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Consensus paper on the surveillance of surgical wound infection
Abstract
A Surgical Wound Infection Task Force was convened by the Society of Hospital Epidemiology of America to evaluate how surgical wound infection surveillance should be done and to identify where more information is needed. The task force reached consensus in the following areas. The Centers for Disease Control definitions of surgical wound infection should be used for routine surveillance because of their current widespread acceptance and reproducibility. The Centers for Disease Control defintions are clarified in an accompanying article. Direct observation of wounds and traditional infection control surveillance techniques are acceptable methods of case finding for hospitalized patients. The optimal method for case finding after discharge or after outpatient surgery is unknown at this time. Surgical wound infection rates should be stratified by surgical wound class plus a measure of patient susceptibility to infection, such as the American Society of Anesthesiology class, and duration of surgery. Surgeon-specific surgical wound infection rates should be calculated and reported to individual surgeons.
... In veterinary medicine, only one study has proved the association between concurrent endocrine disease and a greater risk of suffering SSI. 3 In human medicine, on the other hand, the consensus task force for surveillance of SSI considers that conditions such as diabetes or cancer could be potential triggers for the development of SSI. 17 However, this association is difficult to assess in veterinary medicine due to the low proportion of surgical patients with endocrine disorders. ...
... These results are similar to those reported by Eugster et al. 4 However, in human medicine ASA classification is considered a proven risk factor for development of SSI by the Consensus Supervision of Surgical Wound Infection. 17 In fact, Garibaldi et al 23 showed the independent predictive power of ASA classification in a prospective study of 1852 patients. ...
Objectives
To determine (1) the incidence of surgical site infection (SSI) in patients undergoing soft tissue surgery at a veterinary teaching hospital and to study (2) and describe the main risk factors associated with SSI and (3) assess the economic impact of SSI.
Design
Prospective cohort study.
Setting
Veterinary teaching hospital.
Participants
184 dogs undergoing soft tissue surgery during a 12-month period (October 2013 to September 2014).
Primary outcome measure
Surgical site infection.
Results
Out of the 184 patients analysed, SSI was diagnosed in 16 (8.7 per cent) patients, 13 (81.3 per cent) were classified as superficial incisional infection, 2 (12.5 per cent) as deep incisional infection and 1 (6.3 per cent) as organ/space infection. The administration of steroidal anti-inflammatory drugs (P=0.028), preoperative hyperglycaemia (P=0.015), surgical times longer than 60 minutes (P=0.013), urinary catheterisation (P=0.037) and wrong use of the Elizabethan collar (P=0.025) were identified as risk factors. Total costs increased 74.4 per cent, with an increase in postsurgical costs of 142.2 per cent.
Conclusions
The incidence of SSI was higher than the incidence reported in other published studies, although they were within expected ranges when a surveillance system was implemented. This incidence correlated with an increase in costs. Additionally new important risk factors for its development were detected.
... procedure that occurs at or near the site of a surgical incision within 30 days of the procedure or within 90 days98 if prosthetic material is implanted at the site . SSI is the most common nosocomial infection accounting for about99 38% of all . Cancer patients are prone to infections in the postoperative period due to their disease process and their immunosuppressive treatment in the perioperative period. ...
... Also, studies indicate that surgical site infection (SSI) post-C/S has the highest number among infections [4,5]. According to the Centers for Disease Control and Prevention (CDC), SSI refers to any infections occurring within 30 days after surgical operation [6]. SSIs are common surgical complications among patients who delivered with C/S. ...
Introduction
Cesarean section (C/S) is considered one of the most commonly performed procedures among women. The maternal morbidity due to infection post-C/S reaches eight-fold higher than that of vaginal delivery. Our aim is to identify the incidence and risk factors of surgical site infection (SSI) among patients at King Abdul Aziz Medical City (KAMC), Jeddah, Saudi Arabia, in order to develop a strong strategy to reduce its occurrence.
Methods
This retrospective cohort study was conducted at KAMC, Jeddah. The study included a total of 387 women who underwent cesarean sections from January 2014 to December 2014. The data were collected consecutively by reviewing medical records of pregnant patients who underwent elective or emergency C/S. The risk factors studied included age, presence of underlying diseases, BMI, hemoglobin level, prophylactic antibiotics, pre-labor rupture of membrane, duration of induction of labor, type of C/S, type of uterine incision, duration of operation, type of anesthesia, estimated blood loss, type of organism, and the duration of hospital stay postoperatively.
Results
The incidence rate of wound infections (WI) was 3.4% (13/387). The mean age score was 31.1±5.6 years, and the mean score of BMI was 32.7±6.2, where the majority were obese (255, 65.9%). More than half of the participants (205, 53.0%) had elective C/S, with mean hospitalization duration 2.5±1.3 days, and operation duration mean score 59.5±22.0 minutes. The majority (378, 97.7%) received antibiotics before the operation, where cefazolin was the main antibiotic (376, 97.2%). Only 38 (10%) cases had intra-operative complications, where the main complication was postpartum hemorrhage (18, 44.0%). The majority of WI were superficial (11 cases), the main organism was E. coli in four (36.4%) cases, followed by Staphylococcus aureus in three (27.3%) cases. There was a significant association between WI post-C/S and BMI, type of uterine incision, and induction of labor (P=006, P=0.003, respectively).
Conclusions
This study showed that WI post-C/S is associated with high BMI, prolonged induction of labor, and Pfannenstiel incision. Reducing the rate of SSI will help to reduce its morbidity by identifying the risk factors pre-pregnancy and encouraging the implementation of preconception counseling clinics and antenatal classes to educate and increase awareness among patients.
... The wounds were classified as clean, clean contaminated, contaminated or dirty based on the center for disease control definitions [16]. The wound infections were also classified based on revised center for disease control definitions into superficial incisional, deep incisional and organ/space SSI [17]. ...
To determine the rate of surgical site infection (SSI) and the factors that predispose to it in children undergoing nonspinal orthopaedic surgery. Over a 6-month period, 326 children who underwent 334 nonspinal elective orthopaedic surgical procedures were prospectively reviewed for the development of surgical site infections. A total of 14 sites became infected, with an overall infection rate of 4.19%. All the infections were superficial, and the only causative organism detected was Staphylococcus aureus. Operating times longer than 1 h and surgical wounds greater than 10 cm in length were positively associated with SSIs. Although there were differences between male and females, type of admission, the use of prophylactic antibiotics, degree of wound contamination and the grades of surgeons, these differences were not statistically significant. The results of this prospective study provide valuable information that was not previously available to the practicing paediatric orthopaedic surgeon.
... Alguns autores conseguiram bons resultados com os métodos anteriormente mencionados (14,15) . Ferraz (1 (11,14,15,18) . ...
It is an epidemiologic and prospective study that approaches the problem of the subnotification of the surgical wound infection (SWI), where, data obtained only during the patient's stay underestimated the taxes of SWI, since from 19 to 84% of SWI could be diagnosed after discharge. Accomplished during the stay and after discharge, from August 2001 to March 2002. There were accompanied 501 patients, 140 (27,8%) of SWI were notified during the stay and 109 (77,9%) after discharge, confirming the hypothesis of subestimation of the incidence of SWI, where, without the surveillance after discharge, these 77,9% of infections would have not been notified.
... The plates were further incubated at 37 °C for 24 h. If growth occurred, the organisms were identified using automated means [13,14]. The patients' nutritional condition was assessed by analyzing the serum albumin level, which plays an important role in wound healing, while a lymphocyte count was performed to determine the immunological status of each patient. ...
Purpose: To investigate the effect of sterile and clean dressing techniques on wound management in a Chinese hospital, and to compare their impact on wound healing and the cost of the dressing materials with respect to postoperative surgical wounds.Methods: A total of 130 patients, comprising 70 (53.8 %) males and 60 (46.2 %) females, who had undergone surgery in The Affiliated Hospital of Changchun Traditional Chinese Medicine University, Changchun, China in 2012 – 2014 were enrolled in the study. Of these, 65 (50 %) received sterile dressings and 65 (50 %) clean dressings. A control group comprising 25 patients, 15 (60 %) males and 10 (40 %) females, who attended the clinic for change dressings only, was also included. The patients’ dressings were changed four times daily with 2x sterile and 2x clean dressings. Details of all the changes, including the nutritional status of the patients, were recorded. The patients were followed-up up to the time of their discharge.Results: Twelve (18.5 %) patients out of those who received sterile or clean dressings were found to have acquired an infection. The size of the wounds was approximately 1.8 to 32.4 cm3 (mean: 5.2 ± 6.4 cm3) in size at the start of the study and 0.6 to 4.2 cm3 at the end of the study. A significant difference was identified between the sterile and clean dressing groups at the beginning of the study (U = 72.5; p < 0.12). A decrease in wound size was observed in both of these groups but was not statistically significant, while the change in wound volume, was significantly different (U = 84.5; p < 0.25). When the cost of the two dressing types was compared, the sterile items were more expensive than that of the clean items; thus, sterile dressing procedure was significantly more costly than clean dressing procedure (p < 0.01).Conclusion: With mounting concern regarding antimicrobial resistance and hospital-acquired infections, suitable wound dressing techniques are required to prevent infection and reduce the duration of wound healing after surgery without compromising patient safety.
... Each wound was followed for a minimum of six weeks following surgical closure. Successful closure was defined as greater than 90% split thickness skin graft acceptance, the absence of infection (Sherertz et al., 1992), and the absence of dehiscence following delayed primary closure. Dehiscence was defined as a reopened wound that required additional surgical treatment within 30 days of closure or coverage. ...
Background: Recent conflicts in Afghanistan and Iraq produced a substantial number of critically wounded service-members. We collected biomarker and clinical information from 73 patients who sustained 116 life-threatening combat wounds, and sought to determine if the data could be used to predict the likelihood of wound failure.
Methods: From each patient, we collected clinical information, serum, wound effluent, and tissue prior to and at each surgical débridement. Inflammatory cytokines were quantified in both the serum and effluent, as were gene expression targets. The primary outcome was successful wound healing. Computer intensive methods were used to derive prognostic models that were internally validated using target shuffling and cross-validation methods. A second cohort of eighteen critically injured civilian patients was evaluated to determine if similar inflammatory responses were observed.
Findings: The best-performing models enhanced clinical observation with biomarker data from the serum and wound effluent, an indicator that systemic inflammatory conditions contribute to local wound failure. A Random Forest model containing ten variables demonstrated the highest accuracy (AUC 0.79). Decision Curve Analysis indicated that the use of this model would improve clinical outcomes and reduce unnecessary surgical procedures. Civilian trauma patients demonstrated similar inflammatory responses and an equivalent wound failure rate, indicating that the model may be generalizable to civilian settings.
Interpretation: Using advanced analytics, we successfully codified clinical and biomarker data from combat patients into a potentially generalizable decision support tool. Analysis of inflammatory data from critically ill patients with acute injury may inform decision-making to improve clinical outcomes and reduce healthcare costs.
Funding: United States Department of Defense Health Programs.
... Wound infection and partial dehiscence was significantly much lower in the no-drain group as compared to the drain groups in the present study. Our observations are in agreement with the majority of other investigators [13,[32][33][34] who found drains to be a risk factor for wound sepsis. However, our findings do not agree with those of Pai and associates [27] who observed no significant difference in the main wound infection rates between the drainage and non-drainage groups. ...
Objective: To compare the survival and post-op complications following primary closure of perforated peptic ulcer by omental patch technique in 4 groups of patients as follows: two-drain group, one-drain subhepatic group, one-drain pelvic group and no-drain group. Methods: This is a prospective case-controlled clinical study performed in the Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India. A total of 114 patients with perforated peptic ulcer who underwent emergency laparotomy with primary closure by omental patch technique were studied in 4 groups as mentioned above. Tube drains were used throughout the study. Results: Mean age of patients was 45±12.7 years (range 15- 75) with M:F ratio of 5:1. Clinical profile of patients matched in the 4 groups. Post-operative fever, vomiting, laparotomy wound infection, wound dehiscence and intraperitoneal collection were significantly lower in the no-drain group as compared to drain groups. There was found no significant difference between the no-drain and drain groups with respect to the post-operative abdominal distension, pain, intraabdominal sepsis, gastro-intestinal leak, adult respiratory distress syndrome and mortality. Drain-related complications were recorded in 36.8% of patients with tube drain(s). Conclusion: Peptic perforation closure with omental patch technique is safe without prophylactic drainage and a high rate of drain-related morbidity negates the concept of the routine drainage after this procedure. One drain placement is as good as the two drain placement and sub-hepatic drain is more useful than the pelvic drain. [J Exp Integr Med 2012; 2(1.000): 47-54]
... Há necessidade de programas integrados e responsivos em âmbito multidisciplinar. Neste particular, uma dificuldade identificada na vigilância pós-alta é a monitorização e a identificação precoce de casos infectados e colonizados em procedimentos pós-cirúrgicos (22) Assim, vários são os métodos de vigilância pós-alta de Infecções Relacionadas a Assistência à Saúde (IRAS) recomendados, porém a escolha da forma ideal é difícil, e cada instituição deve utilizar aquele que seja compatível com seus recursos, estrutura e perfil da clientela (22,30) O diagnóstico de infecção por MNT pode ser difícil, não obstante o maior problema enfrentado pelos profissionais de saúde é seu tratamento (31) . Uma característica importante dessas micobactérias é sua resistência aos medicamentos utilizados no tratamento de tuberculose (11) . ...
Infections caused by nontuberculous mycobacteria (MNT) represent an epidemiological and health emergency, especially in patients undergoing invasive procedures. Based on these, we aimed to analyze the scientific evidence, the scientific literature, on the occurrence in Brazil of MNT infections in surgical patients. We used as a research method integrative review of the literature using the databases Lilacs, Medline/Pubmed, ISI Web of Science and the Cochrane Library. We selected 15 publications on this theme from the last 30 years that were directed at methods of prevention and control, with a focus on post-discharge surveillance, the use of antibiotics and glutaraldehyde. Eye surgery, cosmetic, heart, laparoscopic and arthroscopic procedures were the most commonly investigated. The national situation of MNTs is concerning, especially when one recognizes the possibility of underreporting.
... The degree of surgical site contamination at the time of surgery influences the probability of surgical site infec- tion. According to the presence and degree of contamination, wounds can be classified as: " clean wounds " , " clean-contaminated wounds " , " contaminated wounds " , " dirty or infected wounds " [10, 12, 13]. Infection rates in the four surgical classifications have been published in many studies. ...
Surgical site infections (SSI) account for 14% to 17% of all hospital-acquired infections and 38% of nosocomial infections in surgical patients. SSI remain a substantial cause of morbidity and death, possibly because of the larger numbers of elderly surgical patients or those with a variety of chronic and immunocompromising conditions, and emergence of antibiotic-resistant microorganisms.
Factors causing surgical site infection are multifarious. Several studies have identified the main patient-related (endogenous risk factors) and procedure-related (external risk factors) factors that influence the risk of SSI. The rate of surgical wound infections is strongly influenced by operating theatre quality, too. A safe and salubrious operating theatre is an environment in which all sources of pollution and any micro-environmental alterations are kept strictly under control. This can be achieved only through careful planning, maintenance and periodic checks, as well as proper ongoing training for staff.
Many international scientific societies have produced guidelines regarding the environmental features of operating theatres (positive pressure, exchanges of filtered air per hour, air-conditioning systems with HEPA filters, etc.) and issued recommendations on healthcare-associated infection, including SSI, concerning surveillance methods, intervention to actively prevent SSI and approaches to monitoring the implementation of such strategies.
Therefore, the prevention of SSI requires a multidisciplinary approach and the commitment of all concerned, including that of those who are responsible for the design, layout and functioning of operating theatres.
... Surgical site infection (SSI) is one of the most common healthcare-associated infections among surgical patients, and it is estimated that SSIs develop in 2e5% of the >30 million patients who undergo surgical procedures each year. 32,33 Many surgeons believe that local use of antibiotics is a new essential method for postoperative reduction of wound complications. The GM-collagen sponge, an implantable topical antibiotic agent, is approved for surgical implantation in 54 countries, 34 and it was developed to prevent and treat wound infections by providing high GM concentrations locally, avoiding the high systemic concentrations associated with the risk of toxic adverse reactions, such as nephrotoxicity. ...
Gentamicin (GM) was discovered in 1963 and was introduced into parenteral usage in 1971. Since then, GM has been widely used in medicinal applications. The Food and Drug Administration of the United States approved the routine prescription of GM to treat the following infectious disorders: infection due to Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, Citrobacter spp., Enterobacteriaceae spp., Pseudomonas spp.; Staphylococcus infectious disease; bacterial meningitis; bacterial sepsis of newborns; bacterial septicemia; infection of the eye, bone, skin and/or subcutaneous tissue; infective endocarditis; peritoneal dialysis-associated peritonitis due to Pseudomonas and other gram-negative organisms; peritonitis due to gastrointestinal tract infections; respiratory tract infections; and urinary tract infectious disease. GM is an old antibiotic and is used widely beyond its FDA-labeled indications as follows: actinomycotic infection; Staph. saprophyticus bacteremia with pyelonephritis; appendicitis; cystic fibrosis; diverticulitis; adjunct regimen for febrile neutropenia; female genital infection; uterine infection; postnatal infection; necrotizing enterocolitis in fetus or newborn; osteomyelitis; pelvic inflammatory disease; plague; gonorrhea; tularemia; prophylaxis of post-cholecystectomy infection, transrectal prostate biopsy, and post-tympanostomy-related infection; malignant otitis externa; and intratympanically or transtympanically for Ménière's disease. GM is also used in combination regimens, such as with beta-lactam antibiotics to treat mixed infection and with bacteriophage to treat Staph. aureus infections. It is also added to medical materials, such as GM-loaded cement spacers for osteomyelitis and prosthetic joint-associated infections. Overall, there are many medicinal applications for GM. To reduce the development of GM-resistant bacteria and to maintain its effectiveness, GM should be used only to treat or prevent infections that are proven or strongly suspected as being caused by susceptible bacteria. In the future, we believe that GM will be used more widely in combination therapy and applied to medical materials for clinical applications. A definitive, appropriately powered study of this antibiotic and its clinical applications is now required, especially in terms of its effectiveness, safety, and cost.
Background
Spinal infections are still showing increased incidence throughout the years as our surgical capabilities increase, coupled with an overall aging population with greater number of chronic comorbidities. The management of spinal infection is of utmost importance, due to high rates of morbidity and mortality, on top of the general difficulty in eradicating spinal infection due to the ease of hematogenous spread in the spine. We aim to summarize the utility of vacuum-assisted closure (VAC) and local drug delivery systems (LDDS) in the management of spinal infections.
Methods
A narrative review was conducted. All studies that were related to the use of VAC and LDDS in Spinal Infections were included in the study.
Results
A total of 62 studies were included in this review. We discussed the utility of VAC as a tool for the management of wounds requiring secondary closure, as well as how it is increasingly being used after primary closure as prophylaxis for surgical site infections in high-risk wounds of patients undergoing spinal surgery. The role of LDDS in spinal infections was also discussed, with preliminary studies showing good outcomes when patients were treated with various novel LDDS.
Conclusions
We have summarized and given our recommendations for the use of VAC and LDDS for spinal infections. A treatment algorithm has also been established, to act as a guide for spine surgeons to follow when tackling various spinal infections in day-to-day clinical practice.
Background: Many techniques for closure of surgical incisions are available to the surgeon, but there is minimal guidance regarding which technique(s) should be utilized at the conclusion of surgery and under what circumstances. Hypothesis: Management of incisions at the conclusion of surgery lacks consensus and varies among individual surgeons. Methods: The Surgical Infection Society membership was surveyed on the management of incisions at the conclusion of surgery. Several case scenarios were provided to test the influences of operation type, intra-operative contamination, and hemodynamic stability on incision management (e.g., close fascia or skin, use of incision/wound vacuum-assisted closure [VAC] device). Responses by two-thirds of participants were required to achieve consensus. Data analysis by χ2 test and logistic regression, a = 0.05. Response heterogeneity was quantified by the Shannon index (SI). Results: Among 78 respondents, consensus was achieved for elective splenectomy (91% close skin/dry dressing). Open appendectomy and left colectomy/end-colostomy had the greatest heterogeneity (SI, 1.68 and 1.63, respectively). During trauma laparotomy, the majority used damage control for hemodynamic instability (53%-67%) but not for hemodynamically stable patients (0%-1.3%; p < 0.001). Additional consensus was achieved for close skin/dry dressing for hemodynamically stable trauma splenectomy patients (87%) and fascia open/wound VAC for hemodynamically unstable colon resection/anastomosis (67%). Fecal diversion for rectal injury and colon resection/anastomosis (both when hemodynamically stable) had high heterogeneity (SI, 1.56 and 1.48, respectively). In penetrating trauma, sentiment was for more use of wet-to-dry dressings and incision/wound VAC with increased contamination in hemodynamically stable patients. Conclusions: Damage control was favored in hemodynamically unstable trauma patients, with use of wet-to-dry dressings and incision/wound VAC with spillage after penetrating trauma. However, most scenarios did not achieve consensus. High variability of practices regarding incision management at the conclusion of surgery was confirmed. Prospective studies and evidence-based guidance are needed to guide decision making at end-operation.
and purpose
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. ¹ This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
Surgical site infection (SSI) is also known as nosocomial or health acquired infection which is increasing day by day and augmenting morbidity and mortality rate. The presence of the SSI shows the signs and symptoms including redness, pain, heat, presence of pus, and many more. Despite improvements in operational practice and contamination control strategies, SSI plays a major role in high morbidity and mortality and places a heavy burden on the resources of medical services. The purpose of this review article is collection of data that already exists about the pre-operative, intra-operative and post-operative strategies for prevention of the SSIs. The data about the SSI has been collected from the different review articles and research papers. Different keywords like prevention of SSI, cure from SSI, epidemiology of SSI, causes of SSI, and peri-operative strategies for prevention of SSI were used for data collection. Implementation of the pre-operative, intra operative and post-operative strategies can reduce or completely eliminate the surgical site infection. The morbidity and mortality rates that are directly linked with the SSI can be decreased by the alteration of different factors including operation theatre environment, treatment related factors and patient related factors. A proven and thorough strategy to lower the incidence of SSIs is SSI surveillance. Maintaining operation theatre quality is also essential for SSI reduction. But more research is still needed to improve the standards for regular infection control and surveillance in hospitals.
Aim:
The prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after highly contaminated laparotomies has not been sufficiently explored. This study aimed to evaluate the prophylactic effect of negative-pressure wound therapy against incisional surgical site infection after emergency surgery for colorectal perforation.
Methods:
This nationwide, multicenter, retrospective cohort study analyzed data from the 48 emergency hospitals certificated by the Japanese Society for Abdominal Emergency Medicine. Patients who underwent an emergency laparotomy for colorectal perforation between April 2015 and March 2020 were included in this study. Outcomes, including the incidence of incisional surgical site infection, were compared between patients who were treated with prophylactic negative-pressure wound therapy and delayed sutures (i.e., negative-pressure wound therapy group) and patients who were treated with regular wound management (i.e., control group) using 1:4 propensity score matching analysis.
Results:
The negative-pressure wound therapy group comprised 88 patients, whereas the control group consisted of 1535 patients. Of them, 82 propensity score-matched pairs (negative-pressure wound therapy group: 82; control group: 328) were evaluated. The negative-pressure wound therapy group showed a lower incidence of incisional surgical site infection [18 (22.0%) in the negative-pressure wound therapy group and 115 (35.0%) in the control group, odds ratio, 0.52; 95% confidence interval, 0.30 to 0.92; p = 0.026].
Conclusions:
The prophylactic use of negative-pressure wound therapy with delayed sutures was associated with a lower incidence of incisional surgical site infection after emergency surgery for colorectal perforation.
AimTo identify predictive factors for surgical site infection (SSI) in patients with type 2 diabetes and develop a prediction tool.Materials and methodsWe retrospectively analyzed the perioperative blood glucose management of 105 patients with type 2 diabetes treated from 2016 to 2018 at Chiba University Hospital. The primary outcome was SSI onset within 30 postoperative days; moreover, predictive factors were identified using univariate analysis. Principal component analysis and logistic regression analysis were performed to prepare SSI predictive model using the identified predictive factors. The area under the receiver operating characteristic curve (AUC) was evaluated. Based on the predictive model, we developed a risk engine for SSI prediction.ResultsCompared with patients without SSI (n = 70), those with SSI (n = 35) had significantly higher fasting blood glucose levels at referral (169.1 ± 61.8 mg/dL vs. 140.1 ± 56.6, P = 0.036), preoperative mean blood glucose levels (178.3 ± 48.4 mg/dL vs. 155.2 ± 39.7, P = 0.009), preoperative maximum blood glucose levels (280.4 ± 87.3 mg/dL vs. 230.3 ± 92.4, P = 0.009), preoperative blood glucose fluctuations (54.9 ± 24.1 mg/dL vs. 37.7 ± 23.1, P = 0.001), percentage of hospitalization at referral (54.3% vs. 20.0, P < 0.001); longer operation time (432.5 ± 179.6 min vs. 282.5 ± 178.3, P < 0.001); and greater bleeding volume (972.3 ± 920.1 mg/dL vs. 436.4 ± 795.8, P < 0.001). Logistic regression analysis revealed preoperative blood glucose fluctuation and operation time as the most reliable predictive factors. The predictive model had high prediction accuracy (AUC of 0.801). The risk engine prototype for SSI prediction can be accessed at https://www.dm-ope-riskengine.org/.Conclusions
The predictive model developed in this study could screen high-risk patients. It may be useful to prevent SSI in such patients.
Background
Surgical site infections (SSIs) cause significant patient suffering. Surveillance and feedback of SSI rates is an evidence-based strategy to reduce SSIs, but traditional surveillance methods are slow and prone to bias. The objective of this cluster randomized controlled trial (RCT) is to determine if using optimized statistical process control (SPC) charts for SSI surveillance and feedback lead to a reduction in SSI rates compared to traditional surveillance.
Methods
The Early 2RIS Trial is a prospective, multicenter cluster RCT using a stepped wedge design. The trial will be performed in 29 hospitals in the Duke Infection Control Outreach Network (DICON) and 105 clusters over 4 years, from March 2016 through February 2020; year one represents a baseline period; thereafter, 8–9 clusters will be randomized to intervention every 3 months over a 3-year period using a stepped wedge randomization design. All patients who undergo one of 13 targeted procedures at study hospitals will be included in the analysis; these procedures will be included in one of six clusters: cardiac, orthopedic, gastrointestinal, OB-GYN, vascular, and spinal. All clusters will undergo traditional surveillance for SSIs; once randomized to intervention, clusters will also undergo surveillance and feedback using optimized SPC charts. Feedback on surveillance data will be provided to all clusters, regardless of allocation or type of surveillance. The primary endpoint is the difference in rates of SSI between the SPC intervention compared to traditional surveillance and feedback alone.
Discussion
The traditional approach for SSI surveillance and feedback has several major deficiencies because SSIs are rare events. First, traditional statistical methods require aggregation of measurements over time, which delays analysis until enough data accumulate. Second, traditional statistical tests and resulting p values are difficult to interpret. Third, analyses based on average SSI rates during predefined time periods have limited ability to rapidly identify important, real-time trends. Thus, standard analytic methods that compare average SSI rates between arbitrarily designated time intervals may not identify an important SSI rate increase on time unless the “signal” is very strong. Therefore, novel strategies for early identification and investigation of SSI rate increases are needed to decrease SSI rates. While SPC charts are used throughout industry and healthcare to improve and optimize processes, including other types of healthcare-associated infections, they have not been evaluated as a tool for SSI surveillance and feedback in a randomized trial.
Trial registration
ClinicalTrials.gov NCT03075813 , Registered March 9, 2017.
Surgical site infection (SSI) rates in low- and middle-income countries (LMICs) range from 8 to 30% of procedures, making them the most common healthcare acquired infection (HAI) with substantial morbidity, mortality, and economic impacts. Presented here is an approach to surgical site infection prevention based on surveillance and focused on five key areas as identified by international experts. These five areas include:
Collecting valid, high-quality data;
Linking HAIs to economic incapacity, underscoring the need to prioritize infection prevention activities;
Implementing SSI surveillance within infection prevention and control (IPC) programs to enact structural changes, develop procedural skills, and alter healthcare worker behaviors;
Priotiziation of IPC training for healthcare workers in LMICs to conduct broad-based surveillance coupled with the development and implementation of locally applicable IPC programs;
Developing a highly accurate and objective international system for defining SSIs that can be translated globally in a straightforward manner.
Finally, we present a clear, unambiguous framework for successful SSI guideline implementation that supports the development of sustainable IPC programs in LMICs. This entails: i) identifying index operations for targeted surveillance; ii) identifying IPC “champions” and empowering healthcare workers; iii) using multimodal improvement measures; iv) positioning hand hygiene programs as the basis for IPC initiatives; and v), use of telecommunication devices for surveillance and healthcare outcome follow-ups. Additionally, special considerations for pediatric SSIs, antimicrobial resistance development, and antibiotic stewardship programs are addressed.
Background Surveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (< 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders.
Objective This article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability.
Methods Comparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility.
Results Eight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes, p = 0.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5, p = 0.002), spent more time per encounter (2.23 vs. 0.92 minutes, p = 0.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33, p = 0.02), and significantly higher in measures of usability.
Conclusion Compared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.
Incidence and risk factors of surgical site infection following caesarean section in a Tunisian maternity unit
Introduction: Surgical site infection (SSI) is a major health concern and is one of the most common complications following caesarean section, with an incidence of 3%-15%. With the worldwide increase in caesarean section rates, the incidence of SSI is expected to increase in parallel. This study was designed to estimate the incidence and determine the risk factors of SSI after caesarean section in an Obstetrics and Gynaecology department in the Kairouan region in Tunisia.
Methods: A prospective cohort study of all patients who delivered by caesarean section between December 2015 and February 2016 was conducted in the Kairouan Obstetrics and Gynaecology department. The clinical status of these women was monitored during the 30-day postoperative period (in the outpatients department, emergency room or they were contacted by phone). A multivariate logistic regression model was used to identify risk factors.
Results: Of the 714 patients admitted for caesarean delivery, 636 (89%) were monitored for 30 days. Thirty-two of these women were diagnosed with SSI, corresponding to an incidence of 5% (95% CI = 3.3%; 6.6%). 87.5% (n = 28) of SSI were superficial and 12.5% (n = 4) were complex (deep and organ/space). Multivariate logistic regression analysis identified the woman’s age as a risk factor of SSI (RR = 1.07 for every year increment, 95% CI = 1.007; 1.17), whereas drainage was identified as a protective factor (RR = 0.16, 95% CI = 0.05; 0.48).
Conclusion: This study identified the incidence and risk factors of postoperative infection following caesarean section. Prevention of these infections should be a public health priority.
Background
Surgical‐site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested.
Methods
A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time‐series regression.
Results
In a population with a mean BMI of 30 kg/m², diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound‐related rather than organ‐space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5–10) to 6 (5–9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase.
Conclusion
Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital‐wide level.
The present study is a descriptive correlational research with quantitative approach, which had as investigative question: Which is the association between potentially contaminated surgery and risk factors for infection on surgery wound, on surgical patients in a school hospital in Southern Brazil? It aimed to analyze the association between potentially contaminated surgery and risk factors for infection on a surgery wound, in surgical patients in a school hospital in Southern Brazil. The participants were 90 patients from the surgical inpatient units of a school hospital in Southern Brazil. The data collection period was from February to June 2015. Participants were interviewed daily throughout the preoperative period until their discharge. After seven days, the participant was contacted via telephone and answered a few questions about the surgical incision healing process and his/her clinical evolution. To evaluate the risk factors and wound environment infection, the researcher used four forms of interviews, composed by closed questions. The first interview and observation script intended to characterize the sample and evaluation of the clinical condition of the patient. The second script was applied during the intra-operative period in the form of non-participant observation and included questions about the surgical period. During the hospital postoperative period, the third instrument applied contained questions about the patient’s clinical condition after surgical procedure and the observation of the surgical wound infection appearance. A second telephone interview was made when the patient was home, after surgery, aiming to follow up the clinical course and detect possible surgical wound infection in this period. For organization and tabulation of the collected data, the transcript of the questionnaires was held in the database with individual spreadsheets and subsequently exported and stored for each perioperative period in the statistical package system. Initially, all variables were analyzed descriptively through simple frequency and percentage (categorical variables), position and dispersion measures (numeric variables), which were associated and assessed the level of significance and influence to the occurrence of surgical environment infection. Results revealed that the major risk factors of preoperative, intraoperative and hospital and home postoperative influential to the development of surgical environment infection were: living alone; peripheral venous line usage of antiemetic and anti-hypertensive medications; bladder catheterization delay. It was possible to observe that most infections occurred in the home period. There was a study limitation, as the data collection time was reduced, in addition to the impossibility of visiting participants at home. Despite some obstacles, the study will contribute to the knowledge expansion regarding the ISC development risk factors. It is recommended a post-discharge follow-up and monitoring of patients undergoing potentially contaminated surgeries, due to the risk for the occurrence of surgical wound infections, in addition to expanding the productions related to factors associated to this type of infection, thus promoting patient safety.
Background:
Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic.
Objectives:
To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre.
Methods:
Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables.
Main results:
We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors).
Authors' conclusions:
This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
Objective:
To evaluate the impact of postdischarge surveillance on surgical site infection (SSI) diagnosis.
Study design:
Prospective enrollment with retrospective case review SAMPLE POPULATION: Dogs and cats (n = 1271) undergoing surgery April 2012-November 2013.
Methods:
The medical record of each animal was reviewed and a 30-day follow-up questionnaire was sent to each pet owner. A standardized definition of SSI was used to identify all animals with SSI. The method of SSI detection was recorded as: re-presentation to the hospital, scheduled recheck, questionnaire, communication with the referring veterinarian, or a combination of the above.
Results:
SSI was identified in 36 (2.83%) of the 1271 animals included. All SSIs were diagnosed after discharge from the hospital. Seven of the 36 animals with SSI were diagnosed at re-presentation to the hospital, 5/36 at scheduled recheck, 10/36 on questionnaire, 10/36 at re-presentation to the hospital AND on questionnaire, and 4/36 on communication with referring veterinarian. Of the diagnosed SSIs, 72.2% were documented in the medical record. Therefore, without active postdischarge surveillance, 10/36 SSIs (27.8%) would have gone unknown to surgeons at our institution.
Conclusion:
Understanding the incidence of SSI with feedback to surgeons is an important aspect of an infection control program and has been shown to reduce SSI risks. Without active postoperative surveillance, 27.8% of SSIs would have gone unknown to surgeons. Implementing active surveillance will allow accurate reporting of incidence of SSIs in veterinary hospitals.
Background
Pregnant women are at risk of infection during labor and delivery. Infection in obstetrics accounts for the second most common cause of maternal mortality next to post partum hemorrhage. Knowing the prevalence and associated risk factors would help to undertake optimal precautions and standard surgical techniques to reduce surgical site infection which poses increased hospital cost and total hospital stay of the patients.
Method
Facility based retrospective observational study design was carried out purposively to assess the prevalence of surgical site infections and associated risk factors among mothers who had delivery related surgery at obstetric ward of Assela teaching referral hospital from April, 23, 2015 to September 5, 2015. A total of 384 women who had surgery for delivery were included in the study. The risk associated with SSIs was assessed by multivariate regression logistic analysis.
Results
The age of the women ranged from 17 to 40 years with the mean age of 26 (±5) years. The rate of surgical site infection was 9.4%(36/384). The risk factors for surgical site infection were age less than 19 (OR = 3.5, 95%CI 1.17–10.01), preterm gestation age (OR = 4.225 95%CI 1.254–14.238), duration of labor ≥24 h (OR = 2.219 95%CI1.054–4.670), duration of rupture of membrane ≥12 h (OR = 5.99, 95% CI2.75–13.02),chorioamnionitis (OR = 9.743, 95%CI 3.077–30.848), vertical skin incision(OR = 4,95%CI 1.709–13.322), pre operation Hematocrit (OR = 6.4,95%CI1.021–40.137),perioperative blood transfusion(OR = 6.75,95%CI 2.47,18.49), abdominal hysterectomy(OR = 7.9,95%CI1.698–36.960), and diabetic mellitus (OR = 3.7,95%CI 1.112–12.519).
Conclusions
Obstetric ward of Assela teaching referral hospital are encouraged to use properly WHO surgical safety checklist and examine how to sensibly integrate these essential safety steps into their normal operative workflow. Prophylactic antibiotic administration should be provided within one hour before the surgical incision or within two hours if the patient is receiving vancomycin or floroquinolones.
Background
A surgical site infection (SSI) is a frequent complication following gastrointestinal surgery, but the careful selection and administration of prophylactic antibiotics can reduce the risk. The aim of this study was to develop a package of interventions that could be used to improve surgical antibiotic prophylaxis (SAP) at our institution.
Methods
A pre-post quality improvement project at a private hospital in Saudi Arabia was conducted between January 2014 until July 2016. A multidisciplinary team was assembled to identify and overcome barriers that were responsible for patients receiving suboptimal antibiotic prophylaxis. Patients were included if they had undergone surgery on their appendix, colon, rectum, or small intestine. Compliance with use of an adapted order form, as well as appropriate antibiotic selection, dosing, timing, and timing of re-dosing, were measured. Data on the rates of SSI before and after the intervention were also obtained.
Results
Of the 269 patients included in the study, 161 (61.5%) had appendix surgery, 86 (32.8%) had colorectal surgery, and 15 (5.7%) had small bowel surgery. The surgery was performed laparoscopically in 218 (83.5%) of patients. Utilization of the adapted order form increased from 1.8% to 92.0% following the intervention (p < 0.001). Compliance with a bundle of appropriate antibiotic selection, dosing and timing improved from 47.3% to 82.2% after the intervention (p < 0.001). Additionally, there was a non-statistically significant reduction in SSI rate (9.1% vs 5.1%; p = 0.27).
Conclusions
Our quality improvement intervention was successful in improving SAP for patients undergoing gastrointestinal surgery at our institution.
Background:
Significant portions of patients undergoing colorectal surgical procedures have minor incision disturbances, yet very few meet definitions for surgical site infection (SSI). We sought to investigate the natural history of incision disturbances with a focus on the patient experience and resource utilization. We hypothesize that patients who have an incision disturbance consume frequent healthcare resources in the post-operative period despite the fact that most never receive a diagnosis of SSI.
Methods:
A 24-month prospective observational study was undertaken at an academic institution. Patients undergoing elective colorectal operation by two board-certified colorectal surgeons were followed prospectively for 90 days. Incisions were photographed serially and clinically characterized beginning as early as post-operative day two and at follow-up visits. The primary outcome was patient concern for an incision disturbance. Three surgeons reviewed clinical data and photographs to determine the presence of an incisional surgical infection, and diagnosis required agreement from two of three surgeons.
Results:
There were 171 patients included; 31 (15%) sought evaluation from a healthcare provider for concerns related to their incision including 46 telephone calls, six emergency department visits, seven primary care visits, 10 home health and 40 surgical clinic visits. Incision erythema and drainage were the most common sources of patient concern. Mean body mass index was higher in patients with concern for incision disturbances (34 vs. 28 kg/m(2), p < 0.0001). Ultimately, 8% (14/171) received a diagnosis of SSI by study criteria while only 2% (4/171) were captured as having an SSI by the institutional National Surgical Quality Improvement Program database (p < 0.0001).
Conclusions:
Patients undergoing colorectal surgical procedures commonly are concerned with post-operative incision disturbance, yet few are associated with a diagnosis of SSI, and in-person evaluation yields frequent utilization of healthcare resources. This presents an opportunity for secure electronic communication with the surgical team and the patient to potentially reduce consumption of healthcare resources.
Background:
Surgical site infections (SSI) remain a major source of morbidity and cost after resection of intra-abdominal malignancies. Negative pressure wound therapy (NPWT) has been reported to significantly reduce SSI when applied to the closed laparotomy incision. This paper reports results of a randomized clinical trial examining the effect of NPWT on SSI rates in surgical oncology patients with increased risk for infectious complications.
Study design:
From 2012-2016, 265 patients underwent open resection of intra-abdominal neoplasms stratified into three groups: gastrointestinal (n=57), pancreas (n=73), and peritoneal surface malignancy (n=135). They were randomized to NPWT or standard surgical dressing (SSD) applied to the incision from postoperative day one through four. Primary outcomes of combined incisional (superficial and deep) SSI rates were assessed up to 30 days after surgery.
Results:
There were no significant differences in superficial SSI, 12.8% vs 12.9% (p=>0.99) or deep SSI, 3.0% vs 3.0% (p=>0.99) rates between the SSD and NPWT groups, respectively. When stratified by type of surgery there were still no differences in combined incisional SSI rates for gastrointestinal, 25% vs 24% (p=>0.99), pancreas, 22% vs 22% (p=>0.99), and peritoneal surface malignancy, 9% vs 9% (p=>0.99) patients. When performing univariate and multivariate logistic regression analysis of demographic and operative factors for the development of combined incisional SSI, the only independent predictors were preoperative albumin (p=0.0031) and type of operation (p=0.018).
Conclusion:
The use of NPWT did not significantly reduce incisional SSI rates in patients having open resection of gastrointestinal, pancreatic, or peritoneal surface malignancies. Based on these results it cannot be currently recommended as a therapeutic intervention to decrease infectious complications in these patient populations.
BackgroundA surgical site infection is a substantial cause of complications in patients. Different methods are being used to decrease surgical site infections; however, these infections still can cause complications, especially in patients undergoing longer operations (> 3 hours). There is evidence that the efficacy of the scrubbing material fades after 3 hours. However, we do not know the longevity of hand cleanliness after application of scrubbing materials in a long operation. It can be postulated that if the surgeon’s scrubbed hands are recolonized after a certain time, they may serve as a progressive source of contamination during surgery. Questions/purposesWe asked: (1) Is there a correlation between surgical duration and hand contamination at the end of surgery? (2) At what point during surgery does hand contamination reach or exceed prescrub levels? Methods
Three spine surgeons using the same scrubbing technique and materials consisting of chlorhexidine gluconate 1% solution and ethyl alcohol 61% w/w were enrolled in our study. Between December 2014 and April 2015, spine procedures of 3 hours or more, which were the first case of the day, were selected for this study (20 cases). Cases in which glove changing occurred (perforations, reprepping, and redraping) or cultures obtained after scrubbing were positive (indicative of insufficient hand sanitization) were excluded (0% of cases). Twenty cases (100% enrollment) were analyzed. Surgeons’ hands were swabbed with sterile cotton tip applicators and 5 mL sterile phosphate-buffered saline before hand scrubbing (prescrub), immediately after hand scrubbing (postscrub), and immediately after surgery (postoperative). Results were reported in colony-forming units per milliliter. The correlation between duration of surgery and hand recontamination was tested by regression analysis of time versus colony-forming units per milliliter. Receiver-operating characteristic curve tested the cutoff point, where recontamination occurred. ResultsWith a longer duration of surgery, more colony-forming units are recovered from gloved hands at the end of surgery (R = 0.94, R2 = 0.89, p = 0.005). The receiver-operating characteristic curve suggested that 5 hours is the cutoff point for hand recolonization. At 5 hours, contamination reached or exceeded prescrub levels (area under the curve, 0.66; 95% CI, 0.23–1.0), whereas before 5 hours, there was no contamination detected at the end of surgery. Conclusions
Our results show that duration of surgery correlates with hand recontamination and at 5 hours, recolonization of a surgeon’s hands become detectable. Recolonization may have started even earlier than 5 hours. However, these levels are not detectable in the laboratory at earlier times. Clinical RelevanceBased on this pilot study, rescrubbing is highly recommended before the fifth hour of an operation, ideally at some point between the fourth and fifth hours. FutureWe also recommend the surgical site infection rates in operations using rescrubbing should be compared with those from surgeries with just the conventional single-scrubbing technique, in a randomized controlled trial, to determine the effectiveness of this novel rescrubbing method.
From the combination of Greek nosos (disease) with komein (to take care of) as nosokomeion (hospital) and through Latin nosocomium (hospital) comes the English nosocomial (pertaining to a hospital). Nosocomial infections, then, are infections that develop and are recognized in patients and personnel in health-care institutions. These infections are not present or incubating on admission, with the exception that a nosocomial infection may be present on admission if it is directly related to or is the residual of a previous admission. Certain nosocomial infections may not be clinically evident until after discharge. It is common to classify all other infections that fail to meet these criteria as “community-acquired” infections.
Mafraq Hospital performs an average of 10,000 surgeries every year. The impact of having high volume high risk surgical procedures calls for the need to ensure safe surgery and a prevention of surgical site infection (SSI). SSI represents a significant portion of healthcare-associated infections (HAIs). The impact on morbidity, mortality, and cost of care has resulted in identifying the need to reduce SSI as a top priority to prevent healthcare associated infections. The good news is that the majority of SSIs are preventable.
Mafraq Hospital performs a range of surgical procedures that covers 14 surgical specialties. The infection prevention and control team performs surveillance for SSI for all patients who undergo operative procedure included in Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Operative Procedure Category (40 surgical procedures). Out of the 40 CDC NHSN listed, 33 operative procedures were performed at Mafraq Hospital, of which 17 were reported with SSI for 2013 and 2014. Surgical site infection has implicated an increase average length of stay from seven to 10 additional postoperative hospital days and additional costs of AED 10,000 to AED 100,000/SSI depending on procedure and pathogen.
A multidisciplinary team was formed to develop and implement measures to reduce/eliminate surgical site infection, as well as evaluate and monitor compliance. Hence a group of multidisciplinary teams were initiated to analyse the results, find out the gaps, and implement a quality improvement project to correct the deficits. Recommendations for appropriate improvement measures were formed on evidence-based international guidelines from the Institute for Healthcare Improvement (IHI) and CDC. Evidence based practice supports that many of the causes of surgical site infection can be prevented with proper medical attention and care.
Surgical site infections (SSI) remain a major source of postoperative morbidity. The preventive effect of antimicrobial drugs on postoperative infections is without debate. The common basis of accepted indications for prophylaxis is available evidence of effect. Valid reasons to administer antimicrobial prophylaxis include a significant reduction of SSI or reducing the risk of SSI in procedures where the consequences of infection are serious or even disastrous. The antimicrobial drug must be effective against pathogens associated with infection after a given procedure. The first generation cephalosporin, cefazolin, has been considered one of the prophylactic drugs of choice in many authoritative guidelines.
The optimal timing of intravenous antimicrobial prophylaxis in surgery is considered to be about 30 minutes before incision, i.e. at induction of anaesthesia. A single dose of antimicrobial drugs before the operation is sufficient prophylaxis for most surgical procedures. The development of bacterial resistance is associated with antimicrobial use, and therefore prophylactic antibiotics should be used as little as possible; in addition, the spectrum of activity of drugs used should be as narrow as possible. Although the principles of antimicrobial prophylaxis in surgery have been clearly established, many reports continue to describe inappropriate drug use. Overconsumption in terms of invalid indications or use of drugs with too broad a spectrum of activity should be eliminated by adhering to accepted guidelines.
Practical suggestions are given to optimise timing, such as simple reminders on the daily operating programme, the display of prophylaxis regimens according to type of surgery in table format in the operating room and having the anaesthetist note the complete drug regimen on the patient’s anaesthesia record. Such measures will help to optimise antibiotic prophylaxis and restrict if to the operating room where it belongs.
We aimed to develop an effective system for surgical site infection (SSI) surveillance and examine the current domestic state of SSIs for common abdominal surgeries in Korea.
The Korean Surgical Site Infection Surveillance (KOSSIS) program was developed as an SSI surveillance system. A prospective multicenter study in nine university-affiliated or general hospitals was conducted for patients who underwent gastrectomy, cholecystectomy, appendectomy, colectomy, or proctectomy between August 16 and September 30 in 2012. Patients were monitored for up to 30 days by combining direct observation and a postdischarge surgeon survey. Data on SSIs were prospectively collected with KOSSIS secretarial support according to a common protocol. Operation-specific SSI rates were stratified according to risk factors and compared with data from the Korean Nosocomial Infections Surveillance System (KONIS) and National Healthcare Safety Network. A focus group interview was conducted with participating hospitals for feedback.
A total of 1,088 operations were monitored: 207 gastrectomies, 318 cholecystectomies, 270 appendectomies, 197 colectomies, and 96 proctectomies. Operation-specific SSI rates determined by the KOSSIS program were substantially higher than those found in KONIS (7.73% [95% confidence interval, 4.5%-12.3%] vs. 3.4% for gastrectomies, 10.15% [95% confidence interval, 6.1%-15.2%] vs. 4.0% for colectomy, and 13.5% [95% confidence interval, 7.4%-22.0%] vs. 4.2% for proctectomy).
Despite a short surveillance period and heterogenous group of hospitals, our results suggest that KOSSIS could be a useful program to enhance SSI surveillance in Korea.
Unlabelled:
The present study evaluated patients with diagnosis of surgical site infection (SSI) following cesarean section and their controls to determinate risk factors and impact of antibiotic prophylaxis on this condition.
Methods:
All cesareans performed from January 2009 to December 2012 were evaluated for SSI, based on criteria established by CDC/NHSN. Control patients were determined after inclusion of case patients. Medical records of case and control patients were reviewed and compared regarding sociodemographic and clinical characteristics.
Results:
Our study demonstrated an association following univariate analysis between post-cesarean SSI and number of internal vaginal examinations, time of membrane rupture, emergency cesarean and improper use of antibiotic prophylaxis. This same situation did not repeat itself in multivariate analysis with adjustment for risk factors, especially with regard to antibiotic prophylaxis, considering the emergency cesarean factor only.
Conclusion:
The authors of the present study not only question surgical antimicrobial prophylaxis use based on data presented here and in literature, but suggest that the prophylaxis is perhaps indicated primarily in selected groups of patients undergoing cesarean section. Further research with greater number of patients and evaluated risk factors are fundamental for better understanding of the causes and evolution of surgical site infection after cesarean delivery.
Background:
Although some recent reports have proven that incarcerated and/or strangulated hernia is not contraindication to mesh repair, there is still a common concern owing to increased rate of postoperative surgical site infection (SSI). The aim of this clinical study was to evaluate factors that increase the risk of SSI after incarcerated hernia repair, and to identify the pathogens related to SSI.
Methods:
A retrospective analysis was performed on data collected prospectively over a 4-year interval from January 2007 to December 2011. A total of 121 patients who underwent emergency surgery for incarcerated hernias were analyzed.
Results:
107 hernias were repaired using mesh versus 14 primary suture repairs. SSIs were observed in 9 of the 121 patients. Of 15 preoperative and intraoperative variables studied, duration of symptoms, diabetes mellitus, present of ileus, bowel resection or mesh repair performed, bacteria present in hernia sac and cloudy fluid in hernia sac were found to be significant factors predicting SSI. On multivariate analysis only bowel resection, duration of symptoms and bacteria present in hernia sac were independent variables. The most common pathogen found in hernia sac and cultured from wound drainage or swab was Escherichia coli. The strains of bacteria cultured from wound drainage or swab were same as those cultured from fluid in hernia sac in six of nine patients.
Conclusion:
Gut-sourced E. coli is an important common organisms associated with SSI after incarcerated hernia repair. Prosthetic mesh could be used when no bowel resection is performed, duration of symptoms less than 24 h and fluid hernia sac is clear.
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. While gastrointestinal surgery is relatively common in Korea, few studies have evaluated SSI in the context of gastric surgery. Thus, we performed a prospective cohort study to determine the incidence and risk factors of SSI in Korean patients undergoing gastric surgery.
A prospective cohort study of 2,091 patients who underwent gastric surgery was performed in 10 hospitals with more than 500 beds (nine tertiary hospitals and one secondary hospital). Patients were recruited from an SSI surveillance program between June 1, 2010, and August 31, 2011 and followed up for 1 month after the operation. The criteria used to define SSI and a patient's risk index category were established according to the Centers for Disease Control and Prevention and the National Nosocomial Infection Surveillance System. We collected demographic data and potential perioperative risk factors including type and duration of the operation and physical status score in patients who developed SSIs based on a previous study protocol.
A total of 71 SSIs (3.3%) were identified, with hospital rates varying from 0.0 - 15.7%. The results of multivariate analyses indicated that prolonged operation time (P = 0.002), use of a razor for preoperative hair removal (P = 0.010), and absence of laminar flow in the operating room (P = 0.024) were independent risk factors for SSI after gastric surgery.
Longer operation times, razor use, and absence of laminar flow in operating rooms were independently associated with significant increased SSI risk after gastric surgery.
Monitoring surgical site infection (SSI) performed during hospitalization can underestimate its rates due to the shortening in hospital stay. The aim of this study was to determine the actual rates of SSI using a post-discharge monitoring system.
All patients who underwent herniorraphy or mastectomy in the Hospital Universitario Ramón y Cajal from 1 January 2011 to 31 December 2011 were included. SSI data were collected prospectively according to the continuous quality improvement indicators (Indicadores Clinicos de Mejora Continua de la Calidad [INCLIMECC]) monitoring system. Post-discharge follow-up was conducted by telephone survey.
A total of 409patients were included in the study, of whom 299 underwent a herniorraphy procedure, and 110 underwent a mastectomy procedure. For herniorrhaphy, the SSI rate increased from 6.02% to 7.6% (the post-discharge survey detected 21.7% of SSI). For mastectomy, the SSI rate increased from 1.8% to 3.6% (the post-discharge survey detected 50% of SSI).
Post-discharge monitoring showed an increased detection of SSI incidence. Post-discharge monitoring is useful to analyze the real trend of SSI, and evaluate improvement actions. Post-discharge follow-up methods need to standardised.
Objectives
To examine the incidence of adverse events (AE) in a surgical ward.
Design
A descriptive study as the first step in a retrospective cohort study.
Study setting
General and digestive surgery ward.
Study period
1996-2000.
Data collection and inclusion criteria
Clinical data were collected from patients who had been discharged from the surgical ward, had available medical records and were aged more than 11 years old.
Measurement of result
AE were defined as an accident or incident that either caused or could cause damage and that was linked to the patient‘s characteristics or to those of the medical care.
Data sources
Minimum Basic Data Set and nosocomial infections surveillance system.
Principal findings
Specific mortality rates ranged from 1.2% in 1998 to 2.7% in 1996 and standardized mortality ratios ranged from 0.78 in 1996 to 0.32 in 2000 with statistical significance in 1998, 1999 and 2000. There were 392 cases of surgical AE between 1996 and 2000. The rate of surgical complications ranged from 8.5% in 1996 to 4.2% in 2000. In general, the surgical complications occurring among all treated episodes tended to decrease with time. According to the nosocomial infections surveillance system, the overall incidence of inpatient infections ranged from 10.9% in 1997 to 16.6% in 1999. Surgical wound infection, the most frequent infection, tended to decrease. These preliminary results, which do not represent a stable trend, indicate the possibility of strategies to identify AE and to prevent those that are avoidable.
Surveillance of wound infections has been shown to be a powerful preventive tool, and feedback to the clinical staff reduces wound infection rates. The main objectives of this study were to identify the applicability of telephone calls as a method of post-discharge wound infection surveillance, and to identify patients and procedures characteristics associated with loss for follow-up after hospital discharge.
This was a prospective cohort study conducted in Khartoum Teaching Hospital, Sudan. Patients, aged >18 years admitted for elective clean and clean-contaminated surgery during March 1st to 31st October 2010 were recruited. 1-month surveillance of wound infections was conducted with telephone interviews.
Overall 3656 patients were operated on. Of them 1769 (48.4%) were eligible {mean age 37.8+14 years; females, n=1472 (83.3%)}. The performed surgical interventions were 1814. Of these 1277 (70.4%) were clean-contaminated and 537 (29.6%) were clean. Patients who successfully completed the follow-up were 1387 (78.4%), while 368 (20.8%) were lost, and 14 (0.8%) died. The percentage of male patients (85.3%) who successfully completed the follow-up was significantly higher than females (77.8%); (P=0.002). Wound infection was detected in 15 (0.8%) cases during hospital stay and 110 (6.2%) others after hospital discharge.
The majority of wound infections in the current study appeared in post-discharge period; this emphasis the need for establishment of surveillance program in the hospital. Surveillance of wound infections using telephone calls is applicable in this setting and can be used as an alternative method to clinic-based diagnosis of wound infections.
Objectives: To know the rate of nosocomial infections in open prostate surgery and to assess the application of pre-surgery preparation and preoperative antibiotic prophylaxis protocols at three public hospitals in the Autonomous Community of Madrid. Materials and methods: Prospective observational and multicentre study, including all the patients operated on at the services monitored and admitted for more than 48hours between 1 January and 31 December 2009. They were monitored from admittance until their discharge. Results: The rate of hospital infection observed was 3.38%. The most frequent infection was surgical localization, with an incidence rate of 2.77% (superficial=1.23%; deep=0.31%; organ-space=1.23%). The percentage of appropriate surgical prophylaxis, both in the indication and in the selection of antibiotics, initiation and duration, with respect to all those patients that received it, was 47.42%. According to the data obtained from their clinical records, the percentage of patients in which the pre-surgery preparation protocol was correctly complied with, was 92%. Conclusions: The results obtained in this multicentre study can serve not only as a reference to other public hospitals, but they are also comparable to other international monitoring systems. Monitoring and controlling infections associated with healthcare must be a key aspect in Patient Care and Safety programmes.
The term “nosocomial” is derived from the combination of Greek nosos (disease) with komein (to take care of) as nosokomeion (hospital) and the Latin nosocomium (hospital). Nosocomial infections, then, are infections that develop and are recognized in patients and personnel in hospitals.
These infections are not present or incubating on admission, with the exception that a nosocomial infection may be present
on admission if it is directly related to or is the residual of a previous hospitalization. The reader may note that the title
of this chapter has changed in a small but important way from the prior edition. We have acknowledged substantial changes
in the field by revising the title from focusing on “nosocomial” infections to “healthcare-acquired” infections. As a greater
number of individuals are cared for in non-acute-care health facilities (e.g., skilled nursing facilities, long-term care
facilities) an understanding of infections in these settings is also vital.
Background
Twenty-five percent of all nosocomial infections are wound infections. Professional guidelines support the timely use of preoperative prophylaxis for prevention of postoperative wound infections. Barriers exist in implementing this practice. IPRO, the New York State peer review organization, as part of the Health Care Financing Administration's Health Care Quality Improvement Program, sought to determine the proportion of patients receiving timely antibiotic prophylaxis for aortic grafts, hip replacements and colon resections in 44 hospitals in New York State.
Methods
IPRO conducted a retrospective medical record review of 44 hospitals through out New York State stratified for teaching, nonteaching status. A sample was drawn of 2651 patients, 2256 from Medicare and 395 from Medicaid, undergoing either abdominal aortic aneurysm repair, partial or total hip replacement or large bowel resection. The study determined the proportion of patients who had documentation of receiving antibiotics and those who received antibiotics timely, that is less than or equal to 2 hours preoperatively.
Results
Eighty-six percent of patients had documentation of receiving an antibiotic. Forty-six percent of aneurysm repairs and 60% of hip replacements had evidence of receiving timely antibiotic prophylaxis, that is within 2 hours prior to surgery. For colon resections, 73% of cases had either oral prophylaxis or timely parenteral therapy. An increased proportion of patients had received parenteral antibiotics prematurely as the surgical start time occurred later in the day. A total of 44 different antibiotics were recorded for prophylaxis.
Conclusions
Antibiotic prophylaxis was performed in 81% to 94% of cases, however, anywhere from 27% to 54% of all cases did not receive antibiotics in a timely fashion. By delegating implementation of ordered antibiotic prophylaxis to the anesthesia team, timing may be improved and the incidence of postoperative wound infections may decrease.
EXECUTIVE SUMMARYThe “Guideline for Prevention of Surgical Site Infection, 1999” presents the Centers for Disease Control and Prevention (CDC)’s recommendations for the prevention of surgical site infections (SSIs), formerly called surgical wound infections. This two-part guideline updates and replaces previous guidelines.1 and 2 Part I, “Surgical Site Infection: An Overview,” describes the epidemiology, definitions, microbiology, pathogenesis, and surveillance of SSIs. Included is a detailed discussion of the pre-, intra-, and postoperative issues relevant to SSI genesis. Part II, “Recommendations for Prevention of Surgical Site Infection,” represents the consensus of the Hospital Infection Control Practices Advisory Committee (HICPAC) regarding strategies for the prevention of SSIs.3 Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, there are a limited number of studies that clearly validate risk factors and prevention measures for SSI. By necessity, available studies have often been conducted in narrowly defined patient populations or for specific kinds of operations, making generalization of their findings to all specialties and types of operations potentially problematic. This is especially true regarding the implementation of SSI prevention measures. Finally, some of the infection control practices routinely used by surgical teams cannot be rigorously studied for ethical or logistical reasons (e.g., wearing vs not wearing gloves). Thus, some of the recommendations in Part II are based on a strong theoretical rationale and suggestive evidence in the absence of confirmatory scientific knowledge. It has been estimated that approximately 75% of all operations in the United States will be performed in “ambulatory,” “same-day,” or “outpatient” operating rooms by the turn of the century.4 In recommending various SSI prevention methods, this document makes no distinction between surgical care delivered in such settings and that provided in conventional inpatient operating rooms. This document is primarily intended for use by surgeons, operating room nurses, postoperative inpatient and clinic nurses, infection control professionals, anesthesiologists, healthcare epidemiologists, and other personnel directly responsible for the prevention of nosocomial infections. This document does not:•Specifically address issues unique to burns, trauma, transplant procedures, or transmission of bloodborne pathogens from healthcare worker to patient, nor does it specifically address details of SSI prevention in pediatric surgical practice. It has been recently shown in a multicenter study of pediatric surgical patients that characteristics related to the operations are more important than those related to the physiologic status of the patients.5 In general, all SSI prevention measures effective in adult surgical care are indicated in pediatric surgical care.•Specifically address procedures performed outside of the operating room (e.g., endoscopic procedures), nor does it provide guidance for infection prevention for invasive procedures such as cardiac catheterization or interventional radiology. Nonetheless, it is likely that many SSI prevention strategies also could be applied or adapted to reduce infectious complications associated with these procedures.•Specifically recommend SSI prevention methods unique to minimally invasive operations (i.e., laparoscopic surgery). Available SSI surveillance data indicate that laparoscopic operations generally have a lower or comparable SSI risk when contrasted to open operations.6, 7, 8, 9, 10 and 11 SSI prevention measures applicable in open operations (e.g., open cholecystectomy) are indicated for their laparoscopic counterparts (e.g., laparoscopic cholecystectomy).•Recommend specific antiseptic agents for patient preoperative skin preparations or for healthcare worker hand/forearm antisepsis. Hospitals should choose from products recommended for these activities in the latest Food and Drug Administration (FDA) monograph. 12
To predict the likelihood that a patient will develop a surgical wound infection from several risk factors, the authors used information collected on 58,498 patients undergoing operations in 1970 to develop a simple multivariate risk index. Analyzing 10 risk factors with stepwise multiple logistic regression techniques, they developed a model combining information on four of the risk factors to predict a patient's probability of getting a surgical wound infection. Then, with information collected on another sample of 59,352 surgical patients admitted in 1975-1976, the validity of this index as a predictor of surgical wound infection risk was verified. With the simplified index, a subgroup, consisting of half the surgical patients, can be identified in whom 90% of the surgical wound infections will develop. By the inclusion of factors measuring the risk due to the patient's susceptibility as well as that due to the level of wound contamination, the simplified index predicts surgical wound infection risk about twice as well as the traditional classification of wound contamination (Goodman-Kruskal G = 0.67 vs. 0.36, p less than 0.0001). Use of this new index might substantially increase the efficiency of routine surgical wound infection surveillance and control.
• The influence of preoperative shaving v clipping on wound infection rate was studied in 1,013 patients undergoing elective operations at a single hospital. Patients were prospectively randomized to be either shaved or clipped the night before or the morning of operation. The AM clipper method was associated with significantly fewer infections than were the other methods, both at discharge and at 30-day follow-up. The greatest benefit was in the group with clean wounds. For each 1,000 patients treated, a savings of approximately $270,000 could be realized If the AM clipper method replaced shaving for preoperative hair removal. Preoperative shaving is deleterious, and the practice should be abandoned.
(Arch Surg 1983;118:347-352)
In the last year, the Centers for Disease Control (CDC) published a loose-leaf manual, Guidelines for the Prevention and Control of Nosocomial Infections . One copy of the manual was sent to each hospital in the United States. Persons wanting additional copies were instructed to order them through the National Technical Information Service. In addition, the text of the manual was published in the March/April 1981, issue of INFECTION CONTROL.
The manual contained the first of several guidelines that CDC is to publish for prevention of nosocomial infections. CDC is not presently prepared to distribute these guidelines to all U.S. hospitals, but expects to be able to do so within the next 12 months.
A categorization scheme has been used to rank each of the recommendations in the guidelines. A full explanation of the scheme is in the manual and in the March/April 1981, issue of this journal.
Two hundred and fifty patients were admitted to a prospective randomized trial of single dosage prophylaxis against wound infection after appendicectomy. There were 12 exclusions, 72 patients received placebo, 81 received 600 mg i.m. clindamycin phosphate and 85 received 1 g i.m. cefazolin sodium, the agent being given in the anaesthetic room. Clindamycin produced a significant reduction in the overall rate of wound infection from 33 per cent in the controls to 17 per cent. In cases with a gangrenous or perforated appendix the infection rate in controls was 78 per cent; this was reduced to 44 per cent by a single dose of clindamycin.
Cefazolin significantly reduced the number of aerobic organisms isolated from wound infections, but did not significantly reduce the incidence of wound infection. We conclude that anaerobic organisms are more important than faecal aerobic organisms in the pathogenesis of wound infection after appendicectomy.
In a prospective, randomized trial metronidazole was found to be significantly better than povidone-iodine in reducing the incidence of wound infection after appendicectomy (P less than 0.005). The metronidazole was given as a established 7-day course. Over 65 per cent of the wound infections presented after the patients had been discharged from hospital.
Intensive surveillance for postoperative wound infections was conducted for one month on three separate occasions at the Veterans Administration Hospital, West Haven, Connecticut. The mean wound infection rates for clean, clean-contaminated, contaminated, and dirty wounds were 6, 11, 17 and 18%, respectively. During the second survey, the clean-contaminated rate was 25% and was significantly higher than at other periods (p less than 0.05). Most of these infections occurred on a single surgical subspecialty service. The methods used to conduct intensive wound surveillance and the need for close liaison between the infection control team and the surgical service is emphasized. Current problems with wound surveillance are reviewed.
A prospective wound surveillance program (47,917 wounds studied) proved valuable in determining the factors responsible for infection, the operations at risk, and the influence of variables. Because the rate of infection in clean wounds is the most sensitive indicator of surgical technic, it is a useful method of quality control.
A new system of surveillance is described for detecting hospital-aquired infections. Surveillance begins on the ward where a weekly review of the nursing care plan (Kardex) is used to select high risk patients (approximately 65% of the total population) for a subsequent chart review. A nurse-epidemiologist required 16-25 hr per week to perform surveillance and 4 more hr to organize line listings of infected patients. The Kardex review was 82 to 94 percent accurate in detecting nosocomial infections when compared to prospective reviews of the charts of all hospitalized patients. The new surveillance method was more accurate than a system based on weekly chart reviews of all patients receiving systemic antibiotics and/or of all patients with fever (temperature less than or equal to 37.8 C orally). In addition, it was more accurate and offered advantages over a system in which surveillance depended primarily on the bacteriology laboratory. Over a 12-month period 1154 hospital-acquired infections were identified for a 7% annual infection rate. Data from ongoing surveillance are used to record accurate infection rates by service, to define the risk of various hospital procedures, and to monitor for common source outbreaks of infection.
If nosocomial infections are to be used as clinical indicators of quality, their definitions must be accurate. To assess validity and reliability of definitions of nosocomial infection, a study was conducted in two groups of U.S. hospitals. Group A consisted of a stratified, random sample of 715 hospitals and excluded those that are part of the National Nosocomial Infections Surveillance System. The 112 NNIS hospitals were surveyed separately in group B. Both groups used the same instrument, consisting of 36 case studies simulating patients' charts. Content and construct validity were formally tested and demonstrated. Six case studies were presented for each of the four major NI sites and for community-acquired or no infection. The pooled hospital response was 48% (396/827). The pooled number of individual responders whose data were used in the analysis was 469. Their overall mean score was 84%, and the score for correctly identifying any NI was 83%. Both groups were best at identifying urinary nosocomial infections (Group A = 92%, Group B = 93%) and poorest for no infection (Group A = 62%, Group B = 75%). Group A responders had significantly higher scores if they were certified, had a baccalaureate or higher degree, had taken a formal infection control course, had worked in infection control for greater than or equal to 2 years, or had worked full time in infection control in a greater than or equal to 200-bed hospital that was affiliated with a medical school (all p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
At the time of follow-up wound inspection or suture removal, 433 patients were questioned about signs of wound infection. Patients' answers were compared to evaluations by medical examiners. Patients frequently failed to recognize infection and signs of inflammation. When asked if wound infection was present, patients' false positive diagnostic rate was only 8%, but the false negative diagnostic rate was 48%. Medical examiners diagnosed wound infection in 21 wounds, and patients correctly identified their infections in only 11 of these cases. These results indicate that for the population studied, patients cannot be expected to recognize infection in their own wounds using verbal or printed instructions. Clinical investigators of wound healing should not use patient-reported data about wound infection that is obtained by telephone interview or other means.
All skilled nursing facilities (SNFs) in Connecticut were surveyed and more than 71% responded to a Centers for Disease Control-funded project, a component of which is reported herein. The study describes the infection control practitioner (ICP), assistance provided ICPs from external sources, and infection control committees. Almost all ICPs received some training in infection control and worked in the field for an average of 3 1/2 years. Both the number of hours devoted to infection control and the percentage of time spent by the ICP on infection control activities increased with the size of the facility. More than one half of the ICPs in SNFs have relationships with hospital ICPs. The majority of SNF infection control committees met quarterly. The chairperson most often was a physician, although ICPs held this office in almost one third of the reporting SNFs. We conclude that ICPs in Connecticut SNFs have increased in number and that they devote more time and effort to infection control than in previous years.
The moderator for this discussion was Robert E. Condon, MD, from Milwaukee, and the panelists were Robert W. Haley, MD, from Dallas; James T. Lee, Jr, MD, PhD, from Minneapolis; and Jonathan L. Meakins, MD, from Montreal.
Dr Condon: The issue is whether present methods of hospital epidemiology really have an impact on surgical wound infections and other surgically related infections. Inother words, do our present methods of "infection control" work effectively in controlling surgical infections, in deriving reliable data, and in informing the surgical staff? I think the answers to these questions are largely negative.
The panelists are a distinguished group, an epidemiologist and two surgeons with special interest and expertise in this arena. The first panelist is Robert W. Haley, MD, associate professor of medicine and epidemiology at the University of Texas Southwestern Medical School in Dallas. He formerly was director of the Hospital Infection Program of the
A mathematical model for predicting the risk of acquisition of postoperative wound infection in individuals or groups of patients is described. It is based on data from prevalence surveys of 41 hospitals and includes 1980 wounds. The factors included in the model, i.e., age, sex, length of pre-operative stay, type of operation, wound drainage, number of occupied beds in ward, and special factors, e.g., diabetes, steroid therapy, were obtained by stepwise regression analysis of the original data. Most of the ward facilities and practices were excluded as non-significant. The model has been modified for use with incidence studies and its accuracy confirmed in a further 1331 patients by comparing predicted and recorded infection rates.
At the conclusion of 817 abdominal operations, duplicate swabs were taken from the subcutaneous tissues for microbiological examination; one swab was transported to the laboratory in Stuart's thioglycollate medium and the other immediately incubated in Robertson's cooked meat broth. The latter method resulted in significantly more isolations of potentially pathogenic bacteria than the former, (31% compared with 17%, P less than 0.001). Immediate culture in broth with subsequent subculture allowed more accurate prediction of patients at risk of wound infection; using this method we found a 1:3 likelihood of wound infection with a 5% chance of severe infection when a single pathogenic species was cultured, and a 1:2 likelihood of wound infection with a 10% chance of severe infection when two or more pathogenic species were cultured. Transport of swabs in thioglycollate medium, in contrast, detected fewer patients with parietal contamination and showed a 1:5 likelihood of wound infection when the swab was sterile and a 1:2 chance when one or more than one pathogenic species was cultured.
This prospective study of 238 patients undergoing colorectal operations attempted to identify the risk factors for intraoperative bacterial contamination and postoperative infection. The degree of contamination was assessed by the recovery of Enterobacteriaceae spp. or Staphylococcus aureus in peritoneal irrigation fluid using dip-slides. Uni- and multivariate analyses comprised 17 parameters. Intraoperative contamination was strongly associated with postoperative infection (P less than 0.001). Abdominal drains were correlated with contamination (P = 0.019), but not with infection. Decompressive colostomy was over-represented in patients with contamination (P less than 0.001) but contributed to infection independent of its association with contamination (P less than 0.05), as did advanced age (P less than 0.05).
We surveyed 53 randomly chosen Maryland nursing homes for infection control policies and practices. The majority had written infection control policies, an infection control committee, and a designated practitioner for infection control; in most facilities, however, the infection control practitioner had other major duties, spent little time on infection control, and had no specific training in the field. Thirty-four percent of homes in the survey performed routine environmental cultures, and more than half had insufficient or no isolation policies for infected decubiti and acute diarrhea. In general, the intensity of infection surveillance and the extent of infection control measures increased with the level of care provided, from domiciliary homes to homes providing chronic care. Employee health care fared generally well: 60% of homes offered influenza vaccine to employees and 66% had restriction policies for employees with upper respiratory infections. While the majority of homes offered the influenza vaccine to residents, acceptance of other vaccines recommended for the elderly was less widespread. We conclude that infection control efforts are made in most Maryland nursing homes; however, appropriate guidelines and more effort to educate nursing home personnel in proper infection control practices are badly needed.
• We estimated costs of major postoperative infections (wound infection, 1.2%; bacteremia, 0.2%; pneumonia, 0.9%; and symptomatic urinary tract infection, 0.2%) in patients with common elective operations done in 22 community hospitals during 1985 to mid-1987 by review of 3936 medical records randomly drawn from 17500 postoperative patients. Calculations based on observed rates of major infection by class of operation and hospitalization days beyond diagnosis related group assignments assumed that daily costs for infection management would be 13230 to 480 to $4455 for cholecystectomy, hysterectomy, and transurethral prostatectomy. Determination of infection surveillance and control priorities should include consideration of differences in prolongation of hospitalization among various operations by similar infections.
(Arch Surg 1988;123:1305-1308)
tion of the report: how frequently the hospitals reported such rates, what mechanisms they used to report the information, and what kinds of surgery and surgeons were covered. In addition, it is important to remember that there were many exclusions from the SENIC "universe" of hospitals and patients.2 All federal, state, and municipal hospitals were excluded, thus excluding many medical school hospitals and all Veterans Administration hospitals. Also excluded were all single specialty and children's hospitals, as well as all hospitals in Alaska, Hawaii, and those with less than 50 beds. Many surgical procedures and patients were excluded as well. None of the surgical specialties were included in the data base. Only cardiac, thoracic, and abdominal surgery, including ceasarean sections, were reviewed. These exclusions and processes suggest that the above SENIC interpretation of surgeon-specific wound infection rates has limited applicability. Furthermore, a follow-up survey several years later of the hospitals involved in this project showed that very few had adopted surgeon-specific wound infection rates.9 Several other studies have suggested a drop of surgical wound infection incidence-especially in the clean surgery categories-after surgeon-specific wound infection rates were introduced.3-s None of these studies had a concomitant prospective control. Most were done in a milieu where numerous other changes, such as introduction of intensive surveillance of wound infections, discontinuance of preoperative shaving of hair, changes in skin preparation, and changes in patterns of use of prophylactic antibiotics, were being made to control surgical wound infections at the same time. The lack of concurrent controls is important because it makes it difficult to ascertain the real reason for the decline in rates. The National Nosocomial Infection Control Study (NNIS) from the Centers for Disease Control (CDC) has shown a temporal decline in surgical wound infection rates during the same period when most of these studies were being done,'0 and the CDC's own follow-up survey of hospitals shows that less than 13% were calculating surgeon-specific wound infection rates.9 In reports from centers where active research protocols were being used to follow surgical wound infections prospectively, it is possible that at least some of the apparent reduction in infection rates may have been caused by a Hawthorne effect."
Shorter lengths of hospitalization may result in more surgical wound infections being documented after hospital discharge. The current investigation analyzed 1644 surgical procedures performed over a 3-month period, and documented surgical wound infections both before and for 1 month after hospital discharge. Physician and patient questionnaires were used. One hundred eight infections were noted, of which 50 (46%) were seen after hospital discharge by either the patient or the surgeon. Rates of infection were 5.2%, 7.5%, and 7.5% for clean, clean-contaminated, and contaminated-dirty categories, respectively. Had postdischarge surveillance not been used, rates would have appeared to be 2.5%, 6.5%, and 6.8% for the same surgical classes. Infections following clean and clean-contaminated procedures were more likely to be noticed after hospital discharge. Excluding those that were patient-documented, wound infection rates would have been 4.2% (clean), 6.3% (clean-contaminated) and 6.8% (contaminated-dirty). Postdischarge surveillance is imperative to meaningfully document true rates of surgical wound infection, inasmuch as increasing numbers are likely to occur only after patients leave the hospital.
In May 1986, a group of individuals with experience in the field of infection control in long-term care met to discuss several aspects of infection prevention and control in nursing homes. This article provides background information, along with points of general consensus among the group. The consensus items are also intended to stimulate further discussion and research in the field of infection prevention and control in long-term care facilities.
A one-year prospective study of surgeon-specific nosocomial infection rates was done in two community hospitals. Hospital A (93 beds) and Hospital B (158 beds) have nearly identical surgical staffs. Unified criteria for the diagnosis of infections, methods of data collection, and coding were used. Data were processed with an IBM 370 computer using Statistical Analysis System (SAS). Each surgeon received semiannual reports of 1) overall infection rate by site, 2) number of surgical wound infections by wound class and type of procedure, 3) pathogens for each deep and incisional infection, and 4) quarterly wound infection rates by wound class. Analysis of reports revealed high Class I surgical wound infection rates for both general and orthopedic surgeons. One person in each group had inordinately high infection rates. These data serve as an objective incentive to reduce surgical wound infections, identify individual problems, and suggest surgical privileges be evaluated by performance.
In a prospective study of 1,009 adult patients undergoing elective cardiac surgery at The Johns Hopkins Hospital, we determined
the association between a variety of preoperative and operative parameters and the risk of postoperative sternal- or mediastinal-wound
infection. Of the parameters reflecting nutritional state, only one, reduced level of albumin in serum, was significantly
associated with sternal- or mediastinal-wound infection by univariate analysis. The final multiple logistic regression analysis
indicated that four variables were significant (P < .05) independent predictors of sternal- or mediastinal-wound infection: obesity (relative odds = 3.8; 95% confidence limits
= 1.9–7.5), diabetes mellitus (relative odds = 2.6; 95% confidence limits = 1.4–4.8), length of hospital stay before surgery
greater than five days (relative odds = 2.0; 95% confidence limits = 1.2–3.5), and current cigarette smoking (relative odds
= 1.8; 95% confidence limits = 1.1–3.1). Of these variables, perhaps only smoking will lend itself routinely to attempts at
intervention.
To assess the scope of infection control programs in extended care facilities, 1-day surveys were conducted in 12 North Carolina facilities over an 8-month period using a standardized questionnaire. All 12 facilities had a designated infection control practitioner (ICP), although none had attended an infection control education course. Eleven had an Infection Control Committee of which 8 (73%) met regularly. The Director of Nurses generally (58%) was the ICP and spent about 2 hr/wk on infection control. Ten (83%) facilities conducted infection surveillance among residents but did not accurately compute nosocomial infection rates. Eleven (92%) facilities had employee health programs that included preemployment and annual tuberculosis screening. None had a comprehensive resident health program. Infection control aspects of patient care practices often varied from facility to facility. Nosocomial infection surveillance among 336 residents in 9 facilities using modified CDC criteria revealed an overall prevalence rate of 5.4%. Additional infections were suspected but not included because of limitations of laboratory data and chart documentation.
Because infection is a major cause of hospitalization among nursing home residents, we assessed infection control activities and related employee health policies in Minnesota nursing homes, using a questionnaire. The majority of institutions (378/440, 85.9%) responded. We found traditional isolation techniques were widely used, but blood and urine precautions were employed in less than half of the homes. Infection surveillance tended to focus on chart review. Antibiotic utilization studies were done in 76% of homes. Procedures for urinary catheter care were often at variance with current recommendations. Employee health policies required a physical examination of a new employee in a minority of institutions. Policies required by Minnesota statute (eg, skin testing for tuberculosis and documentation of employee illness) were carried out by most institutions. Infection control policies and procedures in nursing homes should be redefined so that, where appropriate, they are more consistent with practices in acute-care hospitals.
To determine the efficacy of perioperative cefazolin in preventing pelvic and wound infections after elective non-radical hysterectomy, a randomised, placebo-controlled, double-blind clinical trial was done. Among 86 patients undergoing vaginal hysterectomy, those who received three perioperative 1 g doses of cefazolin (44) had significantly fewer pelvic infections (21% vs. 2%); less standard febrile morbidity (31% vs. 14%); shorter length of stay (LOS); and fewer courses of antibiotics postoperatively. There was no reduction in rate of urinary-tract infection (UTI) (21% vs. 23%). Among 429 women having abdominal hysterectomy, the 206 who received cefazolin had significantly lower rates of wound and pelvic infections (21% vs. 14%), UTI (21% vs. 9%), and febrile morbidity (20% vs. 14%). They also had shorter LOS and received fewer courses of antibiotics postoperatively. Use of perioperative cefazolin was not accompanied by more side-effects. Three doses of perioperative cefazolin seem to be safe, efficacious, and cost-effective in preventing infection after vaginal or abdominal hysterectomy.
Several facts emerge from this review of infection surveillance programs in ambulatory surgery units. The overall infection rate seems acceptably low - in most cases appreciably less than 1%. When postoperative infections do occur, they seem to be minor in nature. Questionnaires directed to patients postoperatively appear to provide adequate quality assurance of care in ambulatory surgery. However, intermittent use of questionnaires might conceivably permit an outbreak of infection to continue undetected for up to a month. Thus it would appear prudent that periodic questionnaires be supplemented with regular telephone surveys of patients to provide optimum protection.
The overall objectives for implementing an infection control program are to make hospital personnel aware of nosocomial infections and to educate these persons in their role in decreasing the risk of these infections. The infection control practitioner (ICP) implements these objectives by performing surveillance to determine problem areas and by developing policies and procedures that prevent and control nosocomial infections. Appropriate qualities for an ICP include initiative, leadership, communication skills, commitment, and charisma. Expertise in patient care practices, aseptic principles, sterilization practices, education, research, epidemiology, microbiology, infectious diseases, and psychology are acquired skills. Local, state, and national organizations, as well as universities, are responsible for ICP training, In the US the Centers for Disease Control have established a training program for the beginning ICP and the Association of Practitioners in Infection Control (APIC) has developed a study guide for developing infection control skills. The ultimate responsibility for education is an individual obligation, however. Certification of the ICP would insure a minimum level of knowledge, thereby standardizing and upgrading the practice of infection control.
Prophylactic metronidazole was compared with no treatment in a randomly allocated study of patients undergoing appendicectomy. A 1-g suppository of metronidazole was given with the premedication and 200 mg t.d.s. orally for 7 days thereafter.
There were 4 hospital wound infections in the 87 patients receiving metronidazole and 11 out of 83 in the no-treament group (P < 0·05). However, 60 per cent of wound infections occurred at home and the overall infection rates were not significantly different.
The duration of postoperative hospital stay was longer in the control group (5·8 days ± 3·0 s.d.) than in the treated group (4·8·2·3; P < 0·01).
Only one anaerobic infection occurred in a patient receiving metronidazole but late infection was not prevented. Blood levels of metronidazole taken at the end of operation showed a wide variation but there was no correlation with subsequent infection. Culture of the appendix showed aerobic organisms in 88 per cent of cases and anaerobes in 72 per cent.
It is suggested that an antibiotic which is effective against both aerobic and anaerobic organisms might have an advantage over metronidazole in appendicitis.
To compare nosocomial infection rates estimated in different time periods or in different hospitals, it is necessary to control for differences in the distribution of factors that substantially influence a patient's susceptibility to infection. To evaluate the associations of multiple risk factors with the occurrence of infection at each of four major sites and to develop composite measures for use in controlling for differences in the distribution of risk among groups of patients, we used a multivariate categorical data analysis technique to study the infection experience of 169,518 patients admitted in 1970 to the 338 hospitals studied in the Study on the Efficacy of Nosocomial Infection Control (SENIC, Project). The relative importance of risk factors and their complex interactions varied by site. The factors found to be highly important for one or more sites were duration of urinary catheterization, the patients' intrinsic risk as reflected in their diagnoses and types of surgical procedures, duration of preoperative hospitalization, duration of operation, anatomic location of surgical procedure, previous infection and steroid or immunosuppressive therapy. Site-specific risk strata and estimates of each patient's probability of acquiring infection were developed from these data for use in future SENIC analyses.
We performed one-day surveys in seven skilled-care nursing homes in order to evaluate their infection-control policies and to determine the prevalence of infections among their residents. Infection-control programs were not well developed at any of the home surveyed. We noted high patient-to-staff ratios, staffing by nonprofessional personnel, frequent job turnover, infrequent compensation for employee sick leave, and no general policies on immunization of patients or staff. The prevalence of infections among 532 patients was 16.2 per cent. Infected decubitus ulcers, conjunctivitis, symptomatic urinary-tract infections, and lower-respiratory tract infections were the most common types. Eight-five per cent of patients with indwelling urinary catheters had asymptomatic bacteriuria; many were colonized with antibiotic-resistant bacteria. Clustering of cases of upper-respiratory tract infections, diarrhea, conjunctivitis, and specific types of bacteriuria suggested that localized out-breaks of infectious occurred frequently. The high prevalence of infectious diseases and clustering of cases may reflect an increased susceptibility of patients in nursing homes to infections, high employee turnover, or lack of attention to infection-control practices.
Effectiveness of an infection control course for long-term care facility nurses
- Daly
- Pb
- Pw Smith
Daly PB, Smith PW, Rusnak P. Effectiveness of an infection control course for long-term care facility nurses [Abstract]. Third international conference on nosocomial infections.