Getting It Right First Time: the national survey of surgical site infection rates in NHS trusts in England

Surgical site infection and patient-reported outcomes in surgically treated soft tissue facial injury: A meta-analysis

BACKGROUND

Soft tissue facial injuries (STFI) constitute a huge portion of craniofacial trauma, but the risk of surgical site infection (SSI) and patient-reported outcomes (PROs) following surgical management of STFI are unknown.

METHODS

A PRISMA-compliant search was conducted from January 1990 until March 2023, and meta-analysis was performed using R. Pooled effects of the outcomes were estimated using the DerSimonian and Laird random-effects model or generalised linear mixed model, when feasible.

RESULT

Among the 8897 screened studies, 38 were included. Twelve studies reported PROMs (n = 985), whereas 28 studies reported SSI rates (n = 10,996) following operative treatment for STFI. The pooled SSI rate (n = 28) was 3.30 % (95 % CI 1.89 %-5.71 %). Surgical and non-surgical closure did not differ significantly in SSI rate. PROs focused on scar outcomes, cosmetic outcomes, quality of life and psychological impact. Subgroup analysis showed lower SSI risk in operative repair for general facial trauma compared to primary repair, and in general facial trauma compared to other aetiologies. The pooled patient scar assessment scale, score at 6-12 months post-intervention (5 studies, n = 217) was 16.16 (95 % CI 15.34-16.97). Limited evidence is available on the effect and superiority of surgical treatment in cosmetic outcomes, quality of life and psychological impact.

CONCLUSION

Our findings emphasise the limited and unreliable evidence available on PROs following operative treatment for STFI. Future studies employing robust methodologies are needed to investigate optimal approaches for managing STFI.

A comprehensive qualitative investigation of the factors that affect surgical site infection prevention in cardiac surgery in England using observations and interviews

BACKGROUND

Interview and questionnaire studies have identified barriers and challenges to preventing surgical site infections (SSIs) by focusing on compliance with recommendations and care bundles using interviews, questionnaires and expert panels. This study proposes a more comprehensive investigation by using observations of clinical practice plus interviews which will enable a wider focus.

AIM

To comprehensively identify the factors which affect SSI prevention using cardiac surgery as an exemplar.

METHODS

The study consisted of 130 h of observed clinical practice followed by individual semi-structured interviews with 16 surgeons, anaesthetists, theatre staff, and nurses at four cardiac centres in England. Data were analysed thematically.

FINDINGS

The factors were complex and existed at the level of the intervention, the individual, the team, the organization, and even the wider society. Factors included: the attributes of the intervention; the relationship between evidence, personal beliefs, and perceived risk; power and hierarchy; leadership and culture; resources; infrastructure; supplies; organization and planning; patient engagement and power; hospital administration; workforce shortages; COVID-19 pandemic; 'Brexit'; and the war in Ukraine.

CONCLUSION

This is one of the first studies to provide a comprehensive overview of the factors affecting SSI prevention. The factors are complex and need to be fully understood when trying to reduce SSIs. A strong evidence base was insufficient to ensure implementation of an intervention.

Device and surgical procedure-related infections in Canadian acute care hospitals, 2018-2022

Background

Healthcare-associated infections (HAIs) are a significant healthcare burden in Canada. National surveillance of HAIs at sentinel acute care hospitals is conducted by the Canadian Nosocomial Infection Surveillance Program.

Objective

This article describes device and surgical procedure-related HAI epidemiology in Canada from 2018 to 2022.

Methods

Data were collected from over 60 Canadian sentinel acute care hospitals between January 1, 2018, and December 31, 2022, for central line-associated bloodstream infections (CLABSIs), hip and knee surgical site infections (SSIs), cerebrospinal fluid shunt (CSF) SSIs and paediatric cardiac SSIs. Case counts, rates, patient and hospital characteristics, pathogen distributions and antimicrobial resistance data are presented.

Results

Between 2018 and 2022, 2,258 device-related infections and 987 surgical procedure-related infections were reported. A significant rate increase was observed in adult mixed intensive care unit CLABSIs (1.07-1.93 infections per 1,000 line days, p=0.05) and a non-significant rate increase was observed in SSIs following knee arthroplasty (0.31-0.42 infections per 100 surgeries, p=0.45). A fluctuating rate trend was observed in CSF shunt SSIs over the time period and a significant rate decrease in paediatric cardiac SSIs was observed (68%, from 7.5-2.4 infections per 100 surgeries, p=0.01). The most commonly identified pathogens were coagulase-negative staphylococci (22.8%) among CLABSIs and Staphylococcus aureus (42%) among SSIs.

Conclusion

Epidemiological and microbiological trends among selected device and surgical procedure-related HAIs are essential for benchmarking infection rates nationally and internationally, identifying any changes in infection rates or antimicrobial resistance patterns and helping inform hospital infection prevention and control and antimicrobial stewardship policies and programs.

Consent with complications in mind

Parity of esteem describes an aspiration to see mental health valued as much as physical. Proponents point to poorer funding of mental health services, greater stigma and poorer physical health for those with mental illness. Stubborn persistence of such disparities suggests a need to do more than stipulate ethical and legal obligations toward justice or fairness. Here, I propose that we should rely more on our legal obligations toward informed consent. The latter requires clinicians to disclose information about risks in a way that is sufficient to satisfy what a prudent patient would reasonably want to understand in their circumstances. I argue that inadequate disclosure of the mental health complications of common surgeries risks exposing the craft specialists performing them to clinical negligence claims. Patients could argue they were counselled about said risks, improperly or not at all: improperly, if advised by a craft specialist lacking sufficient expertise in mental health; not at all, if mental health complications were simply forgotten. From this, I argue that a prudent approach for craft specialists would be to support and fund 'integrative' specialists (from rehabilitation medicine, liaison psychiatry and health psychology), more often to work alongside them within a multidisciplinary team that is better placed to navigate consent (via a prehabilitation process, for example). Based on duties toward consent, the extension of this type of coworking is another way to improve the resource and understanding accorded to mental health-but by starting within the citadels of physical health.

Cohort study to characterise surgical site infections after open surgery in the UK's National Health Service

OBJECTIVE

To characterise surgical site infections (SSIs) after open surgery in the UK's National Health Service.

DESIGN

Retrospective cohort analysis of electronic records of patients from Clinical Practice Research Datalink, linked with Hospital Episode Statistics' secondary care datasets.

SETTING

Clinical practice in the community and secondary care.

PARTICIPANTS

Cohort of 50 000 adult patients who underwent open surgery between 2017 and 2022.

OUTCOME MEASURES

Incidence of SSI, clinical outcomes, patterns of care and costs of wound management.

RESULTS

11% (5281/50 000) of patients developed an SSI a mean of 18.4±14.7 days after their surgical procedure, of which 15% (806/5281) were inpatients and 85% (4475/5281) were in the community after hospital discharge. The incidence of SSI varied according to anatomical site of surgery. The incidence also varied according to a patient's risk and whether they underwent an emergency procedure. SSI onset reduced the 6 months healing rate by a mean of 3 percentage points and increased time to wound healing by a mean of 15 days per wound. SSIs were predominantly managed in the community by practice and district nurses and 16% (850/5281) of all patients were readmitted into hospital. The total health service cost of surgical wound management following SSI onset was a mean of £3537 per wound ranging from £2542 for a low-risk patient who underwent an elective procedure to £4855 for a high-risk patient who underwent an emergency procedure.

CONCLUSIONS

This study provides important insights into several aspects of SSI management in clinical practice in the UK that have been difficult to ascertain from surveillance data. Surgeons are unlikely to be fully aware of the true incidence of SSI and how they are managed once patients are discharged from hospital. Current SSI surveillance services appear to be under-reporting the actual incidence.

Comparing the Efficacy of Povidone-Iodine Versus Normal Saline in Laparotomy Wound Irrigation to Prevent Surgical Site Infections: A Meta-Analysis

Surgical site infections (SSIs) are a known complication of laparotomies and intra-abdominal surgical operations leading to remarkable consequences on mortality, morbidity, and expenses. The study aims to assess the efficiency of irrigating laparotomy incision sites with povidone-iodine (PVI) or normal saline (NS) in diminishing the rate of SSIs in patients undergoing gastrointestinal operations for varying indications. Randomized controlled trials (RCTs) highlighting the contribution of laparotomy wound irrigation with PVI in opposition to NS in patients planned for laparotomy addressing numerous gastrointestinal issues, and their role in reducing SSI risk were obtained via searching of standard electronic medical databases. The analysis was conducted by utilizing meta-analysis principles procured by statistical software RevMan version 5.3 (Cochrane Collaboration, London, UK). The yield of medical databases exploration and inspection was 13 RCTs on 3816 patients who underwent laparotomy for different gastrointestinal operations. There were 1900 patients in the PVI group whereas 1916 patients received NS wound irrigations preceding closure of the laparotomy skin wound. In the random effects model analysis, the use of PVI for laparotomy wound irrigation was associated with the reduced risk (odds ratio = 0.54, 95% CI (0.30, 0.98), Z = 2.04, P = 0.04) of SSIs. Nevertheless, there was outstanding heterogeneity (Tau2 = 70; chi2 = 40.19, df = 12; P = 0.0001; I2 = 70%) among the included studies. According to the comprehensive analysis outcomes, it has been clinically proven that the use of PVI is highly effective in reducing the occurrence of SSIs, as well as their subsequent implications.

Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models

BACKGROUND

Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk.

METHODS

Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively.

RESULTS

The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits.

CONCLUSIONS

The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.

Perioperative Means to Prevent Surgical Site Infections following Elective Craniotomies: A Single-Center Experience

Background  Postoperative surgical site infections are a recognized complication following craniotomies with an associated increase in morbidity and mortality. Several studies have attempted to identify bundles of care to reduce the incidence of infections. Our study aims to clarify which perioperative measures play a role in reducing surgical infection rates further. Methods  This study is a retrospective audit of all elective craniotomies in years 2018 to 2019. The primary endpoint was the surgical site infection rate at 30 days and 4 months after the procedure. Univariate analysis was used to identify factors predictive of postoperative infection. Results  344 patients were included in this study. Postoperative infections were observed in 5.2% of our cohort. No postoperative infections occurred within 4 months in patients receiving perioperative hair wash and intrawound vancomycin powder. In univariate analysis, craniotomy size (Fisher's exact test, p  = 0.05), lack of perioperative hair wash, and vancomycin powder use (Fisher's exact test, p  = 0.01) were predictive of postoperative infection. No complications relative to the use of intrawound vancomycin were observed. Conclusion  Our study demonstrates that simple measures such as perioperative hair wash combined with intrawound vancomycin powder in addition to standard practice can help reducing infection rates with negligible risks and acceptable costs. Our results should be validated further in future prospective studies.

Getting it right first time: national survey of surgical site infection 2019

INTRODUCTION

Surgical site infections (SSIs) are associated with increased morbidity and mortality. Deep SSI, or prosthetic joint infection (PJI), is associated with revision surgery involving longer operative times with higher infection rates, longer length of stay (LoS) and high costs in addition to the catastrophic effect on the patient. The surveillance of SSI is important for patient decision making, identification of outliers for support and maximising focussed improvement. This paper reports the findings of the second Getting it Right First Time (GIRFT) national SSI survey for orthopaedic and spinal surgery.

METHODS

Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019. For a patient to be included, they had to present with SSI within the study period and within 1 year of the index procedure.

RESULTS

A total of 309 SSIs were reported from primary and revision, total hip, knee, shoulder, elbow and ankle replacements, and 58 SSIs were reported from lumbar spine single level discectomy or decompression, lumbar spine single-level instrumented posterior fusion, posterior cervical spine decompression and instrumented fusion and posterior correction of adolescent idiopathic scoliosis. SSIs rates have remained low compared with the 2017 survey. There were variations in SSI rates by procedure, with primary shoulder replacement reporting the lowest (0.4%) and revision shoulder replacement the highest (2.5%) rates.

CONCLUSIONS

The authors recommend that the elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full SSI prevention bundle to minimise the risk of infection and improve patient outcomes.

Bone flap infections after craniotomy. A review of 63 cases and the implications for definitions, classification and surveillance methodologies

BACKGROUND

Bone flap infections (BFI) occur following neurosurgical procedures such as craniotomies. However, they are poorly defined and often not clearly differentiated from other surgical site infection neurosurgery.

AIM

To review data from a national adult neurosurgical centre to explore some clinical aspects to better inform definitions, classification and surveillance methodologies.

METHODS

We retrospectively reviewed data on clinical samples sent for culture from patients with suspected BFI. We also accessed information recorded prospectively from national and local databases for evidence of BFI or related conditions based upon terms used in surgical operative notes or discharge summaries and documented monomicrobial and polymicrobial infections related to craniotomy sites.

FINDINGS

Between January 2016 and December 2020, we documented 63 patients with a mean age of 45 years (16-80). Craniectomy for infection of the skull was the most common terminology used to describe BFI in the coding used in a national database, 40/63 (63%), but other terms were used. A malignant neoplasm was the most common underlying condition necessitating craniectomy in 28/63 (44%) cases. Specimens submitted for microbiological investigation included 48/63 (76%) bone flaps, 38/63 (60%) fluid/pus, and 29/63 (46%) tissue. Fifty-eight (92%) patients had at least one culture positive specimen; 32 (55%) were monomicrobial and 26 (45%) were polymicrobial. Gram-positive bacteria predominated and Staphylococcus aureus was the most common.

CONCLUSION

Greater clarity on how to define BFI is required to enable better classification and the carrying out of appropriate surveillance. This will inform preventative strategies and more effective patient management.

Differences in risk factors for surgical site infection between laparotomy and laparoscopy in gastrointestinal surgery

Extensive gastrointestinal surgery surveillance data in Japan were analyzed to examine the differences in the risk factors for surgical site infection (SSI) between laparotomy and laparoscopic abdominal procedures. Surgical procedures investigated in the study were gastrectomy, cholecystectomy, colectomy, rectal resection, and appendectomy. A total of 32,629 patients were included in the study. The study participants were divided into two groups according to the year of surgery, 2003–2009 (first study period) and 2010–2015 (second study period), due to the increase in the number of laparoscopic surgeries in the second study period. The incidence of SSI was stratified by three SSI classifications (superficial incisional, deep incisional, and organ/space SSI). Multiple logistic regression analysis was performed to predict the risk factors for SSI. The percentage of laparoscopic surgeries performed has increased linearly since 2010. Patients in the second study period were significantly older and had a higher prevalence of SSI risk factors compared with those in the first study period. In addition, the predictive factors changed substantially in most surgical procedures between the two study periods. Wound class ≥ 3 was a ubiquitous risk factor for superficial incisional SSI (SI-SSI) and organ/space SSI (OS-SSI) in both open (laparotomy) and laparoscopic procedures in the first study period. Meanwhile, in the second study period, operative duration was a ubiquitous risk factor in both procedures. The risk factors for SI-SSI differed from those for OS-SSI in the five abdominal surgeries investigated in the study. Periodic examination of risk factors for SSI is recommended in an aging society.

Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention

A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.

Scaling up Quality Improvement for Surgical Teams (QIST)—avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS

Background

The aim of this trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement.

Methods

We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019.

Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative.

Results

There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52–2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42–2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively.

Conclusions

Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS.

Trial registration

Prospectively registered on 15 February 2018, ISRCTN11085475

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01193-9.

Does the use of surgical adjuncts affect post-operative infection rates in Neuro-oncology surgery?

BACKGROUND

Surgical site infection (SSI) is a significant cause of post-operative morbidity and mortality. As oncological care advances, the use of surgical adjuncts such as intraoperative US (Ultrasound), 5-ALA (5-Aminolevulinic acid) and neurophysiological monitoring has increased. This study set out to identify whether the use of surgical adjuncts in supratentorial tumour surgery lead to increased operative time or increased rates of SSI.

METHODS

This is a retrospective study at a large tertiary clinical neurosciences centre in the UK. We included all patients who underwent an elective supratentorial craniotomy for a tumour over a 12 month period. We retrospectively assessed whether patients had had a post-operative infection at 30 days or 4 months using our electronic patient record system.

RESULTS

267 patients were included. The median age was 58 years (range 17-87 years) with roughly equal numbers of males and females (males = 138/267, 52%). Most operations were carried out for gliomas (149/267, 56%) or metastases (61/267, 23%). The median length of surgery was 3 hours 6 minutes with 24% lasting >4 hours. The overall infection rate was 4.5%. Intraoperative monitoring and 5-ALA was associated with longer operative times although not necessarily larger craniotomy sizes whilst intraoperative US was associated with a shorter operative time and smaller craniotomy size. These adjuncts were not associated with an increased risk of infection.

CONCLUSION

This study adds reassurance that whilst some surgical adjuncts lead to increased operative times in our study there was no apparent increased risk of infection as a result of this.

Wound photography for evaluation of surgical site infection and wound healing after lower limb trauma

AIMS

Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

METHODS

Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs.

RESULTS

Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)).

CONCLUSION

Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802-1808.

Impact of Incisional Surgical Site Infections on Quality of Life and Patient Satisfaction after General Surgery: A Case Controlled Study

Background: Most incisional surgical site infections (ISSI) are now diagnosed after discharge from hospital. In this context, it is important to document the impact ISSI has on our patients. Patients and Methods: Our surgical department sent a validated questionnaire to patients after they had been discharged. This documented incision problems, the 36-Item Short Form Health (SF-36) qualify of life questionnaire, and a patient satisfaction survey (PSS). We retrospectively reviewed records for 115 patients with an ISSI and 115 matched controls with no documented complications. Patient demographics and outcomes were collected. Differences in physical component summary (PCS) score and mental component summary (MCS) score and the PSS score were compared. Results: A majority (87%) of ISSIs were diagnosed after discharge from hospital. There were no differences in demographics, the American Society of Anaesthesiologists grade, or length of stay (LOS) between groups. Two months after surgery, ISSI was associated with lower post-operative SF-36 scores. The PCS was 42.9 (95% confidence interval [CI], 41.3-44.8) for ISSI cases and 47.0 (95% CI, 45.1-48.7) for controls (p ≤ 0.001). The MCS was 45.8 (95% CI, 43.7-47.9) and 50.2 (95% CI, 48.0-52.3), respectively (p = 0.01). Patients had less vitality, increased pain, and a reduction in physical activities and roles. The PSS score was 82.5 (95% CI, 79.6-85.4) in the control group and 74.1 (95% CI, 71.1-77.0) in the ISSI group (p < 0.001). Patients with ISSI reported worse satisfaction ratings with the quality of information received (p = 0.005) and their satisfaction with surgery (p < 0.001). Conclusions: Incisional surgical site infection was correlated with lower quality of life and PSS scores for up to two months after surgery. Prospective studies with pre-operative and post-operative quality of life are required to confirm causality.

Infectious Complication in Relation to the Prophylactic Mesh Position: The PRIMA Trial Revisited

BACKGROUND

Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position.

STUDY DESIGN

Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure.

RESULTS

Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group.

CONCLUSIONS

Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.