Methods For Identifying Surgical Wound Infection After Discharge From Hospital: a systematic review

Department of Health Sciences, University of York, Seebohm Rowntree Building, York, UK.
BMC Infectious Diseases (Impact Factor: 2.61). 02/2006; 6(1):170. DOI: 10.1186/1471-2334-6-170
Source: PubMed


Wound infections are a common complication of surgery that add significantly to the morbidity of patients and costs of treatment. The global trend towards reducing length of hospital stay post-surgery and the increase in day case surgery means that surgical site infections (SSI) will increasingly occur after hospital discharge. Surveillance of SSIs is important because rates of SSI are viewed as a measure of hospital performance, however accurate detection of SSIs post-hospital discharge is not straightforward.
We conducted a systematic review of methods of post discharge surveillance for surgical wound infection and undertook a national audit of methods of post-discharge surveillance for surgical site infection currently used within United Kingdom NHS Trusts.
Seven reports of six comparative studies which examined the validity of post-discharge surveillance methods were located; these involved different comparisons and some had methodological limitations, making it difficult to identify an optimal method. Several studies evaluated automated screening of electronic records and found this to be a useful strategy for the identification of SSIs that occurred post discharge. The audit identified a wide range of relevant post-discharge surveillance programmes in England, Scotland and Wales and Northern Ireland; however, these programmes used varying approaches for which there is little supporting evidence of validity and/or reliability.
In order to establish robust methods of surveillance for those surgical site infections that occur post discharge, there is a need to develop a method of case ascertainment that is valid and reliable post discharge. Existing research has not identified a valid and reliable method. A standardised definition of wound infection (e.g. that of the Centres for Disease Control) should be used as a basis for developing a feasible, valid and reliable approach to defining post discharge SSI. At a local level, the method used to ascertain post discharge SSI will depend upon the purpose of the surveillance, the nature of available routine data and the resources available.

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    • "Most importantly, most SSIs following colon surgery are not identified until after the patient has been discharged. Hospital based surveillance programs will not capture the postdischarge event and require special efforts to capture infectious complications after the patient leaves the hospital [16]. The differences in reported rates can be identified by my study of SSIs in an administrative dataset which represented a 20% sample of an entire year of elective surgical cases in the United States. "
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    ABSTRACT: Infections at the surgical site continue to occur in as many as 20% of elective colon resection cases. Methods to reduce these infections are inconsistently applied. Surgical site infection (SSI) is the result of multiple interactive variables including the inoculum of bacteria that contaminate the site, the virulence of the contaminating microbes, and the local environment at the surgical site. These variables that promote infection are potentially offset by the effectiveness of the host defense. Reduction in the inoculum of bacteria is achieved by appropriate surgical site preparation, systemic preventive antibiotics, and use of mechanical bowel preparation in conjunction with the oral antibiotic bowel preparation. Intraoperative reduction of hematoma, necrotic tissue, foreign bodies, and tissue dead space will reduce infections. Enhancement of the host may be achieved by perioperative supplemental oxygenation, maintenance of normothermia, and glycemic control. These methods require additional research to identify optimum application. Uniform application of currently understood methods and continued research into new methods to reduce microbial contamination and enhancement of host responsiveness can lead to better outcomes.
    12/2013; 2013(10):896297. DOI:10.1155/2013/896297
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    ABSTRACT: Background and aims. Since 1999, hospitals in the Finnish Hospital Infection Program (SIRO) have reported data on surgical site infections (SSI) following major hip and knee surgery. The purpose of this study was to obtain detailed information to support prevention efforts by analyzing SIRO data on SSIs, to evaluate possible factors affecting the surveillance results, and to assess the disease burden of postoperative prosthetic joint infections in Finland. Methods. Procedures under surveillance included total hip (THA) and total knee arthroplasties (TKA), and the open reduction and internal fixation (ORIF) of femur fractures. Hospitals prospectively collected data using common definitions and written protocol, and also performed postdischarge surveillance. In the validation study, a blinded retrospective chart review was performed and infection control nurses were interviewed. Patient charts of deep incisional and organ/space SSIs were reviewed, and data from three sources (SIRO, the Finnish Arthroplasty Register, and the Finnish Patient Insurance Centre) were linked for capture-recapture analyses. Results. During 1999-2002, the overall SSI rate was 3.3% after 11,812 orthopedic procedures (median length of stay, eight days). Of all SSIs, 56% were detected after discharge. The majority of deep incisional and organ/space SSIs (65/108, 60%) were detected on readmission. Positive and negative predictive values, sensitivity, and specificity for SIRO surveillance were 94% (95% CI, 89-99%), 99% (99-100%), 75% (56-93%), and 100% (97-100%), respectively. Of the 9,831 total joint replacements performed during 2001-2004, 7.2% (THA 5.2% and TKA 9.9%) of the implants were inserted in a simultaneous bilateral operation. Patients who underwent bilateral operations were younger, healthier, and more often males than those who underwent unilateral procedures. The rates of deep SSIs or mortality did not differ between bi- and uni-lateral THAs or TKAs. Four deep SSIs were reported following bilateral operations (antimicrobial prophylaxis administered 48-218 minutes before incision). In the three registers, altogether 129 prosthetic joint infections were identified after 13,482 THA and TKA during 1999-2004. After correction with the positive predictive value of SIRO (91%), a log-linear model provided an estimated overall prosthetic joint infection rate of 1.6% after THA and 1.3% after TKA. The sensitivity of the SIRO surveillance ranged from 36% to 57%. According to the estimation, nearly 200 prosthetic joint infections could occur in Finland each year (the average from 1999 to 2004) after THA and TKA. Conclusions. Postdischarge surveillance had a major impact on SSI rates after major hip and knee surgery. A minority of deep incisional and organ/space SSIs would be missed, however, if postdischarge surveillance by questionnaire was not performed. According to the validation study, most SSIs reported to SIRO were true infections. Some SSIs were missed, revealing some weakness in case finding. Variation in diagnostic practices may also affect SSI rates. No differences were found in deep SSI rates or mortality between bi- and unilateral THA and TKA. However, patient materials between these two groups differed. Bilateral operations require specific attention paid to their antimicrobial prophylaxis as well as to data management in the surveillance database. The true disease burden of prosthetic joint infections may be heavier than the rates from national nosocomial surveillance systems usually suggest. Suomessa tehdään vuosittain yli 15 000 lonkan tai polven tekonivelleikkausta. Nykyaikainen tekonivelkirurgia parantaa potilaiden toimintakykyä ja helpottaa kipua. Vaikka leikkauksen jälkeisten infektioiden ilmaantuminen on selvästi vähentynyt tekonivelkirurgian alkuaikoihin verrattuna, edelleen osa tekonivelleikkauksista voi johtaa infektioon. Hoitoon liittyvien infektioiden seuranta on keskeinen osa niiden ehkäisyä. Suomessa sairaalat ovat voineet osallistua vapaaehtoiseen Kansanterveyslaitoksen valtakunnalliseen sairaalainfektio-ohjelmaan (SIRO) vuodesta 1999 lähtien. Tässä väitöskirjatutkimuksessa analysoitiin SIRO-seurannassa todettuja leikkausalueen infektioita ja niiden riskitekijöitä lonkan ja polven tekonivelleikkauksien ja reisiluun murtumien leikkauksien jälkeen. Lisäksi arvioitiin seurantatietojen laatua ja leikkauksen jälkeisten tekonivelinfektioiden kokonaismäärää Suomessa. SIRO-seurannassa sairaalat keräävät tietoja leikkausalueen infektioista käyttäen yhteisiä määritelmiä ja menetelmiä. Infektiotapauksia etsitään myös potilaiden kotiuduttua sairaalasta. Validaatiotutkimuksessa arvioitiin seurantatietojen laatua läpikäymällä sairauskertomuksia ja haastattelemalla sairaaloiden hygieniahoitajia. Kaikki vuosina 1999―2004 ilmoitetut vakavat leikkausalueen infektiotapaukset käytiin läpi. Lisäksi seurantatietoihin yhdistettiin tietoja kahdesta muusta lähteestä: Lääkelaitoksen implanttirekisteri ja Potilasvakuutuskeskus. Vuosina 1999―2002 leikkausalueen infektioiden esiintyvyys oli 3,3 prosenttia seurantaan kuuluneen 11 812 leikkauksen jälkeen. Vakavien infektioiden, joita ovat syvät haavainfektiot ja nivelen/luun infektiot, esiintyvyys oli 0,9 prosenttia. Infektioista yli puolet todettiin potilaan sairaalasta kotiutumisen jälkeen. Pääosa vakavista infektioista todettiin potilaan tullessa uudelleen sairaalahoitoon. SIRO-seurantatietojen laatu oli validaatiotutkimuksessa samaa tasoa kuin muiden maiden kansallisissa seurantajärjestelmissä: SIRO-seurannan herkkyys oli 75 prosenttia ja tarkkuus lähes 100 prosenttia. Infektioiden toteamiskäytännöt vaihtelevat jonkin verran sairaaloittain, mikä saattaa vaikuttaa seurantatuloksiin. Tulevaisuudessa sairaaloiden tietojärjestelmien kehittyminen voi helpottaa sairaalainfektioiden seurantaa ja parantaa sen laatua. Vuosina 2001―2004 asetetuista lonkan tai polven tekonivelistä 7 prosenttia oli asetettu kaksipuolisessa toimenpiteessä, jolloin molempiin lonkkiin tai polviin oli asetettu tekonivel samassa leikkauksessa. Kaksipuolisissa leikkauksissa potilaat olivat nuorempia ja terveempiä kuin yksipuolisissa. Tässä aineistossa vakavien infektioiden esiintyvyydessä ja kuolleisuudessa ei havaittu eroa yksi- ja kaksipuolisten leikkausten välillä. Rekisterien yhdistämistutkimuksen perusteella arvioitiin, että Suomessa esiintyy noin 200 leikkauksen jälkeistä tekonivelinfektiota vuosittain. Leikkauksen jälkeisten tekonivelinfektioiden tautitaakka saattaa olla jonkin verran suurempi kuin yleensä kansallisten seurantaohjelmien tulosten perusteella on arvioitu.
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