Article

Surgical site infection in the elderly following orthopaedic surgery - Risk factors and outcomes

Duke University, Durham, North Carolina, United States
The Journal of Bone and Joint Surgery (Impact Factor: 4.31). 09/2006; 88(8):1705-12. DOI: 10.2106/JBJS.E.01156
Source: PubMed

ABSTRACT Risk factor and outcomes data pertaining to surgical site infection in the elderly following orthopaedic operations are lacking. The aim of this study was to identify risk factors for surgical site infections and to quantify the impact of these infections on health outcomes in elderly patients following orthopaedic surgery.
A risk factor and outcomes study was performed at Duke University Medical Center, a tertiary care center, and seven community hospitals in North Carolina and Virginia between 1991 and 2002. The study included elderly patients in whom a surgical site infection had developed following orthopaedic surgery and elderly patients in whom a surgical site infection had not developed following orthopaedic surgery (controls). Outcome measures included mortality during the one-year postoperative period and the total length of the hospital stay (including readmissions during the ninety-day postoperative period).
One hundred and sixty-nine patients with a surgical site infection were identified, and 171 controls were selected. The mean age of the patients was 74.7 years. The most frequent procedures were hip arthroplasty (n = 74, 22%) and open reduction of fractures (n = 55, 16%). The most common pathogen was Staphylococcus aureus (n = 95, 56%). A risk factor for surgical site infection, identified in the multivariate analysis, was admission from a health-care facility (odds ratio = 4.35; 95% confidence interval = 1.64, 11.11). Multivariate analysis also indicated that surgical site infection was a strong predictor of mortality (odds ratio = 3.80; 95% confidence interval = 1.49, 9.70) and an increased length of stay in the hospital (multiplicative effect = 2.49; 95% confidence interval = 2.10, 2.94; 9.31 mean attributable days per infection, 95% confidence interval = 6.88, 12.13).
Measures for prevention of surgical site infection in elderly patients should target individuals who reside in health-care facilities prior to surgery. Future studies should be done to examine the effectiveness of such interventions in preventing infection and improving outcomes in elderly patients who undergo orthopaedic surgery.

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Available from: Michael P Bolognesi, Aug 13, 2015
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    • "Geriatric patients provide unique challenges in fracture management due to their bone quality and medical comorbidities (Little et al. 2013). SSI is a strong predictor of mortality in elderly patients (Lee et al. 2006), and controversies remain regarding the risks and benefits of operative treatment in geriatric patients (Koval et al. 2007, Strauss and Egol 2007, Hak et al. 2011, Shivarathre et al. 2011, Lynde et al. 2012, Little et al. 2013, McKean et al. 2013, Olsen et al. 2013, Zaghloul et al. 2014). The risks of surgical treatment should be carefully evaluated in all elderly patients (Kettunen and Kröger 2005). "
    Acta orthopaedica. Supplementum 02/2015; 83(358):1-35. DOI:10.3109/17453674.2014.1002273
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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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    ABSTRACT: Surgical site infections (SSI) are the second most frequent healthcare-associated infection (HAI), accounting for approximately 20 % of all HAIs in the United States, and an important cause of morbidity and mortality in older adults. With the aging of the population and the expected increase in surgical procedures in the elderly, strategies for prevention and treatment of SSI, will assume increased importance. In this review we describe risk factors for and outcomes associated with SSI, and recommend treatment and prevention strategies for SSI in older adults.
    09/2013; 2(3). DOI:10.1007/s13670-013-0048-3
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