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Reducing Surgical Site Infections by Bundling Multiple Risk Reduction Strategies and Active Surveillance

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Abstract

Postoperative surgical site infections (SSIs) are serious health care-associated infections that contribute to higher rates of mortality. Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of SSIs. A quality improvement intervention was developed to identify surgical patients with nasal colonization of MRSA, treat them with mupirocin, and introduce a new preoperative skin antisepsis protocol using 2% chlorhexidine gluconate cloths. The total number of SSIs was reduced by 63%, and MRSA SSIs decreased by 78%. Preoperative MRSA screening and treatment and the preoperative skin antisepsis protocol were smoothly integrated into the facility workflow and well accepted by patients. This intervention saved two community hospitals an estimated $240,000.

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... 39,40 Therefore, detection of MRSA colonization may benefit both the colonized patient and other hospitalized patients located near the MRSAcolonized patient. Increasingly, data show that, when AST is combined with placing identified MRSA-colonized or -infected patients in contact isolation (>90% of our respondents report they do this) and performing hand hygiene and environmental cleaning (with or without decolonization), together known as active detection and isolation or ADI, MRSA-infection rates have been documented to be significantly reduced in ICU patients, 15,19,41,42 a variety of surgical populations, 22,[43][44][45][46][47] or even hospital-wide in hospitals with endemic MRSA. 15,17,21,[48][49][50][51][52][53][54][55] In addition, a variety of economic models has documented the value of AST in hemodialysis patients, 56 cardiac surgery patients, 57 or vascular surgery patients. ...
... This includes conducting a risk assessment to identify patients at risk for MRSA colonization or infection; obtaining AST to identify the MRSA reservoir upon admission; placing MRSApositive patients in contact isolation; reinforcing the importance of hand hygiene, including before and after contact with the MRSApositive patient or their potentially contaminated environment; and reinforcing the importance of environmental cleaning. Through such comprehensive control measures, we believe that US health care facilities can be successful in controlling MRSA 15,17,[19][20][21][22][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55] and that future periodic national MRSA prevalence surveys will continue to document further decreases in MRSA infections in US health care facilities. ...
Article
Methicillin-resistant Staphylococcus aureus (MRSA) remains one of the most prevalent multidrug-resistant organisms causing health care-associated infections. Limited data are available about how the prevalence of MRSA has changed over the past several years and what MRSA prevention practices have been implemented since the 2006 Association for Professionals in Infection Control and Epidemiology, Inc, MRSA survey. We conducted a national prevalence survey of MRSA colonization or infection in inpatients at US health care facilities. The survey was developed, received institutional review board approval, and then was distributed to all US Association for Professionals in Infection Control and Epidemiology, Inc, members. Members were asked to complete the survey on 1 day during the period August 1 to December 30, 2010, reporting the number of inpatients with MRSA infection or colonization and facility- and patient-specific information. Personnel at 590 facilities indicated a state and responded to the survey. All states were represented, except for Alaska and Washington, DC (mean, 12 facilities per state; range, 1-38). Respondents reported 4,476 MRSA-colonized/infected patients in 67,412 inpatients; the overall MRSA prevalence rate was 66.4 per 1,000 inpatients (25.3 infections and 41.1 colonizations per 1,000 inpatients). Active surveillance testing was conducted by 75.7% of the respondents; 39.6% used nonselective media, 37.2% used selective media, and 23.3% used polymerase chain reaction. Detailed data were provided on 3,176 MRSA-colonized/infected patients. Of those in whom colonization/infection status was reported (1,908/3,086 [61.8%] were MRSA colonized and 1,778/3,086 [38.2%] were MRSA infected), most MRSA-colonized or infected patients (78.3%) were detected within 48 hours of admission; the most common site of infection was skin and soft tissue (42.9%); and, using the Centers for Disease Control and Prevention's definitions, approximately 50% would be classified as health care-associated infections. Our survey documents that the MRSA prevalence in 2010 is higher than that reported in our 2006 survey. However, the majority of facilities currently are performing active surveillance testing, and, compared with 2006, the rate of MRSA infection has decreased while the rate of MRSA colonization has increased. In addition, compared with 2006, the proportion of MRSA strains recovered from MRSA-colonized/infected patients that are health care-associated strains has deceased, and community-associated strains have increased.
... 7 Surgical site infections are devastating for patients and their families and greatly affect the morbidity and mortality rates of surgical patients. 4,[7][8][9] An individual's likelihood of hospital readmission is two to five times greater with the occurrence of an SSI, 2,3 and his or her risk of dying is 11 times greater. 5 A common source of SSI is the patient's own flora, 1,4,6,10-12 and surgical incisions provide an opportunity to introduce extraneous microorganisms that may cause SSI in the body. ...
... These risk factors include, but are not limited to, diabetes, smoking, obesity, and alcohol consumption. 4,9 There is debate in the literature as to which surgical skin antiseptic is superior in preventing postoperative SSIs. 1,12,16,17 Research on this subject acknowledges an appropriate and effective surgical skin antiseptic plays a vital role in the prevention of devastating postoperative infections. ...
Article
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Surgical site infections (SSIs) are the most common type of health care-associated infection in surgical patients. We wanted to identify which intraoperative prep solution used in our health network for adult open abdominal surgical procedures resulted in the lowest incidence of SSI 30 days after surgery. In addition, we wanted to know specifically how parachoroxylenol compared with chlorhexidine gluconate, povidone-iodine, and 0.7% iodine and 74% isopropyl alcohol as an intraoperative prep solution. We conducted a retrospective medical record review of 162 consecutive patients ages 18 years and older who had undergone elective open abdominal procedures from December 2008 to December 2010 at four acute care community hospitals within an integrated, tertiary health network in the southeastern United States. No SSIs occurred after procedures in which parachoroxylenol intraoperative prep solution was used (n = 71), whereas five SSIs occurred after procedures in which other prep solutions (ie, chlorhexidine gluconate [no SSIs], povidone-iodine [two SSIs], and 0.7% iodine and 74% isopropyl alcohol [three SSIs]) were used (n = 91). A chi-square test indicated a significant difference in the incidence of SSIs among patients prepped with parachoroxylenol intraoperative prep solution compared to patients prepped with the other solutions.
... Active surveillance for MRSA has been studied on a wide range of surgical patients, including surgical intensive care and non-intensive care units; cardiac, vascular, orthopedic, obstetric, head and neck cancer and gastrostomy patients [14,[16][17][18]. The vast amount of the research has centered on the inpatient setting, of which a combinational or bundled approach has emerged as a superior intervention in preventing the spread of MRSA infections [14,18]. ...
... Active surveillance for MRSA has been studied on a wide range of surgical patients, including surgical intensive care and non-intensive care units; cardiac, vascular, orthopedic, obstetric, head and neck cancer and gastrostomy patients [14,[16][17][18]. The vast amount of the research has centered on the inpatient setting, of which a combinational or bundled approach has emerged as a superior intervention in preventing the spread of MRSA infections [14,18]. ...
Article
Full-text available
The Agency for Healthcare Research & Quality (AHRQ) found that Methicillin-resistant Staphylococcus aureus (MRSA) is associated with up to 375,000 infections and 23,000 deaths in the United States. It is a major cause of surgical site infections, with a higher mortality and longer duration of care than Methicillin-sensitive Staphylococcus aureus. A multifactorial bundled approach is needed to control this epidemic, with single interventions unlikely to have a significant impact on attenuating MRSA infection rates. Active surveillance has been studied in a wide range of surgical patients, including surgical intensive care and non-intensive care units; cardiac, vascular, orthopedic, obstetric, head and neck cancer and gastrostomy patients. There is sufficient evidence demonstrating a beneficial effect of surveillance and eradication prior to surgery to recommend its use on an expanded basis. Studies on MRSA surveillance in surgical patients that were published over the last 10 years were reviewed. In at least five of these studies, the MRSA colonization status of patients was reported to be a factor in preoperative antibiotic selection, with the modification of treatment regiments including the switching to vancomycin or teicoplanin in MRSA positive preoperative patients. Several authors also used decolonization protocols on all preoperative patients but used surveillance to determine the duration of the decolonization. Universal decolonization of all patients, regardless of MRSA status has been advocated as an alternative prevention protocol in which surveillance is not utilized. Concern exists regarding antimicrobial stewardship. The daily and universal use of intranasal antibiotics and/or antiseptic washes may encourage the promotion of bacterial resistance and provide a competitive advantage to other more lethal organisms. Decolonization protocols which indiscriminately neutralize all bacteria may not be the best approach. If a patient's microbiome is markedly challenged with antimicrobials, rebuilding it with replacement commensal bacteria may become a future therapy. Preoperative MRSA surveillance allows the selection of appropriate prophylactic antibiotics, the use of extended decolonization protocols in positive patients, and provides needed data for epidemiological studies.
... The varied clinical applications of chlorhexidine gluconate in total joint arthroplasty including preoperative impregnated cloth, bathing cleanser, and hand antisepsis solution are common and easy to be applied in clinical practices and also convenient to the patient. Preoperative CHG showers can effectively reduce SSIs in surgically treated cases and central line-associated bloodstream infections in comparison with those who did not use them in previous reports [34,35]. However, the efficacy of chlorhexidine-based agents in the prevention of PJI for total hip arthroplasty is still inconclusive. ...
Article
Full-text available
Periprosthetic joint infection (PJI) after total hip arthroplasty (THA) is a devastating complication. The aim of this study was to investigate whether preoperative bathing using chlorhexidine gluconate (CHG) before THA can effectively reduce the postoperative PJI rate. A total of 933 primary THA patients, with the majority being female (54.4%) were included in the study. Primary THA patients who performed preoperative chlorhexidine bathing were assigned to the CHG group (190 subjects), and those who did not have preoperative chlorhexidine bathing were in the control group (743 subjects). The effects of chlorhexidine bathing on the prevention of PJI incidence rates were investigated. Differences in age, sex, and the operated side between the two groups were not statistically significant. Postoperative PJI occurred in four subjects, indicating an infection rate of 0.43% (4/933). All four infected subjects belonged to the control group. Although the PJI cases were significantly more in the control group than in the CHG group, statistical analysis revealed no statistical significance in the risk of PJI occurrence between the two groups (p = 0.588). Preoperative skin preparation by bathing with a 2% chlorhexidine gluconate cleanser did not produce significant effects on the prevention of postoperative PJI in primary THA.
... A series of single studies [21][22][23][24][25][26] and bundled interventional studies [27][28][29][30][31][32][33] published since 2009 that address SSI risk reduction in class 1 and class 2 surgical procedures are presented in Tables 3 and 4. These studies were not considered in the CDC draft guideline. ...
... We abstracted 1 RCT study and 47 quasi-experimental studies that compared universal screening to no screening (n ¼ 3 [10][11][12], universal screening to targeted screening (n ¼ 2 10,13 ), screening of ICU patients to no screening (n ¼ 14 10,14-26 ), screening of surgical patients to no screening (n ¼ 18 [26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] ), screening of high-risk patients to no screening (n ¼ 8 [44][45][46][47][48][49][50], or screening of expanded populations to screening of limited populations (n ¼ 10 38,43,46,[51][52][53][54][55][56][57]. The 16 studies that attempted to control for confounding and/or secular trends (CCS studies) had the potential to support causal inferences about the impact of MRSA screening on health outcomes. ...
Article
Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of health care-associated infections. Although the evidence in support of MRSA screening has been promising, a number of questions remain about the effectiveness of active surveillance. We searched the literature for studies that examined MRSA acquisition, MRSA infection, morbidity, mortality, harms of screening, and resource utilization when screening for MRSA carriage was compared with no screening or with targeted screening. Because of heterogeneity of the data and weaknesses in study design, meta-analysis was not performed. Strength of evidence (SOE) was determined using the system developed by the Grading of Recommendations Assessment, Development and Evaluation Working Group. One randomized controlled trial and 47 quasi-experimental studies met our inclusion criteria. We focused on the 14 studies that addressed health care-associated outcomes and that attempted to control for confounding and/or secular trends, because those studies had the potential to support causal inferences. With universal screening for MRSA carriage compared with no screening, 2 large quasi-experimental studies found reductions in health care-associated MRSA infection. The SOE for this finding is low. For each of the other screening strategies evaluated, this review found insufficient evidence to determine the comparative effectiveness of screening. Although there is low SOE that universal screening of hospital patients decreases MRSA infection, there is insufficient evidence to determine the consequences of universal screening or the effectiveness of other screening strategies.
... 10 Several authors have suggested that preadmission showering with chlorhexidine gluconate (CHG) as part of an evidence-based interventional strategy is beneficial in reducing the risk of postoperative SSIs. [11][12][13][14][15] A mitigating factor, which effectively reduces the benefit of any patient-centric intervention, is procedural compliance or patient adherence. Factors associated with patient noncompliance include failure to understand administrative instructions, use of unfamiliar medical terminology, social isolation, language barrier, low educational level, illiteracy, and socioeconomic status. ...
Article
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Background: Surgical site infections (SSIs) are responsible for significant morbidity, mortality and excess utilization of healthcare resources. The preadmission antiseptic shower is accepted as an effective strategy for reducing the risk of SSI. The following study analyzes the benefit of an innovative electronic patient alert system (EAS) for enhancing compliance to a preadmission showering protocol with 4% chlorhexidine gluconate (CHG). Study Design: Following informed consent 80 volunteers were randomized to four CHG showering groups: A1 and A2, showered twice, A1 was prompted to shower via EAS; B1 and B2, showered three times, B1 was prompted via EAS. A2 and B2 subjects were not prompted (Non-EAS). Skin surface skin concentrations of CHG (μg/mL) were analyzed using colorimetric assay at 5 separate anatomic sites. Study personnel were blinded to the randomization code, following final volunteer processing the code was broken and individual groups analyzed. Results: Mean composite CHG skin-surface concentrations were significantly higher (p<0.007) in EAS groups A1 (30.9 + 8.8-μg/mL) and B1 (29.0 + 8.3-μg/mL) compared NEAS groups A2 (10.5 + 3.9-μg/mL) and B2, (9.5 + 3.1-μg/mL). Overall, a 66% and 67%, reduction in CHG skin surface concentrations was observed in NEAS groups A2 and B2 compared to EAS study groups. Analysis of returned (unused) CHG (mL) suggests that a wide variation in volume of biocide used per shower in all groups. Conclusions: The findings suggest that EAS was effective in enhancing patient compliance to a preadmission showering protocol, resulting in significant (p<0.007) increase in skin-surface concentrations of CHG compared to non-EAS controls. However, variation in amount of unused 4% CHG suggests that rigorous standardization is required to maximize the benefits of this patient-centric interventional strategy.
... Among the 24 non-randomised studies identified, 19 reported evidence that the use of mupirocin was effective in reducing infection. Of the seven studies performed in ICUs, six (86%) demonstrated an effect; specifically, a decrease in pneumonia and hospitalacquired S. aureus infection [59], in the overall infection rates in ICUs [50,70], in MRSA SSI and bloodstream infections (BSI) in ICUs [55], and in the overall number of MRSA infections in ICUs [80,81]. Non-controlled studies implementing decolonisation in non-ICU settings led to a decrease in overall and peristomal MRSA infections [57,76], in the incidence of S.aureus/MRSA SSI in surgical units [55,58,64,65,71,77,79], in overall S. aureus/MRSA infections in gastrointestinal surgery and orthopaedics [49,82], and in the total rate of SSI or wound infections [53,60,67]. ...
Article
Full-text available
Meticillin-resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections in Europe. Many examples have demonstrated that the spread of MRSA within healthcare settings can be reduced by targeted infection control measures. The aim of this systematic literature analysis and review was to summarise the evidence for the use of bacterial cultures for active surveillance the benefit of rapid screening tests, as well as the use of decolonisation therapies and different types of isolation measures. We included 83 studies published between 2000 and 2012. Although the studies reported good evidence supporting the role of active surveillance followed by decolonisation therapy, the effectiveness of single-room isolation was mostly shown in non-controlled studies, which should inspire further research regarding this issue. Overall, this review highlighted that when planning the implementation of preventive interventions, there is a need to consider the prevalence of MRSA, the incidence of infections, the competing effect of standard control measures (e.g. hand hygiene) and the likelihood of transmission in the respective settings of implementation. © 2014, European Centre for Disease Prevention and Control (ECDC). All rights reserved.
... Studies published since 2009 have controlled for many of the variables viewed as deficient in earlier investigations, including retrospective, sequential, and prospective cohort analyses; case-control studies; prospective observational and interventional clinical trials; and randomized clinical trials. [21][22][23][24][25][26][27][28][29][30][31][32][33] An analysis 7 of chlorhexidine gluconate skin surface concentrations found that individuals who showered using chlorhexidine gluconate, 4%, without receiving any instructions or guidance had a mean (SD) skin surface concentration of 9.9 (7.1) μg/mL; this concentration is insufficient to inhibit most documented surgical pathogens. ...
Article
Full-text available
To reduce the amount of skin surface bacteria for patients undergoing elective surgery, selective health care facilities have instituted a preadmission antiseptic skin cleansing protocol using chlorhexidine gluconate. A Cochrane Collaborative review suggests that existing data do not justify preoperative skin cleansing as a strategy to reduce surgical site infection. To develop and evaluate the efficacy of a standardized preadmission showering protocol that optimizes skin surface concentrations of chlorhexidine gluconate and to compare the findings with the design and methods of published studies on preoperative skin preparation. A randomized prospective analysis in 120 healthy volunteers was conducted at an academic tertiary care medical center from June 1, 2014, to September, 30, 2014. Data analysis was performed from October 13, 2014, to October 27, 2014. A standardized process of dose, duration, and timing was used to maximize antiseptic skin surface concentrations of chlorhexidine gluconate applied during preoperative showering. The volunteers were randomized to 2 chlorhexidine gluconate, 4%, showering groups (2 vs 3 showers), containing 60 participants each, and 3 subgroups (no pause, 1-minute pause, or 2-minute pause before rinsing), containing 20 participants each. Volunteers used 118 mL of chlorhexidine gluconate, 4%, for each shower. Skin surface concentrations of chlorhexidine gluconate were analyzed using colorimetric assay at 5 separate anatomic sites. Individual groups were analyzed using paired t test and analysis of variance. Preadmission showers using chlorhexidine gluconate, 4%. The primary outcome was to develop a standardized approach for administering the preadmission shower with chlorhexidine gluconate, 4%, resulting in maximal, persistent skin antisepsis by delineating a precise dose (volume) of chlorhexidine gluconate, 4%; duration (number of showers); and timing (pause) before rinsing. The mean (SD) composite chlorhexidine gluconate concentrations were significantly higher (P < .001) in the 1- and 2-minute pause groups compared with the no-pause group in participants taking 2 (978.8 [234.6], 1042.2 [219.9], and 265.6 [113.3] µg/mL, respectively) or 3 (1067.2 [205.6], 1017.9 [227.8], and 387.1 [217.5] µg/mL, respectively) showers. There was no significant difference in concentrations between 2 and 3 showers or between the 1- and 2-minute pauses. A standardized preadmission shower regimen that includes 118 mL of aqueous chlorhexidine gluconate, 4%, per shower; a minimum of 2 sequential showers; and a 1-minute pause before rinsing results in maximal skin surface (16.5 µg/cm2) concentrations of chlorhexidine gluconate that are sufficient to inhibit or kill gram-positive or gram-negative surgical wound pathogens. This showering regimen corrects deficiencies present in current nonstandardized preadmission shower protocols for patients undergoing elective surgery.
... Surgical site wound contaminations from the patients' native skin flora and operating room air are the most predominant proposed etiologies [4,10,23,27], thus necessitating implementation of various preventive measures [1,8,25] as well as cleansing procedures such as wipes, washes, and bathing. Although baths have been shown to be successful in reducing surgical site infections, they have been reported to be less efficient as a result of improper bathing technique, maintaining an effective cutaneous concentration, and compliance issues [4,6,11,17]. Other methods of skin preparation have included mixing solutions or using serial cleansing with antiseptic solutions for several days. ...
Article
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Background Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size. Questions/purposes(1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol? Methods In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category. ResultsUse of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9–20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1–60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5–9.6; p = 0.33] and RR, 11.3 [CI, 0.7–186.7; p = 0.09]). ConclusionsA prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study. Level of EvidenceLevel III, therapeutic study.
... There are also different alternatives for skin preparation prior to the percutaneous implantation of devices (pacemakers, endovascular foreign bodies). Although the more common preparations are the water-soluble iodophors or CHG, alcohol-based solutions in one series proved to be “quick, sustained, and durable, with broader spectrum antimicrobial therapy.”[14] When prosthetic devices were implanted, alcohol best reduced skin colony counts, thereby contributing to a greater reduction in the rates of infected instrumentation. ...
Article
Background: The rate of postoperative spinal infections varies from 0.4% to 3.5%. Although the introduction of additional preoperative, intraoperative, and postoperative methods of prophylaxis should further reduce spinal infection rates, these measures will not succeed unless surgeons are well informed of their availability, utility, and efficacy. This study provides a review of several preoperative, intraoperative, and postoperative methods of prophylaxis that could minimize the risk of postoperative spinal infections. Various preoperative, intraoperative, and postoperative measures could further reduce the risk of spinal infections. Preoperative prophylaxis against methicillin-resistant Staphylococcus aureus could utilize (1) nasal cultures and Bactroban ointment (mupirocin), and (2) multiple prophylactic preoperative applications of chlorhexidine gluconate (CHG) 4% to the skin. Intraoperative prophylactic measures should not only include the routine use of an antibiotic administered within 60 min of the incision, but should also include copious intraoperative irrigation [normal saline (NS) and/or NS with an antibiotic]. Intraoperatively, instrumentation coated with antibiotics, and/or the topical application of antibiotics may further reduce the infection risk. Whether postoperative infections are reduced with the continued use of antibiotic prophylaxis remains controversial. Other postoperative measures may include utilization of a silver (AgNO3)-impregnated dressing (Silverlon dressing) and the continued use of bed baths with CHG 4%. The introduction of multiple preoperative, intraoperative, and postoperative modalities in addition to standardized prophylaxis may further contribute to reducing postoperative spinal infections.
Article
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Seasonal Variation of Surgical Site Infections: Why Does It Occur, Why Does It Matter? - Volume 37 Issue 1 - Farrin A. Manian
Article
Preventing surgical site infection is perhaps the most direct method of decreasing medical expenses. The following is an attempt at comprehensive ways of decreasing surgical site infection as well as decreasing patient discomfort. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
The etiology of surgical site infection (SSI) is multifactorial, with efforts to combat it employing “bundled” initiatives. Preoperative antiseptic wash was classified by the Centers for Disease Control and Prevention as a Category IB strongly recommended and accepted practice. Its inclusion, in a best-practice bundle, may contribute to reduction in SSIs. We describe our quality improvement initiative to increase adherence to this critical bundle element.
Article
Background: Periprosthetic infections are devastating postoperative complications of total joint arthroplasty (TJA), with native skin flora commonly identified as causative organisms. We compared 2% chlorhexidine gluconate-impregnated cloths to standard-of-care antiseptic bathing in patients before TJA, to evaluate periprosthetic infection risk at 1-year follow-up. Methods: This was a prospective, randomized, controlled trial at a single institution of patients undergoing hip or knee arthroplasty. Chlorhexidine-treated patients (275 arthroplasties) applied 2% chlorhexidine gluconate-impregnated cloths the night before and morning of admission. The standard-of-care cohort (279 arthroplasties) bathed with soap and water preadmission. Patients were excluded according to the following: (1) unable to comply with study requirements, (2) pregnant, (3) <18 years, (4) medical history of immunosuppression or steroid use, (5) chronic hepatitis B/C infection, (6) had infection around joint requiring surgery, or (7) chose not to participate. A total of 539 patients (554 arthroplasties) were included in the final population. There were no significant differences in American Society of Anesthesiologists grade, cut time, risk scores, or diabetes and smoking prevalence between cohorts (P > .05). Results: A lower periprosthetic infection rate was found in the chlorhexidine cohort (0.4%) when compared to standard-of-care cohorts (2.9%). The infection odds ratio was 8.15 (95% confidence interval = 1.01-65.6; P = .049) for the standard-of-care cohort compared to the chlorhexidine cohort. No differences in assessed risk factors were found between groups. No severe adverse events were observed. Conclusions: Preoperative chlorhexidine cloth use decreased the risk of periprosthetic infection. This may be an appropriate antiseptic protocol to implement for patients undergoing lower extremity TJA.
Article
Many preventive methodologies seek to reduce the risk of surgical site infections after total knee arthroplasty (TKA), including the use of preoperative chlorhexidine baths and cloths. Although we have demonstrated in previous studies that this may be an efficacious method for infection prevention, our study was underpowered and we therefore set out to evaluate this with a larger sample size. (1) Does a preadmission chlorhexidine cloth skin preparation protocol decrease the risk of surgical site infection in patients undergoing TKA? (2) When stratified using the National Healthcare Safety Network (NHSN) risk categories, which categories are associated with risk reduction from the preadmission chlorhexidine preparation protocol? In our study, all patients (3717 total) who had undergone primary or revision TKA at a single institution between January 1, 2007, and December 31, 2013, were identified, of whom 991 patients used the chlorhexidine cloths before surgery and 2726 patients did not. All patients were provided cloths with instructions before surgery; however, as a result of a lack of compliance, we were able to substratify patients into treatment and control cohorts. Additionally, we substratified patients by NHSN risk category to determine differences in infection between the two cohorts (cloth versus no cloth). Patient medical records and an infection-tracking database were reviewed to determine the development of periprosthetic infection (patients who had superficial infections were excluded from our study) in both groups after 1 year surveillance. We then calculated relative risk reductions with use of chlorhexidine gluconate and stratified results based on NHSN risk category. Use of a preoperative chlorhexidine cloth skin preparation protocol is associated with reduced relative risk of periprosthetic infection after TKA (infections with protocol: three of 991 [0.3%]; infections in control: 52 of 2726 [1.9%]; relative risk [RR]: 6.3 [95% confidence interval [CI], 1.9-20.1]; p = 0.002). When stratified by NHSN risk category, periprosthetic infection risk reduction was seen in the medium-risk category (protocol: one of 402 [0.3%]; control: 25 of 1218 [2.0%]; RR, 8.3 [CI, 1.1-60.7]; p = 0.038), but no significant difference was detected in the low- and medium-risk groups (RR, 2.1 [CI, 0.5-9.6; p = 0.33] and RR, 11.3 [CI, 0.7-186.7; p = 0.09]). A prehospital chlorhexidine gluconate wipe protocol appears to reduce the risk of periprosthetic infections after TKA, primarily in those patients with medium and high risk. Although future multicenter randomized trials will need to confirm these preliminary findings, the intervention is inexpensive and is unlikely to be risky and therefore might be considered on the basis of this retrospective, comparative study. Level III, therapeutic study.
Article
The purpose of this study was to evaluate the efficacy of an advance pre-operative chlorhexidine gluconate preparation protocol on the incidence of surgical site infections following total joint arthroplasty. In our review of 4671 patients at our institution, between 2007 and 2011, we found a significantly lower incidence of periprosthetic infections in the advance preparation group (0.5% and 0.6%) when compared to patients receiving in-hospital perioperative skin preparation only (1.7% and 2.2%) following total hip and knee arthroplasty, respectively. Chlorhexidine cloths may be more efficacious than other antiseptic methods at reducing surgical site infections following lower extremity total joint arthroplasty.
Article
Chlorhexidine gluconate (CHG) has been available as a topical antiseptic for over 50 years, having broad clinical application throughout the health care environment. Evidence-based clinical studies have shown chlorhexidine gluconate to be a safe and effective perioperative skin-prepping agent. Renewed interest has emerged for use of the antiseptic bath/shower to reduce the microbial skin burden prior to hospital admission. Recent clinical studies have documented that multiple applications of 2% or 4% CHG using a standardized protocol results in high skin surface concentrations sufficient to inhibit/kill skin colonizing flora, including methicillin-resistant Staphylococcus aureus. A new focus for the use of CHG in surgical patients involves irrigation of the wound prior to closure with 0.05% CHG followed by saline rinse. Recent laboratory studies suggest that, following a 1-minute exposure, 0.05% CHG produces a >5-log reduction against selective health care-associated pathogens and reduces microbial adherence to the surface of implantable biomedical devices. General, orthopedic, cardiothoracic, and obstetrical surgical studies have documented the safety of selective CHG formulations in elective surgical procedures. The following discussion will address both the evidence-based literature and preliminary findings suggesting that CHG has a broad and safe range of applications when used as an adjunctive interventional strategy for reducing the risk of postoperative surgical site infections (SSI).
Article
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.
Article
The purpose of this study was to evaluate the incidence of surgical site infections in total knee arthroplasty patients using a preadmission cutaneous skin preparation protocol compared with a cohort of patients undergoing standard in-hospital perioperative preparation only. Records between 2007 and 2010 were reviewed to identify deep incisional and periprosthetic infections among patients using the chlorhexidine protocol (478 patients) and patients who did not use the protocol (1,735 patients). Patients using the chlorhexidine cloths were given two packets of six chlorhexidine gluconate-impregnated cloths, with instructions for use, the evening before and morning of surgery. A statistically lower incidence of surgical site infection was found in patients using the chlorhexidine cloths (0.6%) compared with patients undergoing in-hospital perioperative skin preparation only (2.2%). On the basis of the results of this study, a preadmission chlorhexidine protocol seems to be an effective method to prevent surgical site infections in total knee arthroplasty procedures.
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The purpose of this study was to evaluate the incidence of surgical site infections in total hip arthroplasty patients who used an advance pre-admission cutaneous surgical preparation protocol and to compare these results to a cohort of patients who did not use the protocol. Between 2007 and 2010, 557 patients used the chlorhexidine cloths and 1901 patients did not use the cloths. Patient records were reviewed to determine the incidence of deep incisional and periprosthetic infections. A statistically significant lower incidence of infections occurred in patients who used the chlorhexidine cloths (0.5%) when compared to patients undergoing in-hospital perioperative skin preparation only (1.7%). These results confirm prior studies suggesting this as an effective method to prevent periprosthetic hip arthroplasty infections.
Article
Showering preoperatively with chlorhexidine gluconate is an issue that continues to promote debate; however, many studies demonstrate evidence of surgical site infection risk reduction. Methodological issues have been present in many of the studies used to compile guidelines and there has been a lack of standardisation of processes for application of the active agents in papers pre-2009. This review and commentary paper highlights the potential for enhancing compliance with this low-risk and low-cost intervention and provides some guidance for enhancing implementation of preoperative showering with both chlorhexidine in solution and impregnated wipes.
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Data for 479 patients were analyzed to assess the impact of methicillin resistance on the outcomes of patients with Staphylococcus aureus surgical site infections (SSIs). Patients infected with methicillin-resistant S. aureus (MRSA) had a greater 90-day mortality rate than did patients infected with methicillin-susceptible S. aureus (MSSA; adjusted odds ratio, 3.4; 95% confidence interval, 1.5–7.2). Patients infected with MRSA had a greater duration of hospitalization after infection (median additional days, 5; P < .001), although this was not significant on multivariate analysis (P = .11). Median hospital charges were $29,455 for control subjects, $52,791 for patients with MSSA SSI, and $92,363 for patients with MRSA SSI (P < .001 for all group comparisons). Patients with MRSA SSI had a 1.19-fold increase in hospital charges (P = .03) and had mean attributable excess charges of $13,901 per SSI compared with patients who had MSSA SSIs. Methicillin resistance is independently associated with increased mortality and hospital charges among patients with S. aureus SSI.
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Asymptomatic colonization with methicillin-resistant Staphylococcus aureus (MRSA) has been described as a risk factor for subsequent MRSA infection. MRSA is an important nosocomial pathogen but has currently been reported in patients without typical risk factors for nosocomial acquisition. This study was designed to evaluate the impact of asymptomatic nares MRSA colonization on the development of subsequent MRSA infection. The incidence of MRSA infection was examined in patients with and patients without MRSA or methicillin-susceptible S. aureus (MSSA) colonization at admission to the hospital and in those who developed colonization during hospitalization. Patients admitted to 5 representative hospital units were prospectively evaluated. Nares samples were obtained for culture at admission and during hospitalization. Laboratory culture results were monitored to identify all MRSA infections that occurred during the study period and 1 year thereafter. Of the 758 patients who had cultures of nares samples performed at admission, 3.4% were colonized with MRSA, and 21% were colonized with MSSA. A total of 19% of patients with MRSA colonization at admission and 25% who acquired MRSA colonization during hospitalization developed infection with MRSA, compared with 1.5% and 2.0% of patients colonized with MSSA (P<.01) and uncolonized (P<.01), respectively, at admission. MRSA colonization at admission increased the risk of subsequent MRSA infection, compared with MSSA colonization (relative risk [RR], 13; 95% confidence interval [CI], 2.7-64) or no staphylococcal colonization (RR, 9.5; 95% CI, 3.6-25) at admission. Acquisition of MRSA colonization also increased the risk for subsequent MRSA infection, compared with no acquisition (RR, 12; 95% CI, 4.0-38). MRSA colonization of nares, either present at admission to the hospital or acquired during hospitalization, increases the risk for MRSA infection. Identifying MRSA colonization at admission could target a high-risk population that may benefit from interventions to decrease the risk for subsequent MRSA infection.
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We noted a marked increase in healthcare-associated (HA) methicillin-resistant Staphylococcus aureus (MRSA) infections caused by isolates phenotypically consistent with community-associated (CA)-MRSA strains. To study this trend, we retrospectively examined all HA-MRSA isolates from patients in our institution during 1999-2004. An isolate was considered an SCCmecIV phenotype if it had antimicrobial drug susceptibilities consistent with typical CA-MRSA isolates. Our phenotypic definition was validated in a limited subset of isolates by SCCmec genotype, pulsed-field gel electrophoresis, and multilocus sequence typing. Among 352 patients with HA-MRSA isolates, SCCmecIV phenotype increased from 17% in 1999 to 56% in 2003 (p < 0.0001). Antimicrobial drug-susceptibility phenotype and genotype were consistent in 21 (91%) of 23 isolates. In a multivariate model, the SCCmec type IV phenotype was independently associated with wound culture source, later year of collection, and MRSA isolated earlier during hospitalization. In conclusion, MRSA isolates phenotypically similar to CA strains have become the predominant isolates associated with HA-MRSA in our hospital.
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Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains are increasingly recovered from nosocomial settings. We conducted a retrospective study of surgical site infections (SSI) during 2004 and 2005 to determine the prevalence of CA-MRSA; 57% of MRSA strains tested belonged to the USA300 genotype. CA-MRSA has become a prominent cause of SSI at our institution.
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To determine whether patients bathed daily with chlorhexidine gluconate (CHG) have a lower incidence of primary bloodstream infections (BSIs) compared with patients bathed with soap and water. The study design was a 52-week, 2-arm, crossover (ie, concurrent control group) clinical trial with intention-to-treat analysis. The study setting was the 22-bed medical intensive care unit (MICU), which comprises 2 geographically separate, similar 11-bed units, of the John H. Stroger Jr (Cook County) Hospital, a 464-bed public teaching hospital in Chicago, Illinois. The study population comprised 836 MICU patients. During the first of 2 study periods (28 weeks), 1 hospital unit was randomly selected to serve as the intervention unit in which patients were bathed daily with 2% CHG-impregnated washcloths (Sage 2% CHG cloths; Sage Products Inc, Cary, Illinois); patients in the concurrent control unit were bathed daily with soap and water. After a 2-week wash-out period at the end of the first period, cleansing methods were crossed over for 24 more weeks. Main outcome measures included incidences of primary BSIs and clinical (culture-negative) sepsis (primary outcomes) and incidences of other infections (secondary outcomes). Patients in the CHG intervention arm were significantly less likely to acquire a primary BSI (4.1 vs 10.4 infections per 1000 patient days; incidence difference, 6.3 [95% confidence interval, 1.2-11.0). The incidences of other infections, including clinical sepsis, were similar between the units. Protection against primary BSI by CHG cleansing was apparent after 5 or more days in the MICU. Daily cleansing of MICU patients with CHG-impregnated cloths is a simple, effective strategy to decrease the rate of primary BSIs.
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To determine colonization rates of Staphylococcus aureus given the potential for future intervention trials aimed at reducing surgical-site infectious morbidity, and to estimate methicillin-resistant Staphylococcus aureus (MRSA) rates in our patient population. Prospective pilot investigation comprising data from 104 gravidas admitted to an urban labor and delivery unit. All underwent anterior nares culture collection with a subset also undergoing vaginal culture collection. Twenty-two percent of women were colonized in the anterior nares. Of the 28 women who had vaginal cultures collected, 4/28 (14.2%) demonstrated Staphylococcus aureus colonization. There was 82% concordance between the nares and vagina. Nine percent of isolates were MRSA strains. Overall, 2/96 (2.1%) of women were MRSA-colonized. Rates of Staphylococcus aureus colonization among gravidas entering labor and delivery are modest and consistent with the general population. MRSA rates among gravidas appear to be reassuringly low in this pilot study.
Article
Total body bathing with 'Hibiscrub' (chlorhexidine-detergent) solution was compared with non-medicated soap in 224 patients admitted for surgery. Some 9.6 per cent of patients were found to be nasal carriers of Staphylococcus aureus on admission but 17.3 per cent were colonized at some time during their inpatient stay. Skin colonization by Staph, aureus was only seen in four patients (2 per cent), three were cleared by 'Hibiscrub' bathing but carriage persisted in the other patient who used non-medicated soap. A greater reduction in the total bacterial count on the skin and in the perianal region was seen in patients using 'Hibiscrub'. An increase in the bacterial count was frequently seen in patients using non-medicated soap. Postoperative staphylococcal wound infection occurred in nine patients (4-0 per cent) but nasal or skin carriage was only present in two patients. Although there was no difference in the rates of infection using 'Hibiscrub' or ordinary soap, pre-operative bathing with 'Hibiscrub' may be beneficial as there is a greater reduction in the total bacterial count. The use of non-medicated soap is of dubious value and may even increase the numbers of bacteria on the skin.
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Obesity has long been considered a potential risk factor for poor outcome following surgical procedures. However, controversy exists regarding the clinical impact of this problem because of a paucity of data regarding the incidence and risk of nosocomial infections in obese surgical patients. This retrospective study was undertaken to compare the nosocomial infection rate in obese and normal weight surgical patients. All patients undergoing general, urologic, vascular, thoracic, or gynecologic surgical procedures between October 1 and December 31, 1991, were reviewed. Nosocomial infection data were obtained from the Department of Hospital Epidemiology. A total of 849 patients were evaluated, of which 536 (63%) were normal weight (BMI < 27 kg/m2), 175 (21%) were obese (BMI 27-31 kg/m2), and 138 (16%) were severely obese (BMI > 31 kg/m2). Age, mortality, and American Society of Anesthesia (ASA) risk scores did not differ among the three groups. There were significant increases in the number and percent of nosocomial infections in the obese populations, with rates of 0.05 per cent in normal weight, compared to 2.8 per cent and 4.0 per cent in obese and severely obese groups (P < 0.01). Infections consisted of seven wound infections, five C. difficile infections, one pneumonia, and three bacteremias. No differences in distribution between groups were evident. Mortality was similar among the groups. These data support the hypothesis that obesity is a significant risk factor for clinically relevant nosocomial infections in surgical patients.
Article
Increased antibiotic resistance of common bacteria is attributed in part to the widespread use of various antibiotic agents. Prophylactic and therapeutic antibiotic treatments are routinely used in cardiac surgical units, and it is no surprise that methicillin-resistant Staphylococcus aureus infection is becoming a major cause of surgical infections in cardiac patients. We reviewed our experience with patients who underwent cardiac surgery and experienced infection caused by methicillin-resistant Staphylococcus aureus. Between 1992 and 2000 at the Montreal Heart Institute, 39 patients had methicillin-resistant Staphylococcus aureus surgical infections, and 13,199 patients underwent cardiac surgery. The yearly incidence of methicillin-resistant Staphylococcus aureus infection, the relative risk of acute mediastinitis and of superficial wound infections or other types of methicillin-resistant Staphylococcus aureus infection episodes, and the effect of preventive measures were analyzed. The annual incidence of methicillin-resistant Staphylococcus aureus acute mediastinitis decreased from 0.37% (5/1321) of cardiac patients in 1992 and 0.44% (6/1355) in 1993 to 0% between 1994 and 1997, 0.13% (2/1528) in 1999, and 0% (0/1700) in 2000. The total incidence of methicillin-resistant Staphylococcus aureus infection, including mediastinitis, superficial and deep sternal and leg wound infection, and all systemic infection episodes ranged from 0.68% of patients in 1992 and 0.96% of patients in 1993 to 0.46% of patients in 1999 and 0.53% of patients in 2000. The relative risk of severe mediastinal methicillin-resistant Staphylococcus aureus infection to all other methicillin-resistant Staphylococcus aureus infection episodes decreased from 1.65 in 1992 to 0.41 in 1999 and 0 in 2000. Beginning in 1993, all patients given a diagnosis methicillin-resistant Staphylococcus aureus infection and all nasal carriers of methicillin-resistant Staphylococcus aureus were strictly isolated on the surgical unit, and vancomycin was used as the prophylactic antibiotic agent for cardiac surgery in these patients. Moreover, since 1998, all patients admitted in the hospital were screened, and nasal carriers were isolated and treated with topical antibiotic ointment. Mediastinal and other infections caused by methicillin-resistant Staphylococcus aureus have a significant morbidity in cardiac surgical patients. After an outbreak of methicillin-resistant Staphylococcus aureus mediastinal infections, several preventive measures to control methicillin-resistant Staphylococcus aureus contamination of surgical patients were implemented (nasal screening, preventive isolation, application of mupirocin, prophylaxis with vancomycin and alcohol gels) and were effective in decreasing the incidence of methicillin-resistant Staphylococcus aureus infection and mediastinitis after cardiac surgery.
Article
Obesity is an important risk factor for surgical site infections. The incidence of surgical wound infections is directly related to tissue perfusion and oxygenation. Fat tissue mass expands without a concomitant increase in blood flow per cell, which might result in a relative hypoperfusion with decreased tissue oxygenation. Consequently, the authors tested the hypotheses that perioperative tissue oxygen tension is reduced in obese surgical patients. Furthermore, they compared the effect of supplemental oxygen administration on tissue oxygenation in obese and nonobese patients. Forty-six patients undergoing major abdominal surgery were assigned to one of two groups according to their body mass index: body mass index less than 30 kg/m2 (nonobese) or 30 kg/m2 or greater (obese). Intraoperative oxygen administration was adjusted to arterial oxygen tensions of approximately 150 mmHg and approximately 300 mmHg in random order. Anesthesia technique and perioperative fluid management were standardized. Subcutaneous tissue oxygen tension was measured with a polarographic electrode positioned within a subcutaneous tonometer in the lateral upper arm during surgery, in the recovery room, and on the first postoperative day. Postoperative tissue oxygen was also measured adjacent to the wound. Data were compared with unpaired two-tailed t tests and Wilcoxon rank sum test; P < 0.05 was considered statistically significant. Intraoperative subcutaneous tissue oxygen tension was significantly less in the obese patients at baseline (36 vs. 57 mmHg; P = 0.002) and with supplemental oxygen administration (47 vs. 76 mmHg; P = 0.014). Immediate postoperative tissue oxygen tension was also significantly less in subcutaneous tissue of the upper arm (43 vs. 54 mmHg; P = 0.011) as well as near the incision (42 vs. 62 mmHg; P = 0.012) in obese patients. In contrast, tissue oxygen tension was comparable in each group on the first postoperative morning. Wound and tissue hypoxia were common in obese patients in the perioperative period and most pronounced during surgery. Even with supplemental oxygen tissue, oxygen tension in obese patients was reduced to levels that are associated with a substantial increase in infection risk.
Article
To examine the impact of surgical-site infection (SSI) due to Staphylococcus aureus on mortality, duration of hospitalization, and hospital charges among elderly surgical patients and the impact of older age on these outcomes by comparing older and younger patients with S. aureus SSI. A nested cohort study. A 750-bed, tertiary-care hospital and a 350-bed community hospital. Ninety-six elderly patients (70 years and older) with S. aureus SSI were compared with 2 reference groups: 59 uninfected elderly patients and 131 younger patients with S. aureus SSI. Compared with uninfected elderly patients, elderly patients with S. aureus SSI were at risk for increased mortality (odds ratio [OR], 5.4; 95% confidence interval [CI95], 1.5-20.1), postoperative hospital-days (2.5-fold increase; CI95, 2.0-3.1), and hospital charges (2.0-fold increase; CI95, 1.7-2.4; dollar 41,117 mean attributable charges per SSI). Compared with younger patients with S. aureus SSI, elderly patients had increased mortality (adjusted OR, 2.9; CI95, 1.1-7.6), hospital-days (9 vs 13 days; P = .001), and median hospital charges (dollar 45,767 vs dollar 85,648; P < .001). Among elderly surgical patients, S. aureus SSI was independently associated with increased mortality, hospital-days, and cost. In addition, being at least 70 years old was a predictor of death in patients with S. aureus SSI.
Article
Screening of potential MRSA-positive patients at hospital admission is recommended in German and international guidelines. This policy has been shown to be effective in reducing the frequency of nosocomial MRSA transmissions in the event of an outbreak, but the influence of screening on reducing hospital-acquired MRSA infections in a hospital setting where MRSA is endemic is not yet well-documented. This study describes the effect of hospital-wide screening of defined risk groups in a 700-bed acute care hospital during a period of 19 months. In a cohort study with a 19-month control period, the frequencies of hospital-acquired MRSA infections were compared with and without screening. In the control period, there were 119 MRSA-positive patients, of whom 48 had a hospital-acquired MRSA infection. On the basis of this frequency, a predicted total of 73.2 hospital-acquired MRSA infections was calculated for the screening period, but only 52% of the expected number (38 hospital-acquired MRSA infections) were observed, i.e., 48% of the predicted number of hospital-acquired MRSA infections were prevented by the screening programme. The screening programme was performed with minimal effort and can therefore be recommended as an effective measure to help prevent hospital-acquired MRSA infections.
Article
Topical antiseptics are essential for infection control. Antiseptic formulations employ a variety of mechanisms, act at various rates and persistence intervals, demonstrate various levels of toxicity, and are more or less likely to trigger resistance. The desired characteristics are considered when selecting antiseptics for hand washing, surgical scrubbing, and patient preoperative skin preparation. The selection process requires evidence of product safety and efficacy. This article explores currently available topical antimicrobial agents used in medical settings.
Article
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an important cause of staphylococcal infections, but there have been little data on whether CA-MRSA causes health care-associated infections. A case-control study was performed to identify risk factors for prosthetic joint infections (PJI). Antibiograms of isolates associated with PJI were reviewed. Molecular typing of available MRSA isolates was done using pulsed field gel electrophoresis (PFGE). Nares cultures of health care workers who provided care to those orthopedic patients were obtained. Over a 13-month period (January 2003-January 2004), 9.5% of patients with prosthetic hip (THA) or knee (TKA) joint surgery developed PJI (7 TKA and 2 THA). The mean time to development of PJI was 20 days. Five infections were caused by CA-MRSA and 3 by methicillin-susceptible S aureus; one was culture negative. All CA-MRSA isolates had identical antibiograms (resistant to beta-lactams and erythromycin; susceptible to clindamycin, trimethoprim-sulfamethoxazole, rifampin, gentamicin, levofloxacin, and vancomycin). Molecular typing of 2 available CA-MRSA isolates revealed that these were the USA300 clone; these isolates were PVL+ and carried SCCmec IV. CA-MRSA was not recovered from nares cultures from 31 health care workers. In multivariate analysis, TKA (OR, 8.1; 95% CI: 1.3-48.1) and surgery time >180 minutes (OR, 7.4; 95% CI: 1.4-39.6) were associated with PJI. We have demonstrated that the CA-MRSA USA300 clone is no longer just a cause of community-acquired infections but has also emerged as a cause of health care-associated infections, causing PJI at our institution.
Article
Staphylococcus aureus (S aureus) is the major cause of surgical site infections (SSI). At The Christ Hospital, Cincinnati, OH, S aureus accounted for over 80% of sternal wound infections in cardiac surgery patients. Approximately 700 cardiac surgeries are performed each year, with an associated infection rate of 1.8% per 100 procedures performed. In an attempt to reduce S aureus sternal wound infections, the use of prophylactic intranasal mupirocin was examined. Each patient undergoing cardiac surgery was nasally cultured before entering the operating room, and then intranasal mupirocin was applied and continued every 12 hours. Culture results were finalized within 48 hours. Mupirocin was discontinued when the culture returned negative and continued for 7 days when the culture returned positive for S aureus. Cultures showed a S aureus carrier rate of 21%. These patients received mupirocin for 7 days. A decrease in S aureus-associated SSI rates was observed from a case rate of 1.68% to 0.37% per 100 procedures over a 17-month period. Identifying and treating S aureus carriers with a full course of mupirocin does impact the rate of S aureus surgical site infections.
Article
Historically, methods of interrupting pathogen transmission have focused on improving health care workers' adherence to recommended infection control practices. An adjunctive approach may be to use source control (eg, to decontaminate patients' skin). We performed a prospective sequential-group single-arm clinical trial in a teaching hospital's medical intensive care unit from October 2002 to December 2003. We bathed or cleansed 1787 patients and assessed them for acquisition of vancomycin-resistant enterococci (VRE). We performed a nested study of 86 patients with VRE colonization and obtained culture specimens from 758 environmental surfaces and 529 health care workers' hands. All patients were cleansed daily with the procedure specific to the study period as follows: period 1, soap and water baths; period 2, cleansing with cloths saturated with 2% chlorhexidine gluconate; and period 3, cloth cleansing without chlorhexidine. We measured colonization of patient skin by VRE, health care worker hand or environmental surface contamination by VRE, and patient acquisition of VRE rectal colonization. Compared with soap and water baths, cleansing patients with chlorhexidine-saturated cloths resulted in 2.5 log(10) less colonies of VRE on patients' skin and less VRE contamination of health care workers' hands (risk ratio [RR], 0.6; 95% confidence interval [CI], 0.4-0.8) and environmental surfaces (RR, 0.3; 95% CI, 0.2-0.5). The incidence of VRE acquisition decreased from 26 colonizations per 1000 patient-days to 9 per 1000 patient-days (RR, 0.4; 95% CI, 0.1-0.9). For all measures, effectiveness of cleansing with nonmedicated cloths was similar to that of soap and water baths. Cleansing patients with chlorhexidine-saturated cloths is a simple, effective strategy to reduce VRE contamination of patients' skin, the environment, and health care workers' hands and to decrease patient acquisition of VRE.
Article
As many as 5% of patients undergoing surgery develop surgical site infections (SSIs), which may cause much morbidity and may sometimes be fatal. Treating SSIs imposes a substantial strain on the financial resources of the health care system. Review of current practice and guidelines. Important patient-related factors for SSI include existing infection, low serum albumin concentration, older age, obesity, smoking, diabetes mellitus, and ischemia secondary to vascular disease or irradiation. Surgical risk factors include prolonged procedures and inadequacies in either the surgical scrub or the antiseptic preparation of the skin. Physiological states that increase the risk of SSI include trauma, shock, blood transfusion, hypothermia, hypoxia, and hyperglycemia. Parameters that may be associated independently with an increased risk of SSI, and that may predict infection, include abdominal surgery, a contaminated or dirty operation, and more than three diagnoses at the time of discharge. The major sources of infection are microorganisms on the patient's skin and, less often, the alimentary tract or female genital tract. The organism most often isolated is Staphylococcus aureus, which often is resistant to methicillin. Antibiotic-resistant bacteria are a continuing and increasing problem. A wide range of patient-related, surgery-related, and physiological factors heighten the risk of SSI.
Article
Studies examining the incidence of microorganisms isolated from surgical site infections (SSIs) have been conducted primarily at large academic health care centers. Results from these studies have revealed that methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a significant pathogen in SSIs. Minimal data are available from smaller, community hospitals on the incidence of microorganisms associated with SSIs, particularly the incidence of MRSA in SSIs. A retrospective study was performed to identify the microorganisms associated with SSIs in patients who underwent class I and II surgeries at a small urban to rural community hospital from January 2003 through December 2004. A total of 10,672 surgeries was performed, and 89 SSIs were identified. Staphylococcus aureus was the most common pathogen (25.8%). Enterobacteriaceae were the second most frequently isolated organisms (12.4%), followed by streptococci species (11.2%), coagulase-negative staphylococci (10.1%), enterococci species (7.9%), and Pseudomonas aeruginosa (6.7%). MRSA was isolated from 4.5% of the SSIs. We have demonstrated that the spectrum of microorganisms isolated in SSIs at a community hospital is comparable with that reported in studies conducted at large academic health care centers, including the emergence of MRSA as a pathogen in SSIs. This information will guide future infection control initiatives to reduce SSIs.
Article
Decreasing the microbial skin burden reduces the risk of surgical site infection (SSI). The present study compares the activity of an innovative 2% chlorhexidine gluconate (CHG)-impregnated preoperative skin preparation cloth (PC) with a standard application procedure with a 4% CHG surgical skin preparation (SP). A paired, randomized, parallel phase III study was conducted adhering to the Food and Drug Administration (FDA) design criteria for evaluating preoperative skin preparations. Subjects' left and right sides of the inguinal and abdominal skin sites (n = 30) were randomized to either PC or SP treatment. Following baseline cultures, PC sites were prepped for 3 minutes, and SP sites were prepped for 4 minutes. Skin site cultures were obtained at 10 minutes, 30 minutes, and 6 hours postpreparation. Bacterial recovery was expressed as log(10) colony-forming units (cfu)/cm(2) for baseline and postapplication microbial recovery. Mean microbial baseline for the abdominal and inguinal skin sites were as follows: PC = 3.36 cfu/cm(2) and 6.15 cfu/cm(2); SP = 3.51 cfu/cm(2) and 6.16 cfu/cm(2), respectively. Log(10) reduction for PC abdominal and inguinal prepped sites at 10 minutes, 30 minutes, and 6 hours postpreparation were 2.50, 2.33, and 2.54; 3.45, 3.50, and 3.64, respectively. Log(10) reductions for SP abdominal and inguinal prepped sites at 10 minutes, 30 minutes, and 6 hours were 2.18, 2.19, and 2.77; 2.78, 2.63, and 3.15, respectively. Microbial reductions from abdominal-inguinal PC prepped sites were significantly reduced (P < .05) compared with baseline, exceeding the FDA log-reduction criteria for a preoperative topical skin preparation. Compared with baseline, microbial reductions at the SP-prepped abdominal-inguinal sites were significant (P < .05). SP abdominal-prepped sites met the FDA log-reduction criteria; inguinal sites, however, failed to meet expected FDA log-reduction criteria at 10 minutes postpreparation. The PC-treated inguinal sites at 10 minutes, 30 minutes, and 6 hours post-skin preparation demonstrated significantly greater microbial reductions than did the SP-treated inguinal sites (P < .01).
Article
Background: Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures. Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for reducing skin bacteria (microflora). It is less clear whether reducing skin microflora leads to a lower incidence of surgical site infection. Objectives: To review the evidence for preoperative bathing or showering with antiseptics for preventing hospital-acquired (nosocomial) surgical site infections. Search methods: For this fourth update we searched the Cochrane Wounds Group Specialised Register (searched 29 June 2012); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012 Issue 6); Ovid MEDLINE (2010 to June Week 3 2012), Ovid MEDLINE (In-Process & Other Non-Indexed Citations June 27, 2012); Ovid EMBASE (2010 to 2012 Week 25), EBSCO CINAHL (1882 to 21 June 2012) and reference lists of articles. Selection criteria: Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in people undergoing surgery. Data collection and analysis: Two review authors independently assessed studies for selection, risk of bias and extracted data. Study authors were contacted for additional information. Main results: We did not identify any new trials for inclusion in this fourth update. Seven trials involving a total of 10,157 participants were included. Four of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub/Riohex). Three trials involving 7791 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Three trials of 1192 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The smaller studies found no difference between patients who washed with chlorhexidine and those who did not wash preoperatively. Authors' conclusions: This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection. Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.
Article
Surgical site infection (SSI) is a potentially preventable complication. We developed and tested a model to predict patients at high risk for surgical site infection. Data from the Patient Safety in Surgery Study/National Surgical Quality Improvement Program from a 3-year period were used to develop and test a predictive model of SSI using logistic regression analyses. From October 2001 through September 2004, 7,035 of 163,624 (4.30%) patients undergoing vascular and general surgical procedures at 14 academic and 128 Department of Veterans Affairs (VA) medical centers experienced SSI. Fourteen variables independently associated with increased risk of SSI included patient factors (age greater than 40 years, diabetes, dyspnea, use of steroids, alcoholism, smoking, recent radiotherapy, and American Society of Anesthesiologists class 2 or higher), preoperative laboratory values (albumin<3.5 mg/dL, total bilirubin>1.0 mg/dL), and operative characteristics (emergency, complexity [work relative value units>/=10], type of procedure, and wound classification). The SSI risk score is more accurate than the National Nosocomial Infection Surveillance score in predicting SSI (c-indices 0.70, 0.62, respectively). We developed and tested an accurate prediction score for SSI. Clinicians can use this score to predict their patient's risk of an SSI and implement appropriate prevention strategies.
Article
Surgical site infections (SSIs) contribute to morbidity and mortality and increase the costs of patient care. Effective skin decontamination is recommended to reduce the risk of SSI and the transmission of antibiotic-resistant pathogens. A macrodilution broth method and an in vitro time-kill method were used to determine the antimicrobial properties of an alcohol-free 2% chlorhexidine gluconate (CHG) solution against seven bacterial strains, including clinically derived strains of Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus (MRSA). The CHG solution reduced bacterial counts of drug-resistant Acinetobacter baumannii and community-associated MRSA by 99.9% within three minutes of exposure, and effectiveness was maintained with significant dilutions of the CHG solution.
Emergence of community-associated methicillin-resistant Staphylococcus aureus USA 300
  • Ev Kourbatova
  • Halvosa
  • Js
  • King
  • Ray Md
  • Sm
  • N White
  • Blumberg
  • Hm
Kourbatova EV, Halvosa JS, King MD, Ray SM, White N, Blumberg HM. Emergence of community-associated methicillin-resistant Staphylococcus aureus USA 300
Prospective evaluation of 6 pre-operative cutaneous antiseptic regimens for prevention of surgical site infection. Poster presented at: Society for Healthcare Epidemiology of
  • Maki Dg
  • Paulson
Maki DG, Paulson DS. Prospective evaluation of 6 pre-operative cutaneous antiseptic regimens for prevention of surgical site infection. Poster presented at: Society for Healthcare Epidemiology of America (SHEA) Con-ference;
Reducing Surgical site infection: 2% CHG cloth reduces SSI rates by 70% difference resulting in a $154,869 cost avoidance. Poster presented at: The Virginians Improving Patient Care and Safety (VIPC&S) 7th Annual Conference
  • H Rhee
  • B Harris
Rhee H, Harris B. Reducing Surgical site infection: 2% CHG cloth reduces SSI rates by 70% difference resulting in a $154,869 cost avoidance. Poster presented at: The Virginians Improving Patient Care and Safety (VIPC&S) 7th Annual Conference; Richmond, VA; May 23, 2007.
Control of nosocomial Acinetobacter in a university-affiliated medical center. Poster presented at: Association for Professionals in Infection Control and Epidemiology (APIC) meeting
  • K Blanchard
  • J Jefferson
  • L Mermel
Blanchard K, Jefferson J, Mermel L. Control of nosocomial Acinetobacter in a university-affiliated medical center. Poster presented at: Association for Professionals in Infection Control and Epidemiology (APIC) meeting; San Jose, CA; June 2007.
Prospective evaluation of 6 preoperative cutaneous antiseptic regimens for prevention of surgical site infection. Poster presented at: Society for Healthcare Epidemiology of America (SHEA) Conference
  • Dg Maki
  • Ds Paulson
Maki DG, Paulson DS. Prospective evaluation of 6 preoperative cutaneous antiseptic regimens for prevention of surgical site infection. Poster presented at: Society for Healthcare Epidemiology of America (SHEA) Conference; Chicago, IL; March 2006.
Prospective evaluation of 6 preoperative cutaneous antiseptic regimens for prevention of surgical site infection
  • D G Maki
  • D S Paulson
Maki DG, Paulson DS. Prospective evaluation of 6 preoperative cutaneous antiseptic regimens for prevention of surgical site infection. Poster presented at: Society for Healthcare Epidemiology of America (SHEA) Conference;
Reducing Surgical site infection: 2% CHG cloth reduces SSI rates by Ͼ 70% difference resulting in a $154,869 cost avoidance
  • H Rhee
  • B Harris
Rhee H, Harris B. Reducing Surgical site infection: 2% CHG cloth reduces SSI rates by Ͼ 70% difference resulting in a $154,869 cost avoidance. Poster presented at: The Virginians Improving Patient Care and Safety (VIPC&S) 7th Annual Conference; Richmond, VA; May 23, 2007.