The timing of surgical antimicrobial prophylaxis. Ann Surg. 2008;247:918-926. [PMID: 18520217 DOI: 10.1097/sla.0b013e31816c3fec]

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

BACKGROUND

Propionibacterium acnes has been linked to chronic infections in shoulder surgery. Whether the bacterium is a contaminant or commensal of the deep tissue is unclear. We aimed to assess P. acnes in intraoperative samples of different tissue layers in patients undergoing first-time shoulder surgery.

METHODS

In 118 consecutive patients (mean age, 59.2 years; 75 men, 43 women), intraoperative samples were correlated to preoperative subacromial injection, the type of surgical approach, and gender. One skin, one superficial, one deep tissue, and one test sample were cultured for each patient.

RESULTS

The cultures were positive for P. acnes in 36.4% (n = 43) of cases. Subacromial injection was not associated with bacterial growth rates (P = .88 for P. acnes; P = .20 for bacteria other than P. acnes; P = .85 for the anterolateral approach; P = .92 for the deltopectoral approach; P = .56 for men; P = .51 for women). Skin samples were positive for P. acnes in 8.5% (n = 10), superficial samples were positive in 7.6% (n = 9), deep samples were positive in 13.6% (n = 16), and both samples (superficial and deep) were positive in 15.3% (n = 18) of cases (P < .0001). P. acnes was detected in the anterolateral approach in 27.1% (n = 32) of cases and in the deltopectoral approach in 9.3% (n = 11) of cases (P = .01; relative risk, 1.93; 95% confidence interval, 1.08-3.43). Thirty-five of the P. acnes-positive patients were men (81.4%), and 8 patients were women (18.6%; P = .001; relative risk, 2.51; 95% confidence interval, 1.28-4.90).

DISCUSSION

P. acnes was detected in more than one third of patients undergoing first-time shoulder surgery. Preoperative subacromial injection was not associated with bacterial growth. P. acnes was observed more frequently in the deep tissues than in the superficial tissues. The relative risk for obtaining a positive P. acnes culture was 2-fold greater for the anterolateral approach than for the deltopectoral approach, and the risk was 2.5-fold greater for men.

Practice patterns in the perioperative treatment of patients undergoing septorhinoplasty: a survey of facial plastic surgeons

IMPORTANCE The common practices used in the perioperative care of patients undergoing septorhinoplasty are diverse and controversial. A consensus statement on the preferred clinical pathway in the perioperative treatment of patients undergoing septorhinoplasty has yet to be approached formally. OBJECTIVES To investigate the perioperative treatment of patients undergoing septorhinoplasty and to identify common practice patterns based on the preferences of leading facial plastic surgeons. DESIGN, SETTING, AND PARTICIPANTS We distributed an online survey to members of the American Academy of Facial Plastic and Reconstructive Surgery. Specifically, fellowship directors and academic contact members were anonymously polled and stratified by the number of septorhinoplasties performed annually. MAIN OUTCOME AND MEASURE A cohesive clinical guide to perioperative treatment after rhinoplasty. RESULTS Of the 92 members surveyed, 67 (73%) successfully completed the survey. The distribution of respondents included 43 academicians (64%) and 24 physicians in private practice (36%). Twenty-eight surgeons (42%) performed fewer than 50 rhinoplasties a year and 39 (58%), more than 50, representing 3510 to 4549 septorhinoplasties in total among respondents. Forty-four surgeons (66%) refrained from using any packing, and 41 (61%) used intranasal splints, with polymeric silicone splints the most popular of these (n = 24 [59%]). Sixty-six surgeons (99%) used external nasal splints, including 49 (74%) who used a thermoplastic splint and 49 (74%) who left the external nasal splint in place for 7 days or longer. The most common postoperative interventions to reduce edema and ecchymosis were elevation of the head of bed by 62 (93%), ice packs by 50 (75%), and Arnica montana by 33 (49%). Only 12 surgeons (18%) used postoperative corticosteroids to reduce edema. Fifty-six respondents (84%) prohibited participation in contact sports until at least 6 weeks after surgery. CONCLUSIONS AND RELEVANCE Perioperative care and practices after nasal surgery vary among the most highly trained and leading rhinoplasty surgeons. No published communication or consensus on perioperative practices has been disseminated in this setting. Given the results from those surgeons performing the most rhinoplasties in our field, some surgeons may choose to vary their practices to coincide with those of experienced surgeons. These guidelines could facilitate future studies of patient outcomes.

Effectiveness of prophylactic antibiotics in outpatient plastic surgery

BACKGROUND

The effectiveness of prophylactic antibiotics has not been established for patients who undergo plastic surgery as outpatients, and consensus guidelines for antibiotic administration in clean-contaminated plastic surgery are not available.

OBJECTIVES

In a retrospective study of outpatients, the authors examined preoperative timing of prophylactic antibiotics, whether postoperative antibiotics were administered, and whether any correlations existed between these practices and surgical complications.

METHODS

The medical records of 468 plastic surgery outpatients were reviewed. Collected data included preoperative antibiotic timing, postoperative antibiotic use, comorbidities, and complications. Rates of complications were calculated and compared with other data.

RESULTS

All 468 patients received antibiotics preoperatively, but only 93 (19.9%) received them ≥1 hour before the initial incision. Antibiotics were administered 15 to 44 minutes before surgery in 217 patients (46.4%). There was no significant difference in complication rates between the 315 patients who received postoperative prophylactic antibiotics (16.2%) and the 153 who did not (20.9%). Comorbidities had no bearing on postoperative complications.

CONCLUSIONS

Postoperative antibiotic prophylaxis may be unnecessary for outpatient plastic surgery patients.

LEVEL OF EVIDENCE

3.

Breast reconstruction with tissue expanders: implementation of a standardized best-practices protocol to reduce infection rates

BACKGROUND

Periprosthetic infection remains a frustrating and costly complication of breast reconstruction with tissue expanders. Although some specific steps have been previously shown to reduce periprosthetic infections, no comprehensive protocol addressing all aspects of preoperative, intraoperative, and postoperative patient management has been evaluated in the literature. The authors' goal was to evaluate the effectiveness of their protocol at reducing periprosthetic infections.

METHODS

A comprehensive, best-practices protocol was introduced and implemented in November of 2010. All patients undergoing breast reconstruction using tissue expanders at the authors' institution in the 5 years before the protocol, and in the 2 years after, were analyzed.

RESULTS

Three hundred five patients underwent 456 tissue expander reconstructions in the 5 years before the protocol, and 198 patients underwent 313 reconstructions in the 2 years after. Significantly fewer patients developed periprosthetic infection after protocol (11.6 percent versus 18.4 percent; p=0.042), and the number of infected tissue expanders trended toward a decrease (9.3 percent versus 13.2 percent; p=0.097). On multivariate analysis, the protocol significantly reduced the odds of periprosthetic infection (OR, 0.45; p=0.022). Predictors of infection included obesity (OR, 2.01; p=0.045) and preoperative breast size larger than C cup (OR, 2.83; p=0.006).

CONCLUSIONS

The authors' comprehensive, best-practices protocol allowed them to reduce the odds of tissue expander infections by 55 percent (OR, 0.45; p=0.022). The authors were able to identify several potential areas of improvement that may help them lower the rate of infection further in the future.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Perioperative antibiotic prophylaxis for major urological interventions]

BACKGROUND

With the emergence of multidrug resistant bacteria reaching alarming levels and the year-long developmental void of new antimicrobial drugs, the rational and appropriate use of antibiotics is of paramount importance. The number of surgical interventions is still increasing so that surgical site infections represent the most frequent form of nosocomial infection.

METHOD

Fundamental hygiene measures as well as aseptic and tissue-preserving surgical techniques are supported by perioperative antibiotic prophylaxis to prevent surgical site infections. This is accomplished by a single short-term antibiotic administration at the beginning of or at the latest during the operative intervention. Due to its contribution to the total consumption of antibiotics and when misused to the development of multidrug resistance, an appropriate and controlled perioperative antibiotic prophylaxis is mandatory.

INDICATION

The indications for perioperative antibiotic prophylaxis depend on the type of surgical procedure, the classification of operative wounds as well as individual patient and operation-related risk factors.

Perioperative strategies to prevent surgical-site infection

Colon and rectal resections are among the most common surgical procedures performed in the United States. Complication rates of up to 25% have been reported and result in a substantial impact on quality of life and cost of care. Recently, the Surgical Care Improvement Program (SCIP) has promoted guidelines to prevent postoperative and potentially preventable complications. A comprehensive evidenced-based review of these guidelines and other perioperative strategies for practicing colorectal surgeons is the basis of this review.

The economics and timing of preoperative antibiotics for orthopaedic procedures

BACKGROUND

The efficacy of antibiotics in preventing surgical site infections (SSIs) depends on the timing of administration relative to the start of surgery. However, currently, both the timing of and recommendations for administration vary substantially.

AIM

To determine how the economic value from the hospital perspective of preoperative antibiotics varies with the timing of administration for orthopaedic procedures.

METHODS

Computational decision and operational models were developed from the hospital perspective. Baseline analyses looked at current timing of administration, while additional analyses varied the timing of administration, compliance with recommended guidelines, and the goal time-interval.

FINDINGS

Beginning antibiotic administration within 0-30 min prior to surgery resulted in the lowest costs and SSIs. Operationally, linking to a pre-surgical activity, administering antibiotics prior to incision but after anaesthesia-ready time was optimal, as 92.1% of the time, antibiotics were administered in the optimal time-interval (0-30 min prior to incision). Improving administration compliance from 80% to 90% for this pre-surgical activity results in cost savings of $447 per year for a hospital performing 100 orthopaedic operations a year.

CONCLUSION

This study quantifies the potential cost-savings when antibiotic administration timing is improved, which in turn can guide the amount hospitals should invest to address this issue.

Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics: Do Surgical Care Improvement Project Guidelines Need to Be Updated?

BACKGROUND

Prophylactic antibiotics decrease surgical site infection (SSI) rates, and their timing, choice, and discontinuation are measured and reported as part of the Surgical Care Improvement Project (SCIP). The aim of this study was to assess the comparative effectiveness of the SCIP-approved antibiotics for SSI prevention.

METHODS

This retrospective cohort study utilized national Veterans Affairs (VA) data on patients undergoing elective hip or knee arthroplasty from 2005 to 2009. Data on prophylactic antibiotics were merged with VA Surgical Quality Improvement Program data to identify patient and procedure-related risk factors for SSI. Patients were stratified by documented penicillin allergy. Chi-square and Wilcoxon rank-sum tests were used to compare SSI rates among patients receiving SCIP-approved prophylactic antibiotics.

RESULTS

A total of 18,830 elective primary arthroplasties (12,823 knee and 6007 hip) were included. Most patients received prophylactic cefazolin as the sole agent (81.9%), followed by vancomycin as the sole agent (8.0%), vancomycin plus cefazolin (5.6%), and clindamycin (4.5%). Documented penicillin allergy accounted for 54.1% of cases involving vancomycin administration compared with 94.6% of cases involving clindamycin. The overall thirty-day SSI rate was 1.4%, and the unadjusted rate was 2.3% with vancomycin only, 1.5% with vancomycin plus cefazolin, 1.3% with cefazolin only, and 1.1% with clindamycin. Unadjusted analysis of penicillin-allergic patients revealed an SSI rate of 2.0% with vancomycin only compared with 1.0% with clindamycin (p = 0.18). For patients without penicillin allergy, the SSI rate was 2.6% with vancomycin only compared with 1.6% with vancomycin plus cefazolin (p = 0.17) and 1.3% with cefazolin only (p < 0.01).

CONCLUSIONS

Current SCIP guidelines address antibiotic timing but not antibiotic dosage. (The generally accepted recommendation for vancomycin is 15 mg/kg.) Although vancomycin is a narrower-spectrum antibiotic than either cefazolin or clindamycin, our finding of higher SSI rates following prophylaxis with vancomycin only may suggest a failure to use an appropriate dosage rather than an inequality of antibiotic effectiveness.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluating the optimal timing of surgical antimicrobial prophylaxis: study protocol for a randomized controlled trial

BACKGROUND

Surgical site infections are the most common hospital-acquired infections among surgical patients. The administration of surgical antimicrobial prophylaxis reduces the risk of surgical site infections . The optimal timing of this procedure is still a matter of debate. While most studies suggest that it should be given as close to the incision time as possible, others conclude that this may be too late for optimal prevention of surgical site infections. A large observational study suggests that surgical antimicrobial prophylaxis should be administered 74 to 30 minutes before surgery. The aim of this article is to report the design and protocol of a randomized controlled trial investigating the optimal timing of surgical antimicrobial prophylaxis.

METHODS/DESIGN

In this bi-center randomized controlled trial conducted at two tertiary referral centers in Switzerland, we plan to include 5,000 patients undergoing general, oncologic, vascular and orthopedic trauma procedures. Patients are randomized in a 1:1 ratio into two groups: one receiving surgical antimicrobial prophylaxis in the anesthesia room (75 to 30 minutes before incision) and the other receiving surgical antimicrobial prophylaxis in the operating room (less than 30 minutes before incision). We expect a significantly lower rate of surgical site infections with surgical antimicrobial prophylaxis administered more than 30 minutes before the scheduled incision. The primary outcome is the occurrence of surgical site infections during a 30-day follow-up period (one year with an implant in place). When assuming a 5% surgical site infection risk with administration of surgical antimicrobial prophylaxis in the operating room, the planned sample size has an 80% power to detect a relative risk reduction for surgical site infections of 33% when administering surgical antimicrobial prophylaxis in the anesthesia room (with a two-sided type I error of 5%). We expect the study to be completed within three years.

DISCUSSION

The results of this randomized controlled trial will have an important impact on current international guidelines for infection control strategies in the hospital. Moreover, the results of this randomized controlled trial are of significant interest for patient safety and healthcare economics.

TRIAL REGISTRATION

This trial is registered on ClinicalTrials.gov under the identifier NCT01790529.

Surgical wound infection rates in Spain: data summary, January 1997 through June 2012

BACKGROUND

The Indicadores Clínicos de Mejora Continua de la Calidad (INCLIMECC) program was established in Spain in 1997.

METHODS

INCLIMECC is a prospective system of health care-associated infection (HAI) surveillance that collects incidence data in surgical and intensive care unit patients. The protocol is based on the National Healthcare Safety Network (NHSN) surveillance system, formerly known as the National Nosocomial Infection Surveillance (NNIS) system, and uses standard infection definitions from the US Centers for Disease Control and Prevention. Each hospital takes part voluntarily and selects the units and surgical procedures to be surveyed.

RESULTS

This report is a summary of the data collected between January 1997 and June 2012. A total of 370,015 patients were included, and the overall incidence of surgical wound infection (SWI) was 4.51%. SWI rates are provided by NHSN operating procedure category and NNIS risk index category. More than 27% of the patients received inadequate antibiotic prophylaxis, the main reason being unsuitable duration (57.05% of cases).

CONCLUSIONS

Today, the INCLIMECC network includes 64 Spanish hospitals. We believe that an HAI surveillance system with trained personnel external to the surveyed unit is a key component not only in infection control and prevention, but also in a quality improvement system.

Incisional surgical site infection after elective open surgery for colorectal cancer

Background. The purpose of this study was to clarify the incidence and risk factors for incisional surgical site infections (SSI) in patients undergoing elective open surgery for colorectal cancer. Methods. We conducted prospective surveillance of incisional SSI after elective colorectal resections performed by a single surgeon for a 1-year period. Variables associated with infection, as identified in the literature, were collected and statistically analyzed for their association with incisional SSI development. Results. A total of 224 patients were identified for evaluation. The mean patient age was 67 years, and 120 (55%) were male. Thirty-three (14.7%) patients were diagnosed with incisional SSI. Multivariate analysis suggested that incisional SSI was independently associated with TNM stages III and IV (odds ratio [OR], 2.4) and intraoperative hypotension (OR, 3.4). Conclusions. The incidence of incisional SSI in our cohort was well within values generally reported in the literature. Our data suggest the importance of the maintenance of intraoperative normotension to reduce the development of incisional SSI.

A prospective study on surgical-site infections in thyroid operation

BACKGROUND

To evaluate the incidence and the microbe spectrum of surgical-site infections (SSIs) in patients undergoing elective thyroid operation and to develop a risk factor-based predictive model.

METHODS

This prospective study included 6,778 consecutive patients who underwent thyroid operation at a single institution between 2007 and 2012. SSI was defined according to the Centers for Disease Control and Prevention. Regression models were fitted to evaluate risk factors for SSI. A predictive nomogram was constructed from relevant variables in the multivariable analysis. Discrimination and calibration of the nomogram were assessed.

RESULTS

The cumulative incidence of SSI after 30 days was 0.49%. The median time from operation to SSI was 7 days (interquartile range, 4-10.5 days). SSI was classified as superficial incisional in 30 cases (93.8%), deep incisional in 1 case (3.1%), and organ/space in 1 case (3.1%). Staphylococcus aureus was the most common isolate. In multivariable analysis, duration of operation (P = .004) and American Society of Anesthesiologists' score (P = .031) were identified as independent risk factors for SSI. These variables formed the basis of a nomogram, which was validated internally by bootstrapping and reached a predictive accuracy of 70.1%. The calibration curve showed a good agreement between predicted probability and actual observation.

CONCLUSION

The cumulative incidence of SSI in thyroid operation is <0.5%. American Society of Anesthesiologists' score and the duration of operation are independent risk factors for SSI. Antibiotic prophylaxis may be considered for selected patients based on the individual risk profile.

Drainage days-an independent risk factor for serious sternal wound infections after cardiac surgery: a case control study

BACKGROUND

Postoperative sternal wound infections are a potentially devastating complication following cardiac surgery. The aim of our study was to determine risk factors associated with patients' baseline characteristics and peri- and postoperative management for the development of surgical site infections (SSIs) after cardiac surgery involving sternotomy.

METHODS

Since 2009 the University Hospital of Basel, a tertiary care center in Switzerland, has participated in the national SSI-surveillance program by conducting postdischarge surveillance. We conducted a nested case-control study involving 30 consecutive patients with an organ/space SSI after cardiac surgery and 60 control patients.

RESULTS

Receipt of antibiotics before operation (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.41; P = .032), decreased albumin levels (OR, 0.87; 95% CI, 0.76-0.99; P = .040, respectively), time on extracorporal circulation (OR, 1.02; 95% CI, 1.00-1.03; P = .012), number of drainages (OR, 9.15; 95% CI, 2.01-41.76; P = .004), length of drain retention (OR, 1.44; 95% CI, 1.10-1.90; P = .009), and resuscitation (OR, 7.30; 95% CI, 1.53-34.71; P = .012) were associated with SSIs. Incidence density drainage days-accounting for both number of drains and length of retention-were the only independent risk factor (OR, 1.12; 95% CI, 1.02-1.11; P = .018).

CONCLUSIONS

Retention of drainages in the operative site longer than 48 hours was the only independent risk factor for the development of organ/space sternal wound infections after cardiac surgery.

Y, El-Sayed AS, Abdel-Rahman ME. Prophylactic antibiotics and wound infection

INTRODUCTION

Surgical site infections account for 14%-25% of all nosocomial infections. The main aims of this study were to audit the use of prophylactic antibiotic, to quantify the rate of post-operative wound infection, and to identify risk factors for its occurrence in general surgery.

METHODOLOGY

A cross-sectional study was conducted in the General Surgery Department in Khartoum Teaching Hospital- Sudan. All Adult patients (age ≥18 years) admitted during March 1(st) to 31(st) October 2010 were recruited. Multivariable logistic analysis was done to identify wound infection risk factors. Prescriptions were audited against predetermined criteria.

RESULTS

A total of 540 patients were recruited; (females73.7% of total ). The performed surgical procedures were 547. The rate of wound infection was 10.9%. Multivariable logistic analysis showed that; ASA score ≥ 3; (p= <0.001), wound class (p= 0.001), and laparoscopic surgical technique; (p= 0.002) were significantly associated with prevalence of wound infection. Surgical prophylaxis was unnecessarily given to 311 (97.5%) of 319 patients for whom it was not recommended. Prophylaxis was recommended for 221 patients; of them 218 (98.6 %) were given preoperative dose in the operating rooms. Evaluation of prescriptions for those patients showed that; spectrum of antibiotic was adequate for 160 (73.4%) patients, 143 (65.6%) were given accurate doses, only 4 (1.8%) had the first preoperative dose/s in proper time window, and for 186 (85.3%) of them prophylaxis was extended post-operatively. Only 36 (6.7%) prescriptions were found to be complying with the stated criteria.

CONCLUSION

The rate of wound infection was high and prophylactic antibiotics were irrationally used. Multiple interventions are needed to correct the situation.

Periprosthetic knee infection: ten strategies that work

Periprosthetic joint infection (PJI) is one of the most serious complications following total knee arthroplasty (TKA). The demand for TKA is rapidly increasing, resulting in a subsequent increase in infections involving knee prosthesis. Despite the existence of common management practices, the best approach for several aspects in the management of periprosthetic knee infection remains controversial. This review examines the current understanding in the management of the following aspects of PJI: preoperative risk stratification, preoperative antibiotics, preoperative skin preparation, outpatient diagnosis, assessing for infection in revision cases, improving culture utility, irrigation and debridement, one and two-stage revision, and patient prognostic information. Moreover, ten strategies for the management of periprosthetic knee infection based on available literature, and experience of the authors were reviewed.

Is it time to refine? An exploration and simulation of optimal antibiotic timing in general surgery

BACKGROUND

Postoperative infections increase morbidity, resource use, and costs. Our objective was to examine whether within guideline recommendations an optimal time exists for an initial dose of antibiotic to reduce postoperative infections in general surgery, and to simulate the magnitude of a reduction in infections should an optimal time be implemented.

STUDY DESIGN

The population consisted of 6,731 patients who underwent 7,095 general surgery procedures between January 5, 2006 and June 25, 2012. Patients with pre-existing infections, such as pneumonia and sepsis, and patients with no recorded use of antibiotics were excluded, as were patients on vancomycin and surgical procedures longer than 4 hours in duration. The final analysis dataset included 4,453 patients. The National Surgical Quality Improvement Program was used for perioperative variables and outcomes. The end point was a composite of wound disruption; superficial, deep, organ space, surgical site infections; and sepsis. Semi-parametric logistic regression was used to study the association between antibiotic timing and infection.

RESULTS

There were 444 (10%) patients with a primary end point of infectious complication. A nonlinear "bowl-shaped" relationship between duration of interval from antibiotic administration and surgical incision and infection was observed; lowest risk corresponding to administration time close to incision was 4 minutes before incision (95% one-sided CI, 0-18 minutes). The model suggested optimal timing would result in an 11.3% reduction in the primary infection end point.

CONCLUSIONS

Risk of infectious complications decreased as antibiotic administration moved closer to incision time. These data suggest an opportunity to reduce infections by 11.3% by targeting initial antibiotic administration closer to incision.

Abdominal surgical site infections: a prospective study of determinant factors in Harare, Zimbabwe

Surgical site infections (SSIs) are reported in lower frequencies in the developed countries than in the developing world. A prospective evaluation of risk factors in 285 patients undergoing abdominal surgery procedures in Zimbabwe was therefore undertaken. Overall infection rate was 26%. The age group 30-39 years had the highest number of dirty wounds and the highest rate of human immunodeficiency virus (HIV) infection. Multivariate regression analysis showed a correlation between wound class and SSI (P < 0·05). This was also noted for American Society of Anesthesiologists (ASA) score (P < 0·05). HIV-infected patients had 52% SSIs and non-infected patients had 26% (P < 0·05). Patients receiving blood transfusion had 51% SSIs and those not transfused had 17% (P < 0·01). Patients receiving pre- and intra-operative prophylactic antibiotics had 18% SSIs and those receiving postoperative administration had 37% (P < 0·01). Treatment ranged from dressings only in 11% to surgical intervention in 30% resulting in prolongation of median hospital stay from 8 to 18 days (P < 0·001). Mortality was 7%. High wound class, high ASA score, blood transfusion, HIV infection and delayed use of prophylactic antibiotics were risk factors for SSIs, resulting in surgical interventions, prolonged hospital stay and mortality.

Effects of ampicillin/sulbactam and enrofloxacin on the blood pressure of isoflurane anesthetized dogs

A blinded, prospective, randomized crossover study was performed to determine the effects of ampicillin Na/sulbactam Na and enrofloxacin on the blood pressure (BP) of healthy anesthetized dogs. Eight dogs were anesthetized three different times. They randomly received enrofloxacin, ampicillin Na/sulbactam Na, and saline. Systolic, diastolic, and mean arterial BPs (SAP, DAP, and MAP, respectively), heart rate (HR), O2 saturation of hemoglobin, end-tidal CO2 (ETCO2) concentration, inspired isoflurane concentration, end-tidal isoflurane (ETiso) concentration, respiratory rate, electrocardiogram, and body temperature were measured for 20 min prior to administration of treatment, during administration over 30 min, and for 30 min after administration. There was no significant difference in the SAP or ETiso. There was no significant change in the arterial pressure values over time in the enrofloxacin and ampicillin Na/sulbactam Na groups. The control group's MAP increased over time and was increased compared with the enrofloxacin group at times 25, 35, 45, and 55. The statistical difference between the enrofloxacin and the control groups was due to an increase in the MAP in the control group, not a decrease in the enrofloxacin group's BP. Neither enrofloxacin nor ampicillin Na/sulbactam Na caused hypotension in healthy dogs anesthetized with isoflurane and fentanyl.

Factors affecting the risk surgical site infection and methods of reducing

According to estimates by the National Audit Office (NAO) hospital acquired infections (HAl), in particular surgical site infections (SSls), cost the NHS on average 3200 pounds per SSI and cause a mortality rate of at least five thousand patients a year (Leaper 2010). Despite practitioners' knowledge of safe working technique and control of infection, reported cases of nosocomial infections are still high, despite a reduction in-rate from 9% in 1993/4 to 8.2% in 2006 (Roberts & Cookson 2009).

Contemporary perioperative care strategies

Background

Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes.

Methods

A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German.

Results

Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine–alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy.

Conclusion

Multidisciplinary management of perioperative patient care has improved outcomes.

An audit of prophylactic surgical antibiotic use in a Sudanese Teaching Hospital

BACKGROUND

Antibiotic prophylaxis is effective at reducing the risk of postoperative infection for nearly all types of surgery. Objective To audit the use of prophylactic antibiotics for elective surgery.

SETTING

Khartoum Teaching Hospital, Sudan, a 1,000 bed tertiary level hospital.

METHOD

A prospective study was conducted over a 9 month period; patients admitted for elective surgery were included consecutively.

MAIN OUTCOME MEASURE

The use and administration of prophylactic antibiotics for elective surgery.

RESULTS

A total of 1,768 patients with mean age 37.8 ± 14 years were recruited (females, 83.3 % of total) who underwent 1,814 surgical interventions. Of these 1,277 (70.4 %) of procedures were clean-contaminated. A total of 1,758 patients (99.4 % of total) received antibiotics for prophylaxis; 1,730 patients (97.9 %) were given antibiotics in the operating room; for 1,288 (74.5 %) of cases the antibiotics were considered 'recommended', while for 442 (25.5 %) they were not. Out of the patients for whom prophylaxis was recommended and was given, 725 (56.3 %) of patients received a broad spectrum antibiotic or unnecessary combination, 913 (70.9 %) received a sub-therapeutic dose, 120 (9.3 %) were given the first preoperative dose within the proper time window, and 1,250 (97 %) of patients had an extended duration of prophylaxis. Compliance with all stated criteria was achieved in only 47 (2.7 %) of observed prescriptions.

CONCLUSION

This audit showed a wide gap between international standards and local practices; the authors call for urgent action to correct this situation through the development and implementation of local clinical guidelines.

[Comparison of wound infection rates after colon and rectal surgeries using triclosan-coated or bare sutures -- a multi-center, randomized clinical study]

BACKGROUND

Surgical Site Infection (SSI) is the third most frequent nosocomial infection, and accounts for 14-16% of all infections. While the treatment of SSI can be very costly, previous results indicated that triclosan may reduce SSI rate. Therefore, we carried out a prospective randomised trial to further evaluate the effect of triclosan after elective colorectal surgery.

METHODS

Seven surgical units in Hungary were involved in a prospective, randomised, multicentric clinical trial to compare triclosan coated (PDS plus®) and uncoated (PDS II®) sutures for abdominal wall closure in elective colorectal surgery. Pre- and perioperative variables were recorded in an online database. The primary aims of the study were to determine the incidence of SSI and the pathogens associated with it, as well as evaluation of additional cost of treatment.

RESULTS

485 patients were randomised. SSI occurred in 47 cases (12.5%), of those 23 (12.23%) from the triclosan group (n = 188) and 24 (12.18%) from the uncoated group (n = 197, p = 0.982). In 13 (27.66%) cases late appearance of SSI was detected, of those 4 patients with triclosan coated suture (8.51%) and 9 patients with uncoated suture (19.15%, p = 0.041). There was no difference between the type of incisions or elective colon and rectal resections in terms of incidence of SSI.

CONCLUSION

Beneficial effect of triclosan against Gram positive bacteria could not be confirmed in our study due to the relatively low number of patients with SSI. Furthermore, triclosan did not influence the incidence of SSI due to Gram negative bacteria. SSI rate decreased by 50% compared to our previous study, however, it was regardless of the use of coated or uncoated PDS loop. Finally, operative factors were more important than patient's risk factors in terms of incidence of SSI. In case SSI developed, delayed discharge from hospital as well as special wound care significantly increased overall cost of treatment.

Risk factors associated with surgical site infections following vascular surgery at a German university hospital

Surgical site infection (SSI) after vascular surgery is a serious complication increasing morbidity, mortality, and costs for healthcare systems. A 4-year retrospective cohort study was performed in a university hospital with patients who had undergone arterial vascular surgery below the aortic arch. Investigated variables included demographics and clinical data. Forty-four of 756 patients experienced SSI, 29 of which were superficial, five were deep, and 10 had organ/space infections. Coagulase-negative staphylococci (22%), enterococci (20%), and Staphylococcus aureus (18%) were the most common pathogens. Independent risk factors for SSIs were femoral grafting [odds ratio (OR) 6·7], peripheral atherosclerotic disease, Fontaine stages III–IV (OR 4·1), postoperative drainage >5 days (OR 3·6), immunosuppression (OR 2·8), duration of operation >214 min (OR 2·8), and body mass index >29 (OR 2·6). The application of perioperative antibiotic prophylaxis was an independent protective factor (OR 0·2). Patients with certain risk factors for SSIs warrant special attention for infection prevention.

Surgical site infection prophylaxis strategies for cardiothoracic surgery: a decision-analytic model

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of invasive surgical site infection (SSI) in the USA. Antimicrobial prophylaxis for SSI typically includes a cephalosporin. Vancomycin is used to provide MRSA coverage, but the timing of administration is challenging. Linezolid is an attractive agent for SSI prophylaxis, particularly for the prevention of SSI due to MRSA.

METHODS

We developed a decision-analytic model to evaluate linezolid use for cardiothoracic SSI prophylaxis. A theoretical cohort of 10,000 cardiothoracic surgery patients was followed through 2 stages: (1) occurrence of SSI, and (2) mortality after SSI. All patients were administered cefuroxime, vancomycin, or linezolid between 1 and 180 min prior to surgical incision. SSIs were categorized into 3 pathogen categories: (1) methicillin-susceptible Gram-positive, (2) methicillin-resistant Gram-positive, and (3) other organisms. The most effective strategy resulted in the fewest SSIs. Assumptions for antibiotic effectiveness, impact of administration time, and pathogens were based on the published literature.

RESULTS

Compared with cefuroxime, there was a 1% increase in the total number of SSIs in the linezolid group (mean SSI increase = 7), while there was a 12% increase in the vancomycin group (mean SSI increase = 86). Linezolid prophylaxis resulted in fewer SSIs due to methicillin-resistant Gram-positive infections (n = 108) compared with cefuroxime (n = 200, 46% reduction in the linezolid group) and vancomycin (n = 119, 9% reduction in the linezolid group).

CONCLUSIONS

This simulation indicates that linezolid may offer benefits for SSI prophylaxis over existing prophylactic agents, particularly for the prevention of SSI due to Gram-positive methicillin-resistant pathogens.

The application of evidence-based measures to reduce surgical site infections during orthopedic surgery - report of a single-center experience in Sweden

Background

Current knowledge suggests that, by applying evidence-based measures relating to the correct use of prophylactic antibiotics, perioperative normothermia, urinary tract catheterization and hand hygiene, important contributions can be made to reducing the risk of postoperative infections and device-related infections. The aim of this study was to explore and describe the application of intraoperative evidence-based measures, designed to reduce the risk of infection. In addition, we aimed to investigate whether the type of surgery, i.e. total joint arthroplasty compared with tibia and femur/hip fracture surgery, affected the use of protective measures.

Method

Data on the clinical application of evidence-based measures were collected structurally on site during 69 consecutively included operations involving fracture surgery (n = 35) and total joint arthroplasties (n = 34) using a pre-tested observation form. For observations in relation to hand disinfection, a modified version of the World Health Organization hand hygiene observation method was used.

Results

In all, only 29 patients (49%) of 59 received prophylaxis within the recommended time span. The differences in the timing of prophylactic antibiotics between total joint arthroplasty and fracture surgery were significant, i.e. a more accurate timing was implemented in patients undergoing total joint arthroplasty (p = 0.02). Eighteen (53%) of the patients undergoing total joint arthroplasty were actively treated with a forced-air warming system. The corresponding number for fracture surgery was 12 (34%) (p = 0.04).

Observations of 254 opportunities for hand hygiene revealed an overall adherence rate of 10.3% to hand disinfection guidelines.

Conclusions

The results showed that the utilization of evidence-based measures to reduce infections in clinical practice is not sufficient and there are unjustifiable differences in care depending on the type of surgery. The poor adherence to hand hygiene precautions in the operating room is a serious problem for patient safety and further studies should focus on resolving this problem. The WHO Safe Surgery checklist “time out” worked as an important reminder, but is not per se a guarantee of safety; it is the way we act in response to mistakes or lapses that finally matters.

Surgical prophylaxis and other complication avoidance care bundles

Individual health care quality measures that have been shown to improve outcome can be combined together into what are called care bundles, with the expectation that this set of practices produces further improvements in outcome. Prevention of surgical site infection is the focus of several quality measures put forward by the Surgical Care Improvement Project; these can collectively be considered a bundle as well. Whether these process measures, which include several components related to the administration of antibiotic prophylaxis, are effective in decreasing rates of surgical site infection has come under considerable debate recently.

[Prevention of wound infections: basic measures]

Individual patient risk factors for wound infections, such as alcohol abuse, smoking or obesity can usually only be modified to a small extent. Studies have shown a reduction of surgical site infections due to the implementation of a benchmarking surveillance system. In order to prevent surgical site infections a variety of interventions are available, such as glucose control, correction of anemia and malnutrition and antibiotic therapy of infections before elective surgery. Reduction of the microbial skin flora by whole body washing procedures, avoidance of sharp razor shaving, application of antibiotic prophylaxis and correct surgical hand disinfection are additional measures. Intraoperative hypothermia should be avoided and strict compliance with asepsis is mandatory. Postoperative preventive measures include appropriate wound care and rapid removal of wound drainage.

Long-term outcomes in elderly surgical patients

Anesthesia has developed to the point where long-term outcomes are important endpoints. Elderly patients are becoming an increasingly large part of most surgical practices, consistent with demographic shifts. Long-term outcomes are particularly important for this group. In this review, we discuss functional outcomes in the elderly. We describe the areas of cognitive change and frailty, both of which are specific to the elderly. We also discuss prevention of surgical infections and emerging evidence around hemodynamic alterations in the operating room and their impact on long-term outcomes.

Surgical site infections after abdominal closure in colorectal surgery using triclosan-coated absorbable suture (PDS Plus) vs. uncoated sutures (PDS II): a randomized multicenter study

BACKGROUND

Surgical site infections (SSI) are the third most common hospital-acquired infections and account for 14% to 16% of all such infections. In elective colorectal operations, the international SSI rate ranges from 4.7%-25%. In a previous retrospective study in this department, the SSI rate was unacceptably high (25%), and the promising different international evaluations of triclosan-coated suture materials encouraged us to create a multicenter randomized trial to improve our results. The main goal of this study was to compare triclosan-coated and uncoated absorbable suture (PDS Plus(®) with PDS II(®)) in elective colorectal operations.

METHODS

This was an internet-based study involving seven surgical centers. All the elective colorectal operations were performed by experienced surgeons. For abdominal fascia closure, running looped PDS was applied; triclosan-coated or uncoated PDS was chosen by computer randomization. Pre-operative and peri-operative variables such as gender, body mass index, neoadjuvant therapy, type II diabetes mellitus, amount of wound dressing material used, nursing days, and microbiological results were recorded. After the operation, the patient's data and risk factors were collected in a password-protected online database.

RESULTS

From 485 patients randomized, SSI was documented in 47 patients (12.5%), 23 (12.2%) in the group having triclosan-coated sutures (n=188) and 24 (12.2%) in the uncoated suture group (n=197), a non-significant difference. Of all SSIs, 13 (27.7%) were diagnosed only after discharge, being recognized in the outpatient setting, with four patients in the triclosan suture group (8.5%) and nine in the uncoated suture group (19.2%) being affected with no significant differences in the demographic data. Microbiological examinations, in addition to the same colon flora in both groups, revealed two gram-positive infections in the uncoated suture group. The hospital stay and costs of dressings were significantly higher in patients having SSIs.

CONCLUSION

Compared with the previous retrospective studies of this department, the implementation of looped PDS decreased the incidence of SSI by one-half, whether the suture was triclosan-coated or not. It seems that patient factors are less important than operative factors in the occurrence of SSI, and there were no differences between elective colon and rectal operations in the development of incisional infections. No beneficial effect of triclosan against gram-positive bacteria, which has been reported in the literature, could be confirmed in our study. We could not show an effect against gram-negative enteric microorganisms. Higher additional costs and longer hospital stay with SSI were confirmed.