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

Duke University, Durham, North Carolina, United States
The Journal of Bone and Joint Surgery (Impact Factor: 5.28). 09/2006; 88(8):1705-12. DOI: 10.2106/JBJS.E.01156
Source: PubMed


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

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Available from: Michael P Bolognesi
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    • "Geriatric patients provide unique challenges in fracture management due to their bone quality and medical comorbidities (Little et al. 2013). SSI is a strong predictor of mortality in elderly patients (Lee et al. 2006), and controversies remain regarding the risks and benefits of operative treatment in geriatric patients (Koval et al. 2007, Strauss and Egol 2007, Hak et al. 2011, Shivarathre et al. 2011, Lynde et al. 2012, Little et al. 2013, McKean et al. 2013, Olsen et al. 2013, Zaghloul et al. 2014). The risks of surgical treatment should be carefully evaluated in all elderly patients (Kettunen and Kröger 2005). "

    Full-text · Article · Feb 2015 · Acta orthopaedica. Supplementum
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    • "We considered an ORIF patient to have a high risk of developing SSI if he or she had severe systemic disease affecting his or her general health and immunity, extensive skin or tissue injuries with dirty and contaminated wounds at the incision sites, multiple implants, or long duration of surgeries. Other risk factors, such as the patient's age (>65 years) and body mass index (>40 kg/ m 2 ), may also affect the SSI rate [1] [10] [18] [25] [29]. However, to make the scorecard simple and practical, we did not include all possible risk factors. "
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    ABSTRACT: Background: Widespread overuse and inappropriate use of antibiotics contribute to increasingly antibiotic-resistant pathogens and higher health care costs. It is not clear whether routine antibiotic prophylaxis can reduce the rate of surgical site infection (SSI) in low-risk patients undergoing orthopaedic surgery. We designed a simple scorecard to grade SSI risk factors and determined whether routine antibiotic prophylaxis affects SSI occurrence during open reduction and internal fixation (ORIF) orthopaedic surgeries in trauma patients at low risk of developing SSI. Methods: The SSI risk scorecard (possible total points ranged from 5 to 25) was designed to take into account a patient's general health status, the primary cause of fractures, surgical site tissue condition or wound class, types of devices implanted, and surgical duration. Patients with a low SSI risk score (≤8 points) who were undergoing clean ORIF surgery were divided into control (routine antibiotic treatment, cefuroxime) and evaluation (no antibiotic treatment) groups and followed up for 13-17 months after surgery. Results: The infection rate was much higher in patients with high SSI risk scores (≥9 points) than in patients with low risk scores assigned to the control group (10.7% vs. 2.2%, P<0.0001). SSI occurred in 11 of 499 patients in the control group and in 13 of 534 patients in the evaluation group during the follow-up period of 13-17 months. The SSI occurrence rate did not differ significantly (2.2% vs. 2.4%, P=0.97) between the control and evaluation groups. Conclusions: Routine antibiotic prophylaxis does not significantly decrease the rate of SSI in ORIF surgical patients with a low risk score. Implementation of this scoring system could guide the rational use of perioperative antibiotics and ultimately reduce antibiotic resistance, health care costs, and adverse reactions to antibiotics.
    Preview · Article · Aug 2014 · Injury
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    • "Ten studies considered risk factors describing patient dependence and frailty, which were characterized in a variety of ways, including independence and activities of daily living[14,15,25–27], incontinence[15,25,28], and admission from a long-term health-care facility[14,27]. The majority of these factors were only considered in unadjusted analyses; adjusted estimates include an odds ratio for SSI of 4.35 (95% CI: 1.64-11.11) "
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    ABSTRACT: Surgical site infection (SSI) complicates 2-5% of surgeries in the United States. Severity of SSI ranges from superficial skin infection to life-threatening conditions such as severe sepsis, and SSIs are responsible for increased morbidity, mortality, and economic burden associated with surgery. Staphylococcus aureus (S. aureus) is a commonly-isolated organism for SSI, and methicillin-resistant S. aureus SSI incidence is increasing globally. The objective of this systematic review was to characterize risk factors for SSI within observational studies describing incidence of SSI in a real-world setting. An initial search identified 328 titles published in 2002-2012; 57 were identified as relevant for data extraction. Extracted information included study design and methodology, reported cumulative incidence and post-surgical time until onset of SSI, and odds ratios and associated variability for all factors considered in univariate and/or multivariable analyses. Median SSI incidence was 3.7%, ranging from 0.1% to 50.4%. Incidence of overall SSI and S. aureus SSI were both highest in tumor-related and transplant surgeries. Median time until SSI onset was 17.0 days, with longer time-to-onset for orthopedic and transplant surgeries. Risk factors consistently identified as associated with SSI included co-morbidities, advanced age, risk indices, patient frailty, and surgery complexity. Thirteen studies considered diabetes as a risk factor in multivariable analysis; 85% found a significant association with SSI, with odds ratios ranging from 1.5-24.3. Longer surgeries were associated with increased SSI risk, with a median odds ratio of 2.3 across 11 studies reporting significant results. In a broad review of published literature, risk factors for SSI were characterized as describing reduced fitness, patient frailty, surgery duration, and complexity. Recognition of risk factors frequently associated with SSI allows for identification of such patients with the greatest need for optimal preventive measures to be identified and pre-treatment prior to surgery.
    Full-text · Article · Dec 2013 · PLoS ONE
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