Components of Existing National Surgical Site Infection Surveillance Programs Based on a Case Series of Low- and Middle-Income Countries: Building Blocks for Success and Opportunities for Improvement

Background: Surgical site infection (SSI) surveillance programs are recommended to be included in national infection prevention and control (IPC) programs, yet few exist in low- or middle-income countries (LMICs). Our goal was to identify components of surveillance in existing programs that could be replicated elsewhere and note opportunities for improvement to build awareness for other countries in the process of developing their own national surgical site infection surveillance (nSSIS) programs. Methods: We administered a survey built upon the U.S. Centers for Disease Control and Prevention's framework for surveillance system evaluation to systematically deconstruct logistical infrastructure of existing nSSIS programs in LMICs. Qualitative analyses of survey responses by thematic elements were used to identify successful surveillance system components and recognize opportunities for improvement. Results: Three respondents representing countries in Europe and Central Asia, sub-Saharan Africa, and South Asia designated as upper middle-income, lower middle-income, and low-income responded. Notable strengths described by respondents included use of local paper documentation, staggered data entry, and limited data entry fields. Opportunities for improvement included outpatient data capture, broader coverage of healthcare centers within a nation, improved audit processes, defining the denominator of number of surgical procedures, and presence of an easily accessible, free SSI surveillance training program for healthcare workers. Conclusions: Outpatient post-surgery surveillance, national coverage of healthcare facilities, and training on how to take local SSI surveillance data and integrate it within a broader nSSIS program at the national level remain areas of opportunities for countries looking to implement a nSSIS program.

Xenogeneic transplantation of porcine hepatocytes into the CCl4 cirrhotic rat model

Liver support using extracorporeal devices and hepatocyte transplantation has received renewed interest for the management of acute and chronic liver failure. The aim of this study was to determine whether xenogeneic porcine hepatocytes could integrate into the liver parenchyma of cirrhotic Lewis rats when administered by an intrasplenic route. Cirrhosis was induced by carbon tetrachloride (CCl4) inhalation and confirmed histologically. Freshly isolated porcine hepatocytes were infused directly into the splenic pulp at laparotomy over a 5-15-min interval. Using (111)In-labeled hepatocytes, the degree of localization of porcine hepatocytes to the spleen and liver was found to be greater than 60% in both control and cirrhotic rats. Integration of porcine hepatocytes into the rat liver parenchyma was determined by immunohistochemical staining for porcine albumin in rat liver sections. Further confirmation was provided by in situ hybridization using a porcine-specific probe that binds to a distinct repetitive element (PRE) in porcine DNA. Evidence of integrated porcine hepatocytes was seen for over 50 days in animals under cyclosporine immunosuppression. These data demonstrate the integration of xenogeneic porcine hepatocytes into the liver of the cirrhotic rat and their ability to produce porcine albumin for up to 50 days.

Early indicators of prognosis in upper gastrointestinal hemorrhage

OBJECTIVE

Endoscopy allows accurate risk stratification of patients presenting with gastrointestinal bleeding; frequently, however, it is not immediately available. Initial management and triage of patients thus depends on nonendoscopic information. We sought to risk stratify patients with upper gastrointestinal bleeding using variables available on initial presentation (ie., before endoscopy).

METHODS

A retrospective observational study was performed using data from 335 admissions with an initial diagnosis of upper gastrointestinal hemorrhage. All patients underwent endoscopy and were evaluated for an adverse outcome during their hospitalization. An adverse outcome was defined as death, the need for any operation, recurrent hematemesis, recurrent melena after initial clearing, or a hematocrit falling despite transfusion.

RESULTS

Univariate analysis identified 17 distinct variables associated (p < 0.05) with an adverse outcome. A stepwise logistic regression identified five variables as independent predictors (p < 0.05) of an adverse outcome: an initial hematocrit <30%, initial systolic blood pressure < 100 mm Hg, red blood in the nasogastric lavage, history of cirrhosis or ascites on exam, and a history of vomiting red blood. We derived a decision rule based on patients having 0-5 of these independent predictors. This decision rule allowed identification of a large patient population with a <10% chance of an adverse outcome.

CONCLUSION

Risk stratification is possible from information available at the time of initial presentation. If confirmed in other populations, these predictors can be used to identify patients who require a less intensive level of care.