Prevention of surgical site infections

Bacterial Decontamination: Bowel Preparation and Chlorhexidine Bathing

Infectious complications following bowel surgery continues to be a leading cause of postoperative morbidity. Both patient- and procedure-related factors contribute to risk. Compliance with evidence-based process measures is the best strategy for prevention of surgical site infections. Three process measures that aim to reduce the bacterial load present at the time of surgery are mechanical bowel preparation, oral antibiotics, and chlorhexidine bathing. There is heightened awareness of surgical site infections, in part due to improved access to reliable postoperative complication data for colon surgery as well as incorporation of surgical site infection into public reporting and pay-for-performance payment models. As a result, the literature has improved with regard to the effectiveness of these methods in reducing infectious complications. Herein, we provide the evidence to support adoption of these practices into colorectal surgery infection prevention programs.

Comparing the efficacy of povidone-iodine and normal saline in incisional wound irrigation to prevent superficial surgical site infection: a randomized clinical trial in gastric surgery

BACKGROUND

Prevention of surgical site infection (SSI) after gastrectomy has received increasing attention. Prophylactic incisional wound irrigation has been advocated to reduce SSI, but the choice of solution remains under debate.

AIMS

To compare the efficacies of wound irrigation with normal saline (NS) and povidone-iodine (PVI) for the prevention of SSI after gastrectomy, and to identify the risk factors for SSI.

METHODS

This randomized, single-centre clinical trial included 340 patients with gastric cancer. They were assigned at random into two groups (ratio 1:1) to receive either 0.9% NS or 1.0% PVI solution for incisional irrigation before wound closure. The primary endpoint was postoperative SSI within 30 days of gastrectomy, and the secondary endpoint was the length of hospital stay.

FINDINGS

In total, 333 patients were included in the modified intent-to-treat group, and the SSI rate did not differ significantly between the PVI group (11/167, 6.59%) and the NS group (9/166, 5.42%) [odds ratio (OR) 1.131, 95% confidence interval (CI) 0.459-3.712; P=0.655]. Moreover, the difference between the two groups in terms of length of hospital stay was not significant (P=0.301). Body mass index (BMI) (OR 2.639, 95% CI 1.040-6.694; P=0.041) and postoperative complications (OR 2.565, 95% CI 1.023-6.431; P=0.045) were identified as independent risk factors for SSI.

CONCLUSIONS

NS and PVI had similar efficacy as prophylactic wound irrigation for the prevention of SSI after gastrectomy. The risk of SSI was higher in patients with high BMI or postoperative complications.

[Ankle fractures in older patients : What should we do differently?]

As a result of the demographic developments ankle fractures in older patients are part of routine trauma surgery. Due to comorbidities, such as diabetes mellitus, reduced bone quality and limited compliance in follow-up treatment, these fractures are prone to complications. The primary goal in the treatment of older patients with ankle fractures is to maintain mobility. In contrast to young patients most fractures are unstable pronation-abduction injuries. In the diagnostics the recognition and optimization of factors influencing the outcome, such as the blood perfusion and the generous use of computed tomography (CT) are recommended. As in the case of younger patients, conservative treatment is reserved for stable fracture forms and, if there are contraindications, should also be initiated in the case of unstable injuries. The choice of approaches is different for surgical treatment, which is adapted to the soft tissues, if necessary minimally invasive and increasingly carried out by a posterolateral approach. The initial transfixation can reduce soft tissue problems. Special surgical techniques and implants that provide a high level of stability, such as dorsal plate positioning, hook plates, angular stable plate systems and intramedullary systems as well as additional options, such as tibia pro fibula constructs are used. Primary retrograde nail arthrodesis is reserved as a salvage procedure only for exceptional cases. As part of the follow-up treatment, an interdisciplinary approach with respect for and optimization of concomitant diseases seems to make sense.

A socio-technical, probabilistic risk assessment model for surgical site infections in ambulatory surgery centers

BACKGROUND

To understand how structural and process elements may affect the risk for surgical site infections (SSIs) in the ambulatory surgery center (ASC) environment, the researchers employed a tool known as socio-technical probabilistic risk assessment (ST-PRA). ST-PRA is particularly helpful for estimating risks in outcomes that are very rare, such as the risk of SSI in ASCs.

OBJECTIVE

Study objectives were to (1) identify the risk factors associated with SSIs resulting from procedures performed at ASCs and (2) design an intervention to mitigate the likelihood of SSIs for the most common risk factors that were identified by the ST-PRA for a particular surgical procedure.

METHODS

ST-PRA was used to study the SSI risk in the ASC setting. Both quantitative and qualitative data sources were utilized, and sensitivity analysis was performed to ensure the robustness of the results.

RESULTS

The event entitled "fail to protect the patient effectively" accounted for 51.9% of SSIs in the ambulatory care setting. Critical components of this event included several failure risk points related to skin preparation, antibiotic administration, staff training, proper response to glove punctures during surgery, and adherence to surgical preparation rules related to the wearing of jewelry, watches, and artificial nails. Assuming a 75% reduction in noncompliance on any combination of 2 of these 5 components, the risk for an SSI decreased from 0.0044 to between 0.0027 and 0.0035.

CONCLUSION

An intervention that targeted the 5 major components of the major risk point was proposed, and its implications were discussed.

Intraoperative angiography does not lead to increased rates of surgical site infections

BACKGROUND

Intraoperative angiography (IOA) is essential in evaluating residual aneurysm following clip ligation, but it does lead to an additional procedure which increases the duration of the procedure as well as increasing room traffic. We examined whether IOA during microsurgery is a risk factor for developing cranial surgical site infection.

MATERIALS AND METHODS

A retrospective cohort study was performed of all patients undergoing craniotomy for aneurysm treatment between 2005 and 2012 at the University of Michigan. IOA was used at the surgeons' discretion. The primary outcome of interest was occurrence of a surgical site infection and the secondary outcome of interest was clip repositioning following IOA. Variables including IOA were tested for their independent association with the occurrence of a surgical site infection.

RESULTS

During the study period 676 intracranial aneurysms were treated by craniotomy; IOA was used in 104 of these cases. There were a total of 20 surgical site infections, 2 in the IOA group (1.9%) and 18 in the non-IOA group (3.1%), indicating that IOA was not a statistically significant variable for infection (p=0.50). No additional single variable measured could be shown to have a statistically significant increase in infection, and there were no direct complications related to the use of IOA (stroke, dissection, perforation).

CONCLUSIONS

IOA does not increase the risk of developing a surgical site infection. It can be conducted without exposing patients to an undue risk of infection.

Effect of low-concentration povidone iodine on postoperative complications after third molar surgery: a pilot split-mouth study

PURPOSE

Povidone iodine is used primarily as an antiseptic to decrease surgical site infection. Its hemostatic and antiedematous properties in oral surgery also have been investigated recently.

PATIENTS AND METHODS

A randomized controlled clinical trial was performed in 30 patients undergoing mandibular third molar removal in a split-mouth design. In the study group, a povidone iodine solution with a concentration of 0.5 mg/mL was used as the coolant and irrigant solution, whereas normal saline was used in the control group. Swelling (orotragus and mentotragus distances), trismus (maximum interincisal opening), and pain (visual analog scale score) were evaluated on postoperative days 2 and 7.

RESULTS

In the study group, a significant decrease in swelling and trismus was observed at the 2 postoperative visits (P = .00) compared with the control group. The decrease of pain in the study group was not statistically significant at either postoperative visit (P > .05). More patients (63%) were subjectively satisfied with the side treated with povidone iodine.

CONCLUSION

Povidone iodine irrigation is an inexpensive and safe method to lessen the postoperative sequelae of third molar surgery.

Prospective, non-comparative study of daptomycin for the treatment of superficial and deep incisional surgical site infections

BACKGROUND

Skin infections, including surgical site infections (SSIs), usually involve gram-positive pathogens and continue to be a leading cause of morbidity and death among hospital patients. The increasing prevalence of methicillin-resistant Staphylococcus aureus and other resistant strains accentuates the need for effective and safe therapies for such infections. This exploratory study evaluated the efficacy and safety of daptomycin in patients with gram-positive SSI according to wound classification.

METHODS

Eligible patients had an SSI with onset < 30 days after surgery, positive gram stain or culture at least three days before daptomycin therapy began, and three or more clinical signs and symptoms of infection. The incisional SSI was classified as superficial or deep according to the U.S. Centers for Disease Control and Prevention criteria. Patients with organ-space infections were excluded, as were those with major concomitant infections, foreign material in the incision that could not be removed, previous systemic antimicrobial therapy, or creatinine clearance < 30 mL/min. Daptomycin 4 mg/kg was administered intravenously once daily for 7-14 days. The primary efficacy endpoint was clinical response at the end of daptomycin therapy, and the safety assessment was based on adverse events (AEs).

RESULTS

Sixty-nine patients were enrolled, 60 of whom were evaluable for efficacy. Extremity wounds predominated among superficial incisional SSIs (n = 30), whereas abdominal wounds predominated among deep SSIs (n = 30). Patients with deep incisional SSI were more likely to be young, male, white, and febrile and to weigh more than patients with superficial SSIs. The overall clinical success rate was 92% (95% confidence interval [CI] 82-97%); the success rate was 100% in superficial incisional SSI and 83% in deep SSI (17% difference; 95% CI 0-33%). Staphylococcus aureus (28/36 methicillin-resistant) was the pathogen isolated most frequently. In 10 patients who were febrile at baseline, the median time to defervescence was five days, and the mean duration of treatment in the series was 11.2 days. Daptomycin was well tolerated. In most patients, AEs were mild or moderate in intensity; in two patients (one superficial, one deep), daptomycin was discontinued because of AEs.

CONCLUSIONS

The results of this exploratory study of SSI are consistent with those of previous studies of daptomycin in the treatment of diverse complicated skin and skin-structure infections, and suggest that wound classification should be treated as an important covariate in future studies of daptomycin and other antibiotics.

Meta-analysis of intraoperative povidone–iodine application to prevent surgical-site infection

Background

The effectiveness of intraoperative povidone–iodine (PVI) application in the reduction of surgical-site infection (SSI) remains controversial. This meta-analysis was performed to assess the effect of intraoperative PVI application compared with no antiseptic solution (saline or nothing) on the SSI rate.

Methods

The meta-analysis included randomized controlled trials that compared intraoperative PVI lavage with no PVI in patients undergoing surgery with SSI as the primary outcome. A fixed-effects or random-effects model was used as appropriate, and heterogeneity was assessed by the Cochran Q and the I2 value.

Results

Twenty-four randomized controlled trials totalling 5004 patients (2465 patients with PVI and 2539 patients without) were included: 15 in the main analysis and nine in the sensitivity analysis. The rate of SSI was 8·0 per cent in the PVI group and 13·4 per cent in the control group. Intraoperative PVI application significantly decreased the SSI rate (relative risk 0·58, 95 per cent confidence interval 0·40 to 0·83; P = 0·003) and consistent results were observed in subgroup analyses according to the method of PVI administration, its timing and the type of surgery.

Conclusion

The meta-analysis results suggested that the use of intraoperative PVI reduced rates of SSI.

Postoperative outcomes associated with topical skin adhesives among women having hysterectomies

BACKGROUND

Multiple options are available for closure of hysterectomy incisions. This study compared postoperative clinical and economic outcomes using topical skin adhesive (2-octyl cyanoacrylate; OCA) vs. conventional skin closure in women undergoing total abdominal hysterectomy.

METHODS

A multi-hospital administrative database was used to identify women discharged in 2005 who had undergone total abdominal hysterectomy. Patients, classified by skin closure as suture (n = 21,201), staples (n = 23,441), OCA (n = 880), or staples + OCA (n = 489), were compared on length of inpatient stay (LOS), total inpatient cost, and non-prophylactic antibiotic treatment after day four.

RESULTS

The unadjusted mean LOS was 3.9, 4.5, 3.7, and 5.2 days for suture, staples, OCA, and staples + OCA, respectively; and the percentages of patients having antibiotic treatment were 12.93, 17.51, 11.14, and 23.72. There were overall differences in adjusted mean LOS, mean total cost, and antibiotic treatment (p < 0.0001). Pairwise comparisons indicated no difference between sutures and OCA, whereas the outcomes for each of the non-staple groups were more favorable than those for the staple group (p < 0.01). Results were similar in adjusted comparisons, with pairwise comparisons between OCA and staples at or near the threshold for significance.

CONCLUSIONS

2-octyl cyanoacrylate appears to be a safe and cost-effective alternative to topical sutures for patients having total abdominal hysterectomy. There were less favorable outcomes in groups receiving staples.

Does liquid tissue adhesive increase satisfaction with wound and stoma management after surgery?

OBJECTIVE

This pilot study reviews the impact of tissue adhesive to seal skin wounds in elective large bowel resections where a stoma is fashioned.

METHOD

Patients undergoing elective colorectal resection over six-month period were prospectively evaluated for wound infections rates, length of inpatient stay and patient satisfaction with their wound and stoma management. The wounds were observed for 30 days in both inpatient and outpatient settings. A patient satisfaction questionnaire was used with respect to the stoma and wound management.

RESULTS

Fifty patients undergoing elective colorectal resection over a six-month period were prospectively evaluated. The median patient ages were 63.5 years (40-83) for males and 60 years (33-85) for females. Ninety-two per cent of the patients found their wound management satisfactory (overall satisfaction score >5, where 5 represents 'high satisfaction'). Eighty-six per cent reported a stoma management satisfaction score of >4 (where for 4 represents 'satisfaction'). Stoma site leakage was reported by 16%, but none of these developed a SSI. Two patients who had laboratory-confirmed SSI; they had an average length of inpatient stay of 18 days compared with 6.5 days for patients without SSI. .

CONCLUSION

Liquid tissue adhesive provides a flexible, water-resistant and protective coating which increases the satisfaction and ease of surgical wound and stoma management. We recommend a randomised controlled trial be conducted to evaluate these results in larger cohorts.

Surgical site infections following open reduction and internal fixation of ankle fractures

Background:

Ankle fracture fixation is one of the most commonly performed orthopaedic procedures. Although the results are generally favourable, complications are not uncommon, particularly in the case of surgical site infections. These have considerable impact on both postoperative morbidity and healthcare costs. Paradoxically, there is a paucity of literature studying patients who sustain them and therefore little is known about ways such occurrences can be minimised. The purpose of this study was to determine the infection rate following ankle fracture fixation and elucidate variables in their causation.

Methods:

We retrospectively reviewed 50 consecutive patients who underwent open reduction and internal fixation of an ankle fracture. The study group consisted of 26 females and 24 males with an average age of 43 (Range 16-82) years.

Results:

Problems with superficial infections were noted in seven patients and deep infections in five. Of the latter, four patients underwent further surgery including two that had their metal work removed. With use of the Fisher’s exact test we determined that only smoking and a bimalleolar fracture pattern were significant variables, having p-values of 0.02 and 0.04 respectively.

Conclusion:

We recommend that patients with ankle fractures who either have a history of smoking and/or bimalleolar injury be counselled about the potential risk of infection and its implications on their functional recovery. The ability to identify patients at risk of such problems highlights the need for caution during the perioperative period so that care strategies may be altered to facilitate recovery.

Antimicrobial susceptibility pattern of microorganisms involved in the pathogenesis of surgical site infection (SSI); A 1 year of surveillance

The aim of this study is to identify the antibiotic sensitivity pattern of pathogens involved in the process of surgical site infection, in surgical wards. Changes made in the pattern of antibiotic use will result in different microorganism susceptibility patterns, which needs correct determination for precise empiric antibiotic therapy. One thousand patients (62% men and 38% women, 18- 74-years-old, with mean age 43 +/- 8)) who underwent surgical treatment, in Alzahra University Hospital, Isfahan University of Medicine, Isfahan, Iran, were studied from 2005 to 2006. Surgical wound infections, based on the reported criteria, were aspirated for culturing within 1 plus gram staining of prepared smears. Minimum Inhibitory Concentrations (MICs) were determined for samples and all derived data were compared by SPSS 13 and WHO net 5 software. The prevalence of SSI was 13.3% with 150 positive cultures, totally. Of 150 bacteria, isolated from surgical site infections Staphylococcus aureus had most frequency (43%). Resistance of isolated organisms was 41.7% in amikacin, 65 and 78.6% in ceftazidime, 85.7% in ceftriaxone, 61.5% in ciprofloxacin, 78.8% in gentamicine, 6.4% in imipenem, 13% in meropenem and 70.6% in trimethoprim/sulfamethoxazole, respectively. 78.9% of Staphylococcus aureus isolates were MRSA and vancomycine was the most effective antibiotic without any resistance. Among 10 isolates of coagulase negative Staphylococcus, no vancomycine resistance was seen, but in contrast all cases were resistant to oxacillin. The most common gram negative organism was Klebsiella (18 isolates) in which 100 and 80% were sensitive to imipenem and meropenem, respectively. Seventeen cases were E. coli, in which the most sensitivity was to meropenem (80%) and imipenem (77.8%). Thirteen cases of Pseudomonas were detected, in which 16.7% were resistant to imipenem and 8.3% to meropenem. Our results demonstrated that the total antibiotic resistance is increasing among SSIs, with an up sloping pattern, which will contact with a constant empiric antibiotic therapy. So, precise up to date antibiogram tantalize us toward balancing the rate of total antibiotic resistance to SSIs.

Surgical site infection: the host factor

More than 30 million surgical procedures are performed annually in the United States, and surgical site infections (SSIs) remain a major postoperative complication. Although bacteria contaminate all surgical wounds, not all wounds become infected. In most cases, the host response eradicates the microbes. The patient's (ie, host's) responsiveness, therefore, is an important variable in the equation of factors that influence the rate of infection. Optimizing the patient's physiological condition can help prevent SSIs. Initiatives that show promise in reducing SSI rates include use of supplemental oxygen, maintenance of core body temperature, and rigorous management of blood sugar. Perioperative nurses play an important role as the patient's infection control advocate.

Antibody based target tailored antimicrobial chemotherapy - a new approach

Ever since antimicrobial therapy was introduced, two phenomenons have been observed: drug resistance and host toxicity. Mutation(s) in microbes leads to the earlier, while off target effects of therapy cause the latter. Neither of these problems have yet to be resolved. All Microbes express specific antigens, against which monoclonal antibodies can be generated ex vivo. If these specific antibodies are conjugated with antimicrobial drugs, it would lead to an increase in the specificity of antimicrobial chemotherapy agents. Moreover, the antibodies also work as anti-infective agents by directing the human immune response to the pathogen. As a result, antibody conjugated antimicrobial chemotherapy may have lower side effects, higher potency and efficacy.