Incidence and Etiology of Surgical Site Infections in Appendectomies: A 3-Year Prospective Study

Comparison of abdominal depth with subcutaneous fat thickness in predicting surgical site infection among patients undergoing hepatopancreatobiliary surgery: a prospective observational study

Introduction

Surgical site infection (SSI) is a significant cause of postoperative morbidity resulting in an increased hospital stay and cost. Various measures have been used to predict SSI such as subcutaneous fat thickness (SCFT) and abdominal depth (AD) in case of abdominal surgeries. The objective of the study was to compare SCFT with AD to predict SSI in HPB surgeries.

Methods

A prospective observational study was conducted from February 2020 to February 2021, which included 76 patients who underwent elective open hepatopancreatobiliary surgeries. SCFT and AD at the level of the umbilicus were measured preoperatively using the computed tomography abdomen. The occurrence of SSI was evaluated in correlation with SCFT and AD. SCFT and AD were compared using the receiver operating characteristic curve for prediction of SSI.

Results

Twenty-five (32.3%) patients who underwent elective HPB surgeries developed SSI. 72% of the SSI were superficial. In multivariate analysis, only SCFT was associated with SSI, which was statistically significant. It was compared with AD using the receiver operating characteristic curve where SCFT proved to be better at predicting SSI (AUC=0.884) with cut-off =2.13 cm, sensitivity 84%, and specificity 86%), compared to AD with an AUC of 0.449.

Conclusion

SSI is the common cause of increased morbidity following hepato-pancreato-biliary surgeries with risk factors including SCFT and AD. Approximately one-third of patient developed SSI, with most the common being superficial SSI. SCFT at the incision site was associated with an increased rate of SSI and the better predictor for SSI as compared with the AD.

Data-Driven Technologies as Enablers for Value Creation in the Prevention of Surgical Site Infections: a Systematic Review

Despite the advances in modern medicine, the use of data-driven technologies (DDTs) to prevent surgical site infections (SSIs) remains a major challenge. Scholars recognise that data management is the next frontier in infection prevention, but many aspects related to the benefits and advantages of using DDTs to mitigate SSI risk factors remain unclear and underexplored in the literature. This study explores how DDTs enable value creation in the prevention of SSIs. This study follows a systematic literature review approach and the PRISMA statement to analyse peer-reviewed articles from seven databases. Fifty-nine articles were included in the review and were analysed through a descriptive and a thematic analysis. The findings suggest a growing interest in DDTs in SSI prevention in the last 5 years, and that machine learning and smartphone applications are widely used in SSI prevention. DDTs are mainly applied to prevent SSIs in clean and clean-contaminated surgeries and often used to manage patient-related data in the postoperative stage. DDTs enable the creation of nine categories of value that are classified in four dimensions: cost/sacrifice, functional/instrumental, experiential/hedonic, and symbolic/expressive. This study offers a unique and systematic overview of the value creation aspects enabled by DDT applications in SSI prevention and suggests that additional research is needed in four areas: value co-creation and product-service systems, DDTs in contaminated and dirty surgeries, data legitimation and explainability, and data-driven interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41666-023-00129-2.

Rhamnolipid Nano-Micelles Inhibit SARS-CoV-2 Infection and Have No Dermal or Eye Toxic Effects in Rabbits

Hand hygiene is considered to be the key factor in controlling and preventing infection, either in hospital care settings or in the community. Alcohol-based hand sanitizers are commonly used due to their rapid action and broad spectrum of microbicidal activity, offering protection against bacteria and viruses. However, their frequent administration during COVID-19 pandemic was associated with serious hazards, such as skin toxicity, including irritation, skin dermatitis, skin dryness or cracking, along with peeling redness or itching, with the higher possibility of getting infections. Thus, there is a need to find alternative and novel approaches for hand sanitation. In our previous publications, we reported that rhamnolipids nano-micelles had a comparable antibacterial activity to alcohol-based hand sanitizer and a lower cytotoxicity against human dermal fibroblast cells. In the current study, we investigated the antiviral activity of rhamnolipids nano-micelles against SARS-CoV-2. There was no cytotoxic effect on Vero cells noted at the tested concentrations of rhamnolipids nano-micelles. The rhamnolipids nano-micelles solution at 20, 78, and 312 µg/mL all demonstrated a significant (p < 0.05) decrease of virus infectivity compared to the virus only and the blank vehicle sample. In addition, an acute irritation test was performed on rabbits to further ascertain the biosafety of rhamnolipids nano-micelles. In the eye and skin irritation tests, no degree of irritation was recorded after topical application of rhamnolipids nano-micelles. In addition, histopathological, biomarker, and hematological analyses from animals treated with rhamnolipids nano-micelles were identical to those recorded for untreated animal. From the above, we can conclude that rhamnolipids nano-micelles are a good candidate to be used as a hand sanitizer instead of alcohol-based hand sanitizers. However, they must still be tested in the future among healthcare workers (HCW) in a health care setting to ascertain their antimicrobial efficacy and safety compared to alcohol-based hand sanitizers.

Rhamnolipid Nano-Micelles versus Alcohol-Based Hand Sanitizer: A Comparative Study for Antibacterial Activity against Hospital-Acquired Infections and Toxicity Concerns

Hospital-acquired infections (HAIs) are considered to be a major global healthcare challenge, in large part because of the development of microbial resistance to currently approved antimicrobial drugs. HAIs are frequently preventable through infection prevention and control measures, with hand hygiene as a key activity. Improving hand hygiene was reported to reduce the transmission of healthcare-associated pathogens and HAIs. Alcohol-based hand sanitizers are commonly used due to their rapid action and broad spectrum of microbicidal activity, offering protection against bacteria and viruses. However, their frequent administration has been reported to be associated with many side effects, such as skin sensitivity, skin drying, and cracks, which promote further skin infections. Thus, there is an essential need to find alternative approaches to hand sanitation. Rhamnolipids are glycolipids produced by Pseudomonas aeruginosa, and were shown to have broad antimicrobial activity as biosurfactants. We have previously demonstrated the antimicrobial activity of rhamnolipid nano-micelles against selected drug-resistant Gram-negative (Salmonella Montevideo and Salmonella Typhimurium) and Gram-positive bacteria (Staphylococcus aureus, Streptococcus pneumoniae). To the best of our knowledge, the antimicrobial activity of rhamnolipid nano-micelles in comparison to alcohol-based hand sanitizers against microorganisms commonly causing HAIs in Egypt—such as Acinetobacter baumannii and Staphylococcus aureus—has not yet been studied. In the present work, a comparative study of the antibacterial activity of rhamnolipid nano-micelles versus alcohol-based hand sanitizers was performed, and their safety profiles were also assessed. It was demonstrated that rhamnolipid nano-micelles had a comparable antibacterial activity to alcohol-based hand sanitizer, with a better safety profile, i.e., rhamnolipid nano-micelles are unlikely to cause any harmful effects on the skin. Thus, rhamnolipid nano-micelles could be recommended to replace alcohol-based hand sanitizers; however, they must still be tested by healthcare workers in healthcare settings to ascertain their antimicrobial activity and safety.

Emerging Status of Multidrug-Resistant Bacteria and Fungi in the Arabian Peninsula

Simple Summary

The incidence and developing status of multidrug-resistant bacteria and fungi, as well as their related mortality, is reviewed by a systematic published literature search from nine countries in the Arabian Peninsula. In order to analyse the emerging status and mortality, a total of 382 research articles were selected from a comprehensive screening of 1705 papers. More than 850 deaths reported since 2010 in the Arabian Peninsula due to the infection of multidrug-resistant bacteria and fungi. Multidrug-resistant bacteria Acinetobacter baumannii, Mycobacterium tuberculosis, Staphylococcus aureus, and fungi Candida auris are the most prevalent and causing high deaths. To control these infections and associated deaths in the Arabian Peninsula, continuous preventive measures, accurate methods for early diagnosis of infection, active surveillance, constant monitoring, developing vaccines, eradicating multidrug resistance modulators, and data sharing among countries are required.

Abstract

We aimed to identify the prevalence and emerging status of multidrug-resistant bacteria and fungi and their associated mortality in nine countries in the Arabian Peninsula. Original research articles and case studies regarding multidrug-resistant bacteria and fungi in the Arabian Peninsula, published during the last 10 years, were retrieved from PubMed and Scopus. A total of 382 studies were included as per the inclusion and exclusion criteria, as well as the PRISMA guidelines, from a thorough screening of 1705 articles, in order to analyse the emerging status and mortality. The emerging nature of >120 multidrug-resistant (MDR) bacteria and fungi in the Arabian Peninsula is a serious concern that requires continuous monitoring and immediate preventive measures. More than 50% (n = 453) of multidrug-resistant, microbe-associated mortality (n = 871) in the Arabian Peninsula was due to MDR Acinetobacter baumannii, Mycobacterium tuberculosis and Staphylococcus aureus infection. Overall, a 16.51% mortality was reported among MDR-infected patients in the Arabian Peninsula from the 382 articles of this registered systematic review. MDR A. baumannii (5600 isolates) prevailed in all the nine countries of the Arabian Peninsula and was one of the fastest emerging MDR bacteria with the highest mortality (n = 210). A total of 13,087 Mycobacterium tuberculosis isolates were reported in the region. Candida auris (580 strains) is the most prevalent among the MDR fungal pathogen in the Arabian Peninsula, having caused 54 mortalities. Active surveillance, constant monitoring, the development of a candidate vaccine, an early diagnosis of MDR infection, the elimination of multidrug resistance modulators and uninterrupted preventive measures with enhanced data sharing are mandatory to control MDR infection and associated diseases of the Arabian Peninsula. Accurate and rapid detection methods are needed to differentiate MDR strain from other strains of the species. This review summarises the logical relation, prevalence, emerging status and associated mortality of MDR microbes in the Arabian Peninsula.

Surgical Site Infection Post-appendectomy in a Tertiary Hospital, Jeddah, Saudi Arabia

BACKGROUND AND PURPOSE

Appendectomy considered at the top of emergency surgical procedures worldwide, and surgical site infection (SSI) is not an uncommon complication postoperatively. Many factors may be contributed to SSI occurrence; either during preoperative, intraoperative, or postoperative periods. No recent studies focusing on SSI post-appendectomy and the related factors in our region. So, we aim to find the prevalence and detect the factors that may lead to SSI in post-appendectomy patients at King Abdulaziz University Hospital (KAUH) between 2013 and 2017.

METHODS

This is a retrospective chart review study. Data were collected by data collection sheet from (KAUH) patient's database, as we include: patients' demographics, blood investigations, operation details, co-morbidities, and hospitalization time. All patients who underwent appendectomy between 2013 and 2017 were included. We used frequencies, Mann-Whitney U test, and binary logistic regression tests for data analysis.

RESULT

SSI post-appendectomy was found in 31 patients out of 433. SSI was statistically significant related more with an open technique of appendectomy (p=0.0001), longer duration of the surgery (p=0.0001), perforated type of appendicitis (p=0.002), more hospitalization time (p=0.0004), postoperative lab results of high WBC count (p=0.004), and low albumin (p=0.011). Other factors including demographics and clinical characteristics, intraoperative, perioperative, and hemoglobin level showed no significant relations.

CONCLUSION

Controlling the high rate of SSI by using the optimal technique of approach, decreasing the duration of the surgery, and early intervention may help more in reducing SSI post-appendectomy. Taking into consideration the other perioperative factors will lead to better outcomes for the patients.

Rodent-Related Zoonotic Pathogens at the Human-Animal-Environment Interface in Qatar: A Systematic Review and Meta-Analysis

Rodents are one of the most diversified terrestrial mammals, and they perform several beneficial activities in nature. These animals are also important as carriers of many pathogens with public health importance. The current systematic review was conducted to formulate a true depiction of rodent-related zoonoses in Qatar. Following systematic searches on PubMed, Scopus, Science Direct, and Web of Science and a screening process, a total of 94 published articles were selected and studied. The studied articles reported 23 rodent-related zoonotic pathogens that include nine bacterial, eleven parasitic, and three viral pathogens, from which the frequently reported pathogens were Mycobacterium tuberculosis (32 reports), Escherichia coli (23), and Salmonella spp. (16). The possible pathway of entry of the rodent-borne pathogens can be the land port, seaports, and airport of Qatar through carrier humans and animals, contaminated food, and agricultural products. The pathogens can be conserved internally by rodents, pets, and livestock; by agricultural production systems; and by food marketing chains. The overall estimated pooled prevalence of the pathogens among the human population was 4.27% (95%CI: 4.03–4.51%; p < 0.001) with significant heterogeneity (I² = 99.50%). The top three highest prevalent pathogens were M.tuberculosis (30.90%; 22.75–39.04%; p < 0.001; I² = 99.70%) followed by Toxoplasma gondii (21.93%; 6.23–37.61%; p < 0.001; I² = 99.30%) and hepatitis E virus (18.29%; 11.72–24.86%; p < 0.001; I² = 96.70%). However, there is a knowledge gap about the listed pathogens regarding the occurrence, transmission pathways, and rodent role in transmission dynamics at the human–animal–environment interface in Qatar. Further studies are required to explore the role of rodents in spreading zoonotic pathogens through the One Health framework, consisting of zoologists, ecologists, microbiologists, entomologists, veterinarians, and public health experts in this country.

Prevalence of infections and antimicrobial use in the acute-care hospital setting in the Middle East: Results from the first point-prevalence survey in the region

OBJECTIVES

Community-acquired (CAIs) and healthcare-associated (HAIs) infections are associated with significant morbidity and mortality. Data related to the epidemiology of these infections in the Middle East is scarce. The aim of this study is to estimate the prevalence of infections and antimicrobial use in the acute hospital setting in this region.

METHODS

A multicentre Point-Prevalence Survey was conducted in seven Middle Eastern countries: Egypt, Kingdom of Saudi Arabia, United Arab Emirates, Lebanon, Oman, Kuwait and Bahrain. Data were collected by the infection control and infectious diseases teams of the respective hospitals. Study surveys were completed in one day (03 April 2018).

RESULTS

The overall point prevalence of infection was 28.3%; HAI and CAI point prevalence was 11.2% and 16.8%, respectively. The majority of patients with an infection (98.2%) were receiving antimicrobial therapy. There were high levels of resistance to antimicrobials among Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae and other Klebsiella sp.

CONCLUSIONS

Our findings indicate that the point prevalence of both HAI and CAI is high in a sample of Middle Eastern countries. These findings along with the increased use of antimicrobials represent a significant public health problem in the region; particularly in light of the growing regional antimicrobial resistance.

Epidemiology and Risk Factors for Superficial Surgical Site Infections after Appendectomy for Acute Appendicitis: A Secondary Data Analysis

Background: The identification of risk factors for superficial surgical site infections (SSSIs) associated with appendectomy is paramount in the management of patients with acute appendicitis (AA). Methods: This study was a secondary data analysis from a prospective multi-center observational study. It included all consecutive hospitalized patients with AA who underwent appendectomy and were monitored for complications at 30 days after the intervention. A case-control approach was used to evaluate risk factors associated with the occurrence of SSSI. Results: Among 2,667 patients, 156 (5.8%) developed an SSSI. The series included 1,449 males (54.3%) and 1,218 females with a median age of 29 years (interquartile range [IQR] 20-45 years). Antimicrobial therapy within the previous 30 days was reported by 170 patients (6.4%), and a C-reactive protein concentration (CRP) >50 mg/L was observed in 609 (22.8%). A total of 960 patients (36.0%) underwent open surgery, 1,699 (63.7%) laparoscopic surgery, and 8 (0.3%) another surgical intervention. In 2,575 patients (95.6%), a pathological appendix was detected during the operation. In 776 patients (29.1%), an intra-operative abdominal drain (IAD) was placed; 125 patients (4.7%) were admitted to the intensive care unit. The median hospital length of stay was 3 days (IQR 2-5 days). The overall mortality rate was 0.11%. Multinomial logistic regression analysis of risk factors demonstrated that statistically significant risk factors independently associated with the occurrence of SSSIs were antimicrobial therapy within the previous 30 days, CRP >50 mg/L, open surgical procedures, presence of IAD, and intra-operative findings of complex appendicitis. Conclusions: Knowledge of five easily recognizable variables, assessable at hospital admission or as soon as the surgical intervention is concluded, might identify patients with a greater risk of developing an SSSI.

Surgical site infections in Eastern Mediterranean region: a systematic review and meta-analysis

Background: Surgical site infections (SSIs) are the most common and costly type of hospital-acquired infections (HAIs) worldwide. Despite individual studies, there is also no clear statistics on the SSI prevalence rate in the East Mediterranean region. The aim of this study was to investigate the prevalence of SSI in the Eastern Mediterranean region. Methods: This systematic review and meta-analysis were performed by searching three international databases (Web of Science, PubMed and Scopus) from 1 January 2001 to 31 December 2018. The keywords used included 'Prevalence' OR 'incidence' OR 'surgical site infection' OR 'wound infection' OR 'Postoperative Wound Infections' and 'Middle east'. The Hoy et al.'s tool was used to evaluate the quality of the articles. Result: Out of 889 initial studies, 40 studies from 12 countries of the Eastern Mediterranean region were included in the final stage of the study. Based on the results of random effect method, the overall prevalence of SSI in 137,452 patients was 7.9% (95% Confidence Interval (CI): 7.1, 8.8; I²=96.7%). The prevalence of SSI in cardiac surgery and general surgery wards was 10 and 9.2%, respectively. The prevalence of SSI was lower in women than in males, although this difference was related to caesarean section. Conclusions: Considering the high prevalence of SSI in the Eastern Mediterranean region, timely diagnosis, proper prevention and postoperative control are necessary in the region using the same international guides in all countries.

Global prevalence and incidence of surgical site infections after appendectomy: a systematic review and meta-analysis protocol

INTRODUCTION

Acute appendicitis is a surgical emergency and the most frequent aetiology of acute surgical abdominal pain in developed countries. Universally, its widely approved treatment is appendectomy. Like all surgical procedures, appendectomy can be associated with many complications among which are surgical site infections (SSIs).Despite the increasing number of appendectomies done around the world and the associated morbidities related to SSI after appendectomy, there is still scarcity of data concerning the global epidemiology of SSI after appendectomy. The current review aims at providing a summary of the published data on epidemiology of SSI after appendectomy.

METHODS AND DESIGN

We will include randomised controlled trials, cohort studies, case-control and cross-sectional studies. Electronic databases including Embase, MEDLINE and ISI Web of Science (Science Citation Index) will be searched for relevant abstracts of studies published between 1 January 2000 and 30 December 2017, without language restriction. The review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After screening of abstracts, study selection, data extraction and assessment of risk of bias, we shall assess the studies individually for clinical and statistical heterogeneity. Appropriate meta-analytic techniques will then be used to pool studies judged to be clinically homogenous. Visual inspection of funnel plots and Egger's test will be used to detect publication bias. Results will be presented by country and continent.

ETHICS AND DISSEMINATION

Since primary data are not collected in this study, ethical approval is not required. This review is expected to provide relevant data to help in quantifying the global burden of SSI after appendectomy. The final report will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42017075257.

Efficacy of emergency laparoscopic appendectomy in treating complicated appendicitis for elderly patients

To assess the therapeutic effects of emergency laparoscopic appendectomy (LA) in treating complicated appendicitis (CA) for elderly patients (defined as age 65 years and above). Methods: We conducted a retrospective study of 115 elderly patients with CA who underwent surgical therapy in the Affiliated Huizhou Hospital of Sun Yat-Sun University, Huizhou, Guangdong Province, China between September 2014 and August 2016. Of these, 59 patients consented to open appendectomy (OA), and LA was performed in the other 56 patients. The perioperative and follow-up variables of the 2 groups were analyzed. Results: The operative time in the LA group was longer than the OA group (LA: 70.5±16.0 min versus [vs.] OA: 59.3±12.0 min, p greater than 0.001). The LA group had lower chances of incision infections (LA: 8.9% vs OA: 28.8 %, p=0.007) and shorter hospital stay (LA: 6.1± 2.5 days vs. OA: 9.6±3.5 days, p greater than 0.001). Return to soft diet (LA: 1.4 ± 0.8 days vs OA: 3.0 ± 1.6 days, p greater than 0.001) and time to out of bed (LA: 1.3±0.5 days vs OA: 2.5±0.9 days, p greater than 0.001) was faster in the LA group. The incidence of complications and 30-day readmission rate in the LA group was much lower than the OA group. Conclusion: Emergency LA in treating elderly patients with CA has the advantages of less trauma, definite curative effect, low complication rates, and fast recovery when compared with OA.

Safety of perioperative ketorolac administration in pediatric appendectomy

BACKGROUND

Recent studies in adults undergoing gastrointestinal surgeries show an increased rate of complications with the use of ketorolac. This calls into question the safety of ketorolac in certain procedures. We sought to evaluate the impact of perioperative ketorolac administration on outcomes in pediatric appendectomy.

METHODS

The Pediatric Health Information System database was queried for patients aged 5-17 y with a primary diagnosis of appendicitis and a primary procedure of appendectomy during the period 2010-2014. Patients with procedures suggesting incidental appendectomy, those records with data quality issues, deaths, and extracorporeal membrane oxygenation were excluded. Variables recorded included age, sex, race, ethnicity, discharge year, complex chronic conditions, geographic region, intensive care unit admission, mechanical ventilation, and whether appendicitis was coded as complicated. The exposure variable was ketorolac administration on the day of or day after operation. The primary outcomes of interest were any surgical complications during the initial encounter, postoperative length of stay (LOS), total cost for the initial visit, any readmission to ambulatory, observation, or inpatient status within 30 d, and readmission with a diagnosis of peritoneal abscess or other postoperative infection or with transabdominal drainage performed.

RESULTS

A total of 78,926 patients were included in the analysis cohort. Mean age was 11.4 y (standard deviation 3.3 y), the majority were males (61%), White (70%), and non-Hispanic (65%). Few had a complex chronic condition (3%) or required mechanical ventilation (2%) or an intensive care unit admission (1%). Patients with complicated appendicitis comprised 28% of the cohort. Most (73%) received ketorolac on postoperative day 0-1; those with complicated appendicitis were more likely to receive ketorolac. In all, 2.6% of the cohort had a surgical complication during the index visit, 4.3% were readmitted within 30 d, and 2% had a postoperative infection or transabdominal drainage (1% in the uncomplicated group and 5% in the complicated group). Median postoperative LOS was 1 d and mean cost was $9811 ± $9509. On bivariate analysis, ketorolac administration was associated with a decrease in same-visit surgical complications (P = 0.004) and cost ($459 decrease, P < 0.001) but was not associated with readmission, postoperative LOS, or postoperative infection. On multivariate analysis, ketorolac administration was associated with a significant decrease in any complication (adjusted odds ratio 0.89, 95% confidence interval 0.80-0.99) and cost (analysis of variance P < 0.001) but was not associated with readmission, postoperative LOS, or postoperative infection.

CONCLUSIONS

Based on a large, contemporary data set from children's hospitals, ketorolac administration in the immediate postoperative period after appendectomy for appendicitis is common and was not associated with an increase in postoperative LOS, postoperative infection, or any-cause 30-d readmission. Ketorolac was, however, independently associated with a lower overall rate of postoperative complications and cost in this population.