients were grouped into pre-implementation (Group A, January 1, 2011-December 31, 2012), implementation (Group B, January 1, 2013-December 31, 2014) and post-implementation (Group C, January 1, 2015-December 31, 2016). Primary endpoints were superficial SSI, deep SSI, wound separation and total SSI.

RESULTS

After the bundle was implemented, there was a significant reduction in superficial (6.6%-4%, p < 0.05), deep (3.7%-1.1%, p < 0.05), and total SSI rates (10.9%-4.7%, p < 0.05). Comparing Group A to Group C there was a decrease in total SSI (9.4%-4.7%, p < 0.05).

CONCLUSION

Implementation of the bundle resulted in a reduction in overall SSI rates particularly as compliance increased. This study offers evidence that small changes can lead to significant decreases in surgical site infections.

Implementation of an abdominal closure bundle to reduce surgical site infection in patients on a gynecologic oncology service undergoing exploratory laparotomy

OBJECTIVE

Surgical site infections (SSI) are associated with increased morbidity, mortality, and healthcare costs. This study investigated whether implementation of an abdominal closure bundle reduces surgical site infection rates. We aimed to identify sub-populations that would benefit the most from this intervention.

METHODS

We conducted a retrospective cohort study of all patients that underwent exploratory laparotomy by a Gynecologic Oncologist from January 1, 2011 to April 1, 2017. The abdominal closure bundle was implemented on May 6, 2014. SSI rates were assessed overall and within subgroups.

RESULTS

875 patients were included in the analysis. Overall, SSI rate was reduced, albeit not significantly, from 48/471 (10.2%) to 32/404 (7.9%) (p=0.148) with implementation of the closing bundle. In patients that underwent a tumor debulking procedure, SSI was noted in 36/277 (13.0%) in the pre-bundle group and 14/208 (6.7%) in the post-bundle cohort (p=0.017). In patients with malignant pathology, the pre-bundle cohort had an SSI rate of 38/282 (13.5%), which reduced to 18/215 (8.4%) in the post-bundle group (p=0.049). In patients with FIGO stage III or IV disease, the SSI rate was reduced from 21/114 (18.4%) to 8/87 (8.4%) with implantation of the closure bundle (p=0.028). In patients with intra-operative ascites, SSI rate decreased from 19/119 (15.9%) pre-bundle to 4/104 (3.8%) in the post-bundle group (p=0.002).

CONCLUSIONS

Implementation of an abdominal closure bundle was not associated with a significant reduction in overall SSI rate. However, multiple subpopulations associated with advanced gynecologic cancer benefited from this intervention.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery

BACKGROUND

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery.

METHODS

A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded.

RESULTS

A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028).

CONCLUSIONS

The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

Bundles Prevent Surgical Site Infections After Colorectal Surgery: Meta-analysis and Systematic Review

INTRODUCTION

Colorectal surgeries (CRS) have one of the highest rates of surgical site infections (SSIs) with rates 15 to >30%. Prevention "bundles" or sets of evidence-based interventions are structured ways to improve patient outcomes. The aim sof this study is to evaluate CRS SSI prevention bundles, bundle components, and implementation and compliance strategies.

METHODS

A meta-analysis of studies with pre- and post-implementation data was conducted to assess the impact of bundles on SSI rates (superficial, deep, and organ/space). Subgroup analysis of bundle components identified optimal bundle designs.

RESULTS

Thirty-five studies (51,413 patients) were identified and 23 (17,557 patients) were included in the meta-analysis. A SSI risk reduction of 40% (p < 0.001) was noted with 44% for superficial SSI (p < 0.001) and 34% for organ/space (p = 0.048). Bundles with sterile closure trays (58.6 vs 33.1%), MBP with oral antibiotics (55.4 vs 31.8%), and pre-closure glove changes (56.9 vs 28.5%) had significantly greater SSI risk reduction.

CONCLUSION

Bundles can effectively reduce the risk of SSIs after CRS, by fostering a cohesive environment, standardization, and reduction in operative variance. If implemented successfully and complied with, bundles can become vital to improving patients' surgical quality of care.

Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery

OBJECTIVE

Surgical site infections (SSIs) can lead to substantial morbidity, prolonged hospitalization, increased costs, and death in patients undergoing colorectal procedures. We sought to investigate the effect of using an SSI reduction bundle on the rate of SSIs in gynecologic cancer patients undergoing colon surgery.

METHODS

We identified all gynecologic cancer patients who underwent colon resection at our institution from 2014 to 2016, during which time a service-wide SSI reduction bundle was introduced. The intervention included preoperative oral antibiotics with optional mechanical bowel preparation, skin preparation with antibacterial solution, and the use of a separate surgical closing tray. SSI rates were assessed within 30days post-surgery.

RESULTS

Of 233 identified patients, 115 had undergone colon surgery prior to (PRE) and 118 after (POST) the implementation of the intervention. A low anterior resection was the most common colon surgery in both cohorts. The incidence of SSI within 30days of surgery was 43/115 (37%) in the PRE and 14/118 (12%) in the POST cohorts (p≤0.001). Wound dehiscence was noted in 30/115 (26%) and 2/118 (2%) patients, respectively (p≤0.001). In patients whose operation took longer than 360min, 30-day SSI rates were 37% (28/76) and 12% (8/67), respectively (p≤0.001). In patients with an estimated blood loss >500cm³, SSI rates were 44% (27/62) and 15% (10/67), respectively (p≤0.001).

CONCLUSIONS

The implementation of an SSI reduction bundle was associated with a significant reduction in 30-day SSIs in these patients. The intervention remained effective in patients undergoing longer operations and in those with increased blood loss.

Colorectal surgery and surgical site infection: is a change of attitude necessary?

INTRODUCTION

Surgical site infection (SSI) can be as high as 30% in patients undergoing colorectal surgery and is associated with an increase in morbidity and mortality. The aim of this study is to evaluate the impact of a set of simple preventive measures that have resulted in a reduction in surgical site infection in colorectal surgery.

APPLIED METHOD

Prospective study with two groups of patients treated in the colorectal unit of the "Clinico Universitario Lozano Blesa" hospital in Zaragoza. One group was subject to our measures from February to May 2015. The control group was given conventional treatment within a time period of 3 months before the set of measures were implemented.

RESULTS

One hundred forty-nine patients underwent a major colorectal surgical procedure. Seventy (47%) belonged to the control group and were compared to the remaining 79 patients (53% of the total), who were subject to our treatment bundle in the period tested. Comparing the two groups revealed that our set of measures led to a general reduction in SSI (31.4 vs. 13.6%, p = 0.010) and in superficial site infection (17.1 vs. 2.5%, p = 0.002). As a consequence, the postoperative hospital stay was shortened (10.0 vs. 8.0 days, p = 0.048). However, it did not, the number of readmissions nor the re-operation rate. SSI was clearly related to open surgery.

CONCLUSIONS

The preventive set of measures applied in colorectal surgery led to a significant reduction of the SSI and of the length of hospital stay.

The role of antimicrobial sutures in preventing surgical site infection

INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patient's pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).

Vaccine development to prevent Staphylococcus aureus surgical-site infections

BACKGROUND

Staphylococcus aureus surgical-site infections (SSIs) are a major cause of poor health outcomes, including mortality, across surgical specialties. Despite current advances as a result of preventive interventions, the disease burden of S. aureus SSI remains high, and increasing antibiotic resistance continues to be a concern. Prophylactic S. aureus vaccines may represent an opportunity to prevent SSI.

METHODS

A review of SSI pathophysiology was undertaken in the context of evaluating new approaches to developing a prophylactic vaccine to prevent S. aureus SSI.

RESULTS

A prophylactic vaccine ideally would provide protective immunity at the time of the surgical incision to prevent initiation and progression of infection. Although the pathogenicity of S. aureus is attributed to many virulence factors, previous attempts to develop S. aureus vaccines targeted only a single virulence mechanism. The field has now moved towards multiple-antigen vaccine strategies, and promising results have been observed in early-phase clinical studies that supported the recent initiation of an efficacy trial to prevent SSI.

CONCLUSION

There is an unmet medical need for novel S. aureus SSI prevention measures. Advances in understanding of S. aureus SSI pathophysiology could lead to the development of effective and safe prophylactic multiple-antigen vaccines to prevent S. aureus SSI.