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Kawamura H, Imuta N, Ooka T, Shigemi A, Nakamura M, Mougi K, Obama Y, Fukuyama R, Arimura S, Murata N, Tominaga H, Sasaki H, Nagano S, Taniguchi N, Nishi J. Impact of control measures including decolonization and hand hygiene for orthopaedic surgical site infection caused by MRSA at a Japanese tertiary-care hospital. J Hosp Infect 2024; 146:151-159. [PMID: 37516280 DOI: 10.1016/j.jhin.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/16/2023] [Accepted: 07/01/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Meticillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen in orthopaedic surgical site infections (SSIs). However, few studies have investigated the transmission process of orthopaedic MRSA SSI. AIM To investigate the transmission process of orthopaedic MRSA SSI using epidemiological and molecular analyses and to determine a method to prevent MRSA SSI in nosocomial orthopaedic surgery. METHODS Active MRSA surveillance, preoperative decolonization and contact precautions for MRSA-positive cases was performed at our institution. Changes in epidemic strains were evaluated and the possibility of transmission from patients in an orthopaedic ward of a Japanese tertiary-care hospital was assessed by genotyping stored MRSA strains. In addition, data on the prevalence of MRSA SSI, MRSA colonization, and use of an alcohol antiseptic agent (mL/patient-days) during 2005-2022 were retrospectively assessed. FINDINGS SCCmec type II strain in the SSI group decreased over time, associated with fewer outbreaks. Even during a period of high infection rates, no cases of transmission-induced SSI from nasal MRSA carriers were identified. The infection rate correlated negatively with the use of an alcohol antiseptic agent (r = -0.82; P < 0.0001). Two cases among five nasal carriers developed MRSA SSI caused by strains different from those related to nasal colonization. CONCLUSION The infection control measures for transmission from the hospital reservoirs including strict adherence to hand hygiene and decolonization of carriers is likely to be important for the prevention of orthopaedic MRSA SSI. However, the need for contact precautions for decolonized nasal carriers might be low.
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Affiliation(s)
- H Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | - N Imuta
- Department of Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - T Ooka
- Department of Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - A Shigemi
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - M Nakamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - K Mougi
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - Y Obama
- Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - R Fukuyama
- Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - S Arimura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - N Murata
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - H Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - H Sasaki
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - S Nagano
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - N Taniguchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - J Nishi
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Department of Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Whelan L, Leal J, Leslie M, Barkema HW, Ocampo W, May ER. Patient compliance with the implementation of a decolonization strategy for Staphylococcus aureus in hip and knee replacements. Am J Infect Control 2024; 52:207-213. [PMID: 37355096 DOI: 10.1016/j.ajic.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND A preoperative, in-community antimicrobial decolonization protocol combining chlorohexidine gluconate (CHG) sponges and mupirocin ointment to reduce surgical site infections amongst hip and knee replacement patients has been adopted in Alberta, Canada. Patient compliance with the protocol is essential for effectiveness. It is, therefore, important to understand patterns, and reasons why, patients do, and do not, comply. METHODS A descriptive survey of patients having elective total hip or knee replacement at seven clinics in Alberta was conducted to determine patient compliance and reasons for noncompliance. Descriptive statistics and multivariate logistic regression were computed. RESULTS Patient compliance was assessed in 3,427 patients. There were no differences in compliance based on the baseline protocols and enhanced protocols, but there was a difference based on clinic location. The odds of compliance with three CHG sponges were 4.47 times higher in rural versus urban clinics (P < .001). The most common reason for noncompliance for patients instructed to use 3 CHG sponges was "patient forgot". CONCLUSIONS Compliance did not change when enhanced protocols were introduced; however, compliance differed by clinic location. Reasons for noncompliance included "sponges not provided", "patient forgot", and "surgery date moved". Results may inform clinics on areas where improvements could be made to increase patient compliance.
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Affiliation(s)
- Lindsay Whelan
- Strategic Clinical Network, Alberta Health Services, AMR-One Health Consortium, Departments of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Jenine Leal
- Departments of Community Health Sciences, and Microbiology Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, O'Brien Institute for Public Health, University of Calgary, AMR-One Health Consortium, Infection Prevention and Control, Alberta Health Services, Calgary, AB, Canada
| | - Myles Leslie
- Department of Community Health Sciences, Cumming School of Medicine, and School of Public Policy, University of Calgary, AMR-One Health Consortium, Calgary, AB, Canada
| | - Herman W Barkema
- Departments of Production Animal Health, Faculty of Veterinary Medicine and Cumming School of Medicine, University of Calgary, AMR-One Health Consortium, One Health at UCalgary, University of Calgary Biostatistics Centre, Calgary, AB, Canada; Departments of Medicine, W21 Research and Innovation Centre, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Wrechelle Ocampo
- W21C Research and Innovation Centre, University of Calgary, Calgary, AB, Canada
| | - Elissa R May
- Departments of Medicine, and Community Health Sciences, and Microbiology Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Departments of Medicine, University of Calgary, O'Brien Institute for Public Health and Snyder Institute for Chronic Diseases, AMR-One Health Consortium, Calgary, AB, Canada
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Dukes KC, Reisinger HS, Schweizer M, Ward MA, Chapin L, Ryken TC, Perl TM, Herwaldt LA. Examining barriers to implementing a surgical-site infection bundle. Infect Control Hosp Epidemiol 2024; 45:13-20. [PMID: 37493031 PMCID: PMC10782202 DOI: 10.1017/ice.2023.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Surgical-site infections (SSIs) can be catastrophic. Bundles of evidence-based practices can reduce SSIs but can be difficult to implement and sustain. OBJECTIVE We sought to understand the implementation of SSI prevention bundles in 6 US hospitals. DESIGN Qualitative study. METHODS We conducted in-depth semistructured interviews with personnel involved in bundle implementation and conducted a thematic analysis of the transcripts. SETTING The study was conducted in 6 US hospitals: 2 academic tertiary-care hospitals, 3 academic-affiliated community hospitals, 1 unaffiliated community hospital. PARTICIPANTS In total, 30 hospital personnel participated. Participants included surgeons, laboratory directors, clinical personnel, and infection preventionists. RESULTS Bundle complexity impeded implementation. Other barriers varied across services, even within the same hospital. Multiple strategies were needed, and successful strategies in one service did not always apply in other areas. However, early and sustained interprofessional collaboration facilitated implementation. CONCLUSIONS The evidence-based SSI bundle is complicated and can be difficult to implement. One implementation process probably will not work for all settings. Multiple strategies were needed to overcome contextual and implementation barriers that varied by setting and implementation climate. Appropriate adaptations for specific settings and populations may improve bundle adoption, fidelity, acceptability, and sustainability.
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Affiliation(s)
- Kimberly C. Dukes
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans’ Affairs (VA) Health Care System (ICVAHCS), Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- College of Public Health, University of Iowa, Iowa City, Iowa
| | - Heather Schacht Reisinger
- Center for Access & Delivery Research & Evaluations (CADRE), Iowa City Veterans’ Affairs (VA) Health Care System (ICVAHCS), Iowa City, Iowa
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
| | - Marin Schweizer
- Department of Internal Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Melissa A. Ward
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | - Timothy C. Ryken
- MercyOne Northeast Iowa Neurosurgery, Iowa City, Iowa
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Trish M. Perl
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Loreen A. Herwaldt
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
- College of Public Health, University of Iowa, Iowa City, Iowa
- University of Iowa Hospitals and Clinics (UIHC), Iowa City, Iowa
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Hammond JB, Madura GM, Chang YHH, Lim ES, Habermann E, Cima R, Colibaseanu D, Siebeneck ET, Etzioni DA. The influence of operating room temperature and humidity on surgical site infection: A multisite ACS-NSQIP analysis. Am J Surg 2023; 226:840-844. [PMID: 37482475 DOI: 10.1016/j.amjsurg.2023.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/18/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Literature evaluating intraoperative temperature/humidity and risk of surgical site infection (SSI) is lacking. METHODS All operations at three centers reported to the ACS-NSQIP were reviewed (2016-2020); ambient intraoperative temperature (⁰F) and relative humidity (RH) were recorded in 15-min intervals. The primary endpoint was superficial SSI, which was evaluated with multi-level logistic regression. RESULTS 14,519 operations were analyzed with 179 SSIs (1.2%). The lower/upper 10th percentiles for temperature and RH were 64.4/71.4 °F and 33.5/55.5% respectively. Low or high temperature carried no significant increased risk for SSI (Low ⁰F OR = 0.95, 95% CI 0.51-1.77, P = 0.86; High ⁰F OR = 1.13, 95% CI = 0.69-1.86, P = 0.63). This was also true for low and high RH (Low RH OR = 0.96, 95% CI 0.58-1.61, p = 0.88; High RH OR = 0.61, 95% CI = 0.33-1.14, P = 0.12). Analysis of combined temperature/humidity showed no increased risk for SSI. CONCLUSION Significant deviations in intraoperative temperature/humidity are not associated with increased risk of SSI.
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Affiliation(s)
| | | | - Yu-Hui H Chang
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | - Elisabeth S Lim
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Robert Cima
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Eder M, Sommerstein R, Szelecsenyi A, Schweiger A, Schlegel M, Atkinson A, Kuster SP, Vuichard-Gysin D, Troillet N, Widmer AF. Association between the introduction of a national targeted intervention program and the incidence of surgical site infections in Swiss acute care hospitals. Antimicrob Resist Infect Control 2023; 12:134. [PMID: 37996935 PMCID: PMC10668371 DOI: 10.1186/s13756-023-01336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND In Switzerland, the national surgical site infection (SSI) surveillance program showed a modest decrease in SSI rates for different procedures over the last decade. The study aimed to determine whether a multimodal, targeted intervention program in addition to existing SSI surveillance is associated with decreased SSI rates in the participating hospitals. METHODS Prospective multicenter pre- and postintervention study conducted in eight Swiss acute care hospitals between 2013 and 2020. All consecutive patients > 18 years undergoing cardiac, colon, or hip/knee replacement surgery were included. The follow-up period was 30 days and one year for implant-related surgery. Patients with at least one follow-up were included. The intervention was to optimize three elements of preoperative management: (i) hair removal; (ii) skin disinfection; and (iii) perioperative antimicrobial prophylaxis. We compared SSI incidence rates (main outcome measure) pre- and postintervention (three years each) adjusted for potential confounders. Poisson generalized linear mixed models fitted to quarter-yearly confirmed SSIs and adjusted for baseline differences between hospitals and procedures. Adherence was routinely monitored through on-site visits. RESULTS A total of 10 151 patients were included, with a similar median age pre- and postintervention (69.6 and IQR 60.9, 76.8 years, vs 69.5 and IQR 60.4, 76.8 years, respectively; P = 0.55) and similar proportions of females (44.8% vs. 46.1%, respectively; P = 0.227). Preintervention, 309 SSIs occurred in 5 489 patients (5.6%), compared to 226 infections in 4 662 cases (4.8%, P = 0.09) postintervention. The adjusted incidence rate ratio (aIRR) for overall SSI after intervention implementation was 0.81 (95% CI, 0.68 to 0.96, P = 0.02). For cardiac surgery (n = 2 927), the aIRR of SSI was 0.48 (95% CI, 0.32 to 0.72, P < 0.001). For hip/knee replacement surgery (n = 4 522), the aIRR was 0.88 (95% CI, 0.52 to 1.48, P = 0.63), and for colon surgery (n = 2 702), the aIRR was 0.92 (95% CI, 0.75 to 1.14, P = 0.49). CONCLUSIONS The SSI intervention bundle was associated with a statistically significant decrease in SSI cases. A significant association was observed for cardiac surgery. Adding a specific intervention program can add value compared to routine surveillance only. Further prevention modules might be necessary for colon and orthopedic surgery.
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Affiliation(s)
- Marcus Eder
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
| | - Rami Sommerstein
- Swissnoso, the National Center for Infection Control, Bern, Switzerland.
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
| | | | - Alexander Schweiger
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Medicine and Infectious Diseases, Cantonal Hospital Zug, Zug, Switzerland
| | - Matthias Schlegel
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Andrew Atkinson
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Stefan P Kuster
- Department of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Danielle Vuichard-Gysin
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Infectious Diseases, Thurgau Hospital Group, Muensterlingen and Frauenfeld, Switzerland
| | - Nicolas Troillet
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Service of Infectious Diseases, Central Institute, Valais Hospitals, Sion, Switzerland
| | - Andreas F Widmer
- Swissnoso, the National Center for Infection Control, Bern, Switzerland
- Department of Infectious Diseases, University Hospital Basel, Basel, Switzerland
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Smith M, Herwaldt L. Nasal decolonization: What antimicrobials and antiseptics are most effective before surgery and in the ICU. Am J Infect Control 2023; 51:A64-A71. [PMID: 37890955 DOI: 10.1016/j.ajic.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND Staphylococcus aureus colonization is a key risk factor for S. aureus infections in surgical patients and in hospitalized patients. Many studies have assessed various decolonization agents, protocols, and settings. This review summarizes key findings about nasal decolonization for 2 different patient populations: patients undergoing surgery and patients hospitalized in intensive care units. METHODS We reviewed major studies related to decolonization of patients colonized with S. aureus and who were either undergoing surgical procedures or were hospitalized in intensive care units. We focused on recent studies, particularly randomized controlled trials and robust quasi-experimental trials. We also reviewed select non-randomized trials when more rigorous trials were limited. DISCUSSION/CONCLUSIONS Mupirocin is the best-studied agent for decolonization. Its use reduces the risk of surgical site infection following orthopedic surgery (strongest data) and cardiac surgery. Mupirocin decolonization also reduces the incidence of S. aureus clinical cultures in the intensive care unit. Povidone-iodine is less well-studied. Current data suggest that it decreases the risk of surgical site infections after orthopedic surgical procedures. In contrast, povidone-iodine is less effective than mupirocin for reducing the incidence of S aureus clinical cultures in the intensive care unit. Both mupirocin and povidone-iodine have important limitations, highlighting the need for future decolonization research.
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Affiliation(s)
- Matthew Smith
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA.
| | - Loreen Herwaldt
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
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Peel TN, Astbury S, Cheng AC, Paterson DL, Buising KL, Spelman T, Tran-Duy A, Adie S, Boyce G, McDougall C, Molnar R, Mulford J, Rehfisch P, Solomon M, Crawford R, Harris-Brown T, Roney J, Wisniewski J, de Steiger R. Trial of Vancomycin and Cefazolin as Surgical Prophylaxis in Arthroplasty. N Engl J Med 2023; 389:1488-1498. [PMID: 37851875 DOI: 10.1056/nejmoa2301401] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
BACKGROUND The addition of vancomycin to beta-lactam prophylaxis in arthroplasty may reduce surgical-site infections; however, the efficacy and safety are unclear. METHODS In this multicenter, double-blind, superiority, placebo-controlled trial, we randomly assigned adult patients without known methicillin-resistant Staphylococcus aureus (MRSA) colonization who were undergoing arthroplasty to receive 1.5 g of vancomycin or normal saline placebo, in addition to cefazolin prophylaxis. The primary outcome was surgical-site infection within 90 days after surgery. RESULTS A total of 4239 patients underwent randomization. Among 4113 patients in the modified intention-to-treat population (2233 undergoing knee arthroplasty, 1850 undergoing hip arthroplasty, and 30 undergoing shoulder arthroplasty), surgical-site infections occurred in 91 of 2044 patients (4.5%) in the vancomycin group and in 72 of 2069 patients (3.5%) in the placebo group (relative risk, 1.28; 95% confidence interval [CI], 0.94 to 1.73; P = 0.11). Among patients undergoing knee arthroplasty, surgical-site infections occurred in 63 of 1109 patients (5.7%) in the vancomyin group and in 42 of 1124 patients (3.7%) in the placebo group (relative risk, 1.52; 95% CI, 1.04 to 2.23). Among patients undergoing hip arthroplasty, surgical-site infections occurred in 28 of 920 patients (3.0%) in the vancomyin group and in 29 of 930 patients (3.1%) in the placebo group (relative risk, 0.98; 95% CI, 0.59 to 1.63). Adverse events occurred in 35 of 2010 patients (1.7%) in the vancomycin group and in 35 of 2030 patients (1.7%) in the placebo group, including hypersensitivity reactions in 24 of 2010 patients (1.2%) and 11 of 2030 patients (0.5%), respectively (relative risk, 2.20; 95% CI, 1.08 to 4.49), and acute kidney injury in 42 of 2010 patients (2.1%) and 74 of 2030 patients (3.6%), respectively (relative risk, 0.57; 95% CI, 0.39 to 0.83). CONCLUSIONS The addition of vancomycin to cefazolin prophylaxis was not superior to placebo for the prevention of surgical-site infections in arthroplasty among patients without known MRSA colonization. (Funded by the Australian National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618000642280.).
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Affiliation(s)
- Trisha N Peel
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Sarah Astbury
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Allen C Cheng
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - David L Paterson
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Kirsty L Buising
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Tim Spelman
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - An Tran-Duy
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Sam Adie
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Glenn Boyce
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Catherine McDougall
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Robert Molnar
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Jonathan Mulford
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Peter Rehfisch
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Michael Solomon
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Ross Crawford
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Tiffany Harris-Brown
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Janine Roney
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Jessica Wisniewski
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
| | - Richard de Steiger
- From the Department of Infectious Diseases, Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences (T.N.P., S. Astbury, J.W.), and the Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine (A.C.C.), Monash University, the Department of Infectious Diseases, Alfred Health (T.N.P., S. Astbury, A.C.C., J.R., J.W.), the Department of Infectious Diseases, Doherty Institute (K.L.B.), the Department of Surgery, St. Vincent's Hospital (T.S.), the Centre for Health Policy, Melbourne School of Population and Global Health (A.T.-D.), and the Department of Surgery, Epworth HealthCare (R.S.), University of Melbourne, the Victorian Infectious Diseases Service, Royal Melbourne Hospital (K.L.B.), and the Department of Health Services Research, Peter MacCallum Cancer Centre, and Burnet Institute (T.S.), Melbourne, VIC, the St. George and Sutherland Clinical Campuses, School of Clinical Medicine, University of New South Wales Medicine and Health, Sydney (S. Adie, R.M.), Bendigo Health, Bendigo, VIC (G.B.), the Department of Orthopaedics, Prince Charles Hospital, Metro North Hospital and Health Service (C.M., R.C.), the Department of Medicine (C.M.) and the Centre for Clinical Research (T.H.-B.), University of Queensland, and Queensland University of Technology (R.C.), Brisbane, the Department of Orthopaedics, Launceston General Hospital, Tasmanian Health Service, Launceston, TAS (J.M.), Gippsland Orthopaedic Group, Traralgon, VIC (P.R.), and Prince of Wales Hospital and Prince of Wales Private Hospital, Randwick, NSW (M.S.) - all in Australia; Advancing Clinical Evidence in Infectious Diseases, Saw Swee Hock School of Public Health, and the Infectious Diseases Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (D.L.P.); and the Department of Clinical Neuroscience, Karolinska Institute, Stockholm (T.S.)
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Goudelocke C, Hill H, Major N, Couvaras A, Long A. A novel sacral neuromodulation protocol is associated with reduction in removal for device infection. Int Urogynecol J 2023; 34:2421-2428. [PMID: 37154899 DOI: 10.1007/s00192-023-05543-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/26/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Sacral neuromodulation (SNM) has been established as an effective third-line therapy for non-obstructive urinary retention and urinary urgency-frequency syndrome. Device infection, ranging from 2-10%, is a severe complication usually necessitating device explanation. This study sought to demonstrate an infection protocol founded upon established device implantation risk factors and novel approaches to reduce the incidence of device infection, while maintaining good antibiotic stewardship following best practice statements. METHODS A single-surgeon protocol was enacted from 2013 to 2022. Preoperatively, nasal swabs were cultured from each patient. If positive for methicillin-resistant Staphylococcus aureus or methicillin-sensitive Staphylococcus aureus, preoperative treatment with intranasal mupirocin was employed. Preoperative cefazolin was administered in patients with negative cultures or MSSA-positive. All protocol patients were given chlorhexidine wipes before surgery and prepped with a chlorhexidine scrub followed by alcohol/iodine paint. Post-procedural antibiotics were not given. Pre-protocol patients from 2011 to 2013 served as controls. RESULTS Pre-protocol (n = 87) patients had a significantly higher rate of device infection compared to protocol patients (n = 444) in both the percentage of patients experiencing device infection (4.6% vs 0.9%, p = 0.01) and percentage of procedures associated with device infection (2.9% vs 0.5%, p < 0.05). A successful culture of the nares was achieved in 91.4% of protocol patients, with 11.6% MRSA-positive. Risk ratio for infection of pre-protocol/protocol patients was 0.19 (0.05-0.77) with odds ratio 5.1 (1.3-20.0). CONCLUSIONS Utilization of a novel SNM infection protocol tailored to a patient's preoperative MRSA colonization is associated with a reduction in the overall incidence of explant for device infection while avoiding prolonged postoperative antibiotic regimens. CLINICAL TRIAL REGISTRATION The study was initiated prior to January 18, 2017 and does not meet the definition of an applicable clinical trial (ACT) as defined in section 402 (J) of the US PHS Act.
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Affiliation(s)
- Colin Goudelocke
- Department of Urology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA, 70121, USA.
| | - Hayden Hill
- Department of Urology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA, 70121, USA
| | - Nicholas Major
- Department of Urology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA, 70121, USA
| | - Anastasia Couvaras
- Department of Urology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA, 70121, USA
| | - Amy Long
- Department of Urology, Erlanger Health Center, Chattanooga, TN, USA
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9
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Price L, Gozdzielewska L, Hendry K, McFarland A, Reilly J. Effectiveness of national and subnational interventions for prevention and control of health-care-associated infections in acute hospitals in high-income and upper-middle-income counties: a systematic review update. THE LANCET. INFECTIOUS DISEASES 2023; 23:e347-e360. [PMID: 37023784 DOI: 10.1016/s1473-3099(23)00049-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 04/05/2023]
Abstract
This systematic review, commissioned and funded by WHO, aimed to update a review of infection prevention and control (IPC) interventions at a national level to inform a review of their IPC Core Components guidelines (PROSPERO CRD42021297376). CENTRAL, CINAHL, Embase, MEDLINE, and WHO IRIS were searched for studies meeting Cochrane's Effective Practice and Organisation of Care (EPOC) design criteria, published from April 19, 2017, to Oct 14, 2021. Primary research studies examining national IPC interventions in acute hospitals in any country with outcomes related to rates of health-care-associated infections were included. Two independent reviewers extracted data and assessed quality using the EPOC risk of bias criteria. 36 studies were categorised per intervention type and synthesised narratively: care bundles (n=2), care bundles with implementation strategies (n=9), IPC programmes (n=16), and regulations (n=9). Designs included 21 interrupted time-series, nine controlled before-and-after studies, four cluster-randomised trials, and two non-randomised trials. Evidence supports the effectiveness of care bundles with implementation strategies. However, evidence for IPC programmes and regulations was inconclusive as studies were heterogeneous regarding populations, interventions, and outcomes. The overall risk of bias was high. Recommendations include the involvement of implementation strategies in care bundles and for further research on national IPC interventions with robust study designs and in low-income and middle-income settings.
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Affiliation(s)
- Lesley Price
- Research Centre for Health, Glasgow Caledonian University, Glasgow UK
| | | | - Katie Hendry
- Research Centre for Health, Glasgow Caledonian University, Glasgow UK
| | - Agi McFarland
- Research Centre for Health, Glasgow Caledonian University, Glasgow UK
| | - Jacqui Reilly
- Research Centre for Health, Glasgow Caledonian University, Glasgow UK
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10
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Schaffzin JK, Sickbert-Bennett EE, Deloney VM, Weber DJ. Implementation should be a standard component of practice guidelines and guidance documents. Infect Control Hosp Epidemiol 2023; 44:1365-1368. [PMID: 36858810 DOI: 10.1017/ice.2022.294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Joshua K Schaffzin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Emily E Sickbert-Bennett
- Division of Infectious Diseases, Department of Medicine, UNC- Chapel Hill, Chapel Hill, North Carolina
- Department of Infection Prevention, UNC Medical Center, Chapel Hill, North Carolina
| | - Valerie M Deloney
- Society for Healthcare Epidemiology of America (SHEA), Arlington, Virginia
| | - David J Weber
- Division of Infectious Diseases, Department of Medicine, UNC- Chapel Hill, Chapel Hill, North Carolina
- Department of Infection Prevention, UNC Medical Center, Chapel Hill, North Carolina
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11
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McCoy C, Keshvani N, Warsi M, Brown LS, Girod C, Chu ES, Hegde AA. Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival. BMJ Open Qual 2023; 12:e002220. [PMID: 37730270 PMCID: PMC10510939 DOI: 10.1136/bmjoq-2022-002220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 08/09/2023] [Indexed: 09/22/2023] Open
Abstract
Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.
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Affiliation(s)
- Cody McCoy
- Division of Cardiology, Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Maryam Warsi
- Fred Hutchinson Cancer Research Center, Statistical Center for HIV/AIDS Research and Prevention, University of Washington School of Medicine, Seattle, Washington, USA
| | - L Steven Brown
- Department of Health Systems Research, Parkland Health, Dallas, Texas, USA
| | - Carlos Girod
- Division of Pulmonary & Critical Care, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
- Medicine Services, Parkland Health, Dallas, Texas, USA
| | - Eugene S Chu
- Medicine Services, Parkland Health, Dallas, Texas, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Anita A Hegde
- Medicine Services, Parkland Health, Dallas, Texas, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
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12
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Suzuki H, Perencevich EN, Hockett Sherlock S, Clore GS, O'Shea AMJ, Forrest GN, Pfeiffer CD, Safdar N, Crnich C, Gupta K, Strymish J, Lira GB, Bradley S, Cadena-Zuluaga J, Rubin M, Bittner M, Morgan D, DeVries A, Miell K, Alexander B, Schweizer ML. Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals. JAMA Netw Open 2023; 6:e2324516. [PMID: 37471087 DOI: 10.1001/jamanetworkopen.2023.24516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Importance While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors. Objective To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates. Design, Setting, and Participants This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023. Interventions Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed. Main Outcomes and Measures The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods. Results Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found. Conclusions and Relevance Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.
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Affiliation(s)
- Hiroyuki Suzuki
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Eli N Perencevich
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Stacey Hockett Sherlock
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Gosia S Clore
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Amy M J O'Shea
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Graeme N Forrest
- Division of Infectious Disease, Rush University Medical Center, Chicago, Illinois
| | - Christopher D Pfeiffer
- Infectious Diseases Section, VA Portland Health Care System, Portland, Oregon
- Division of Infectious Diseases, OHSU, Portland, Oregon
| | - Nasia Safdar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Christopher Crnich
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Kalpana Gupta
- Division of Infectious Diseases, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research (CHOIR), Boston VA Healthcare System, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Judith Strymish
- Division of Infectious Diseases, Department of Medicine, Boston VA Healthcare System, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Gio Baracco Lira
- Division of Infectious Diseases, Miller School of Medicine, University of Miami, Miami, Florida
- Hospital Epidemiology and Occupational Health Service, Miami VA Healthcare System, Miami, Florida
| | - Suzanne Bradley
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
- Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jose Cadena-Zuluaga
- South Texas Veterans Health Care System, San Antonio
- Long School of Medicine, UT Health San Antonio, San Antonio, Texas
| | - Michael Rubin
- Department of Veterans' Affairs, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Marvin Bittner
- Nebraska-Western Iowa Veterans Affairs Health Care System, Omaha, Nebraska
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Daniel Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- VA Maryland Health Care System, Baltimore
| | - Aaron DeVries
- Minneapolis VA Medical Center, Minneapolis, Minnesota
| | - Kelly Miell
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Bruce Alexander
- Center for Access and Delivery Research & Evaluation (CADRE), Iowa City Veterans' Affairs Health Care System, Iowa City, Iowa
| | - Marin L Schweizer
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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13
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Popovich KJ, Aureden K, Ham DC, Harris AD, Hessels AJ, Huang SS, Maragakis LL, Milstone AM, Moody J, Yokoe D, Calfee DP. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:1039-1067. [PMID: 37381690 PMCID: PMC10369222 DOI: 10.1017/ice.2023.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 06/29/2023]
Abstract
Previously published guidelines have provided 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 efforts to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and infection. This document updates the "Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals" published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
- Kyle J. Popovich
- Department of Internal Medicine, RUSH Medical College, Chicago, Illinois
| | - Kathy Aureden
- Infection Prevention, Advocate Aurora Health, Downers Grove, Illinois
| | - D. Cal Ham
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anthony D. Harris
- Health Care Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda J. Hessels
- Columbia School of Nursing, New York, New York
- Hackensack Meridian Health, Edison, New Jersey
| | - Susan S. Huang
- Division of Infectious Diseases, University of California Irvine School of Medicine, Irvine, California
| | - Lisa L. Maragakis
- Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Aaron M. Milstone
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Julia Moody
- Infection Prevention, HCA Healthcare, Nashville, Tennessee
| | - Deborah Yokoe
- Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California
- Transplant Infectious Diseases, UCSF Medical Center, San Francisco, California
| | - David P. Calfee
- Department of Medicine, Weill Cornell Medicine, New York, New York
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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14
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Cabral SM, Harris AD, Cosgrove SE, Magder LS, Tamma PD, Goodman KE. Adherence to Antimicrobial Prophylaxis Guidelines for Elective Surgeries Across 825 US Hospitals, 2019-2020. Clin Infect Dis 2023; 76:2106-2115. [PMID: 36774539 DOI: 10.1093/cid/ciad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND There are limited US data assessing adherence to surgical antimicrobial prophylaxis guidelines, particularly across a large, nationwide sample. Moreover, commonly prescribed inappropriate antimicrobial prophylaxis regimens remain unknown, hindering improvement initiatives. METHODS We conducted a retrospective cohort study of adults who underwent elective craniotomy, hip replacement, knee replacement, spinal procedure, or hernia repair in 2019-2020 at hospitals in the PINC AI (Premier) Healthcare Database. We evaluated adherence of prophylaxis regimens, with respect to antimicrobial agents endorsed in the American Society of Health-System Pharmacist guidelines, accounting for patient antibiotic allergy and methicillin-resistant Staphylococcus aureus colonization status. We used multivariable logistic regression with random effects by hospital to evaluate associations between patient, procedural, and hospital characteristics and guideline adherence. RESULTS Across 825 hospitals and 521 091 inpatient elective surgeries, 308 760 (59%) were adherent to prophylaxis guidelines. In adjusted analysis, adherence varied significantly by US Census division (adjusted OR [aOR] range: .61-1.61) and was significantly lower in 2020 compared with 2019 (aOR: .92; 95% CI: .91-.94; P < .001). The most common reason for nonadherence was unnecessary vancomycin use. In a post hoc analysis, controlling for patient age, comorbidities, other nephrotoxic agent use, and patient and procedure characteristics, patients receiving cefazolin plus vancomycin had 19% higher odds of acute kidney injury (AKI) compared with patients receiving cefazolin alone (aOR: 1.19; 95% CI: 1.11-1.27; P < .001). CONCLUSIONS Adherence to antimicrobial prophylaxis guidelines remains suboptimal, largely driven by unnecessary vancomycin use, which may increase the risk of AKI. Adherence decreased in the first year of the COVID-19 pandemic.
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Affiliation(s)
- Stephanie M Cabral
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, The University of Maryland School of Medicine, Baltimore, Maryland, USA
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Loftus RW, Dexter F, Brown J. The importance of targeting intraoperative transmission of bacteria with antibiotic resistance and strain characteristics. Am J Infect Control 2023; 51:612-618. [PMID: 35926685 PMCID: PMC10918765 DOI: 10.1016/j.ajic.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Evidence-based intraoperative infection control measures can reduce Staphylococcus aureus transmission and infections. We aimed to determine whether transmitted S. aureus isolates were associated with increased risk of multidrug resistance and associated traits. METHODS S. aureus isolates obtained from intraoperative environmental, patient skin, and provider hand reservoirs among 274 operating room case pairs (1st and 2nd case of the day) across 3 major academic medical centers from March 2009 to February 2010 underwent systematic-phenotypic-genomic analysis to identify clonal transmission events. The association of clonal S. aureus transmission with multidrug resistance and resistance traits was investigated. Transmission dynamics were characterized. RESULTS Transmitted isolates (N=58) were associated with increased risk of multi-drug antibiotic resistance [33% (19/58) transmitted vs. 10% (12/115) other isolates, risk ratio 3.14, 99% CI 1.34-7.38, P=0.0006]. Transmission was associated with a significant increase in resistance traits including mecA [40% transmitted isolates vs. 17% other isolates, risk ratio 2.28, P=0.0026] and ant (6)-Ia [26% transmitted isolates vs. 9% other isolates, risk ratio 2.97, P=0.0050]. Provider hands were a frequent reservoir of origin, between-case a common mode of transmission, and patient skin and provider hands frequent transmission locations for multidrug resistant pathogens. CONCLUSIONS Intraoperative S. aureus transmission was associated with multidrug resistance and resistance traits. Proven infection control measures should be leveraged to target intraoperative transmission of multidrug resistant pathogens.
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16
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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17
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Krezalek MA, Alverdy JC. The Role of the Gut Microbiome on the Development of Surgical Site Infections. Clin Colon Rectal Surg 2023; 36:133-137. [PMID: 36844709 PMCID: PMC9946714 DOI: 10.1055/s-0043-1760719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Despite advances in antisepsis techniques, surgical site infection remains the most common and most costly reason for hospital readmission after surgery. Wound infections are conventionally thought to be directly caused by wound contamination. However, despite strict adherence to surgical site infection prevention techniques and bundles, these infections continue to occur at high rates. The contaminant theory of surgical site infection fails to predict and explain most postoperative infections and still remains unproven. In this article we provide evidence that the process of surgical site infection development is far more complex than what can be explained by simple bacterial contamination and hosts' ability to clear the contaminating pathogen. We show a link between the intestinal microbiome and distant surgical site infections, even in the absence of intestinal barrier breach. We discuss the Trojan-horse mechanisms by which surgical wounds may become seeded by pathogens from within one's own body and the contingencies that need to be met for an infection to develop.
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Affiliation(s)
- Monika A. Krezalek
- Division of Gastrointestinal and General Surgery, Department of Surgery, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Evanston, Illinois
| | - John C. Alverdy
- Sarah and Harold Lincoln Thompson Professor of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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18
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Miller LG, Singh R, Eells SJ, Gillen D, McKinnell JA, Park S, Tjoa T, Chang J, Rashid S, Macias-Gil R, Heim L, Gombosev A, Kim D, Cui E, Lequieu J, Cao C, Hong SS, Peterson EM, Evans KD, Launer B, Tam S, Bolaris M, Huang SS. Chlorhexidine and Mupirocin for Clearance of Methicillin-Resistant Staphylococcus aureus Colonization After Hospital Discharge: A Secondary Analysis of the Changing Lives by Eradicating Antibiotic Resistance Trial. Clin Infect Dis 2023; 76:e1208-e1216. [PMID: 35640877 PMCID: PMC10169430 DOI: 10.1093/cid/ciac402] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The CLEAR Trial demonstrated that a multisite body decolonization regimen reduced post-discharge infection and hospitalization in methicillin-resistant Staphylococcus aureus (MRSA) carriers. Here, we describe decolonization efficacy. METHODS We performed a large, multicenter, randomized clinical trial of MRSA decolonization among adult patients after hospital discharge with MRSA infection or colonization. Participants were randomized 1:1 to either MRSA prevention education or education plus decolonization with topical chlorhexidine, oral chlorhexidine, and nasal mupirocin. Participants were swabbed in the nares, throat, axilla/groin, and wound (if applicable) at baseline and 1, 3, 6, and 9 months after randomization. The primary outcomes of this study are follow-up colonization differences between groups. RESULTS Among 2121 participants, 1058 were randomized to decolonization. By 1 month, MRSA colonization was lower in the decolonization group compared with the education-only group (odds ration [OR] = 0.44; 95% confidence interval [CI], .36-.54; P ≤ .001). A similar magnitude of reduction was seen in the nares (OR = 0.34; 95% CI, .27-.42; P < .001), throat (OR = 0.55; 95% CI, .42-.73; P < .001), and axilla/groin (OR = 0.57; 95% CI, .43-.75; P < .001). These differences persisted through month 9 except at the wound site, which had a relatively small sample size. Higher regimen adherence was associated with lower MRSA colonization (P ≤ .01). CONCLUSIONS In a randomized, clinical trial, a repeated post-discharge decolonization regimen for MRSA carriers reduced MRSA colonization overall and at multiple body sites. Higher treatment adherence was associated with greater reductions in MRSA colonization.
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Affiliation(s)
- Loren G Miller
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Raveena Singh
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Samantha J Eells
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Daniel Gillen
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - James A McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Steven Park
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Tom Tjoa
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Justin Chang
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Syma Rashid
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Raul Macias-Gil
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Lauren Heim
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Adrijana Gombosev
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Diane Kim
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Eric Cui
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Jennifer Lequieu
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Chenghua Cao
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Suzie S Hong
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Ellena M Peterson
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Kaye D Evans
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Bryn Launer
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Steven Tam
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Michael Bolaris
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Susan S Huang
- Division of Infectious Diseases and Health Policy Research Institute, University of California, Irvine School of Medicine, Irvine, California, USA
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Xiong GX, Greene NE, Hershman SH, Fogel HA, Schwab JH, Bono CM, Tobert DG. Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion? Clin Spine Surg 2023; 36:E51-E58. [PMID: 35676748 DOI: 10.1097/bsd.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/18/2022] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. SUMMARY OF BACKGROUND DATA Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. MATERIALS AND METHODS Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. RESULTS This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. CONCLUSIONS There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.
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Rodríguez-Fernández M, López Cortés LE. Patogenia, factores de riesgo y prevención de las infecciones de dispositivos de estimulación cardiaca. CIRUGIA CARDIOVASCULAR 2023. [DOI: 10.1016/j.circv.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
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Wilson E, Marra AR, Ward M, Chapin L, Boulden S, Ryken TC, Jones LC, Herwaldt LA. Patients' experiences and compliance with preoperative screening and decolonization. Am J Infect Control 2023; 51:78-82. [PMID: 35339622 DOI: 10.1016/j.ajic.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND To improve adherence with pre-surgical screening for Staphylococcus aureus nasal carriage and decolonization, we need more information about patients' experiences with these protocols. METHODS We surveyed patients undergoing orthopedic, neurosurgical, or cardiac operations at Johns Hopkins Hospitals (JHH), the University of Iowa Hospitals and Clinics (UIHC) at MercyOne Northeast Iowa Neurosurgery (MONIN) to assess patients' experiences with decolonization protocols. RESULTS Five hundred thirty-four patients responded. Respondents at JHH were significantly more likely than those at the UIHC to report using mupirocin and were significantly more likely than those at the UIHC and MONIN to feel they received adequate information about surgical site infection (SSI) prevention and decolonization. Respondents at JHH were the least likely to not worry about SSI and they were more willing to do anything they could to prevent SSI. Few patients reported barriers to adherence and side effects of mupirocin or chlorhexidine. CONCLUSION Respondents did not report either major side effects or barriers to adherence. Patients varied in their level of concern about SSI, their willingness to invest effort in preventing SSI, and their assessments of preoperative information. To improve patients' adherence, clinicians and hospitals should assess their patients' needs and desires and tailor their preoperative processes, education, and prophylaxis accordingly.
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Affiliation(s)
- Ethan Wilson
- University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA, USA
| | - Alexandre R Marra
- University of Iowa Hospitals & Clinics, Iowa City, IA, USA; Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Melissa Ward
- University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA, USA
| | - Laura Chapin
- MercyOne Northeast Iowa Neurosurgery, Iowa City, IA, USA
| | | | - Timothy C Ryken
- MercyOne Northeast Iowa Neurosurgery, Iowa City, IA, USA; Dartmouth-Hitchcock Medical Center, Department of Neurosurgery, Lebanon, NH, USA
| | - Lynne C Jones
- Johns Hopkins School of Medicine, Department of Orthopaedic Surgery, Baltimore, MD, USA
| | - Loreen A Herwaldt
- University of Iowa College of Public Health, Department of Epidemiology, Iowa City, IA, USA; University of Iowa Carver College of Medicine, Department of Internal Medicine, Iowa City, IA, USA.
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22
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Muacevic A, Adler JR. Intranasal Mupirocin to Reduce Surgical Site Infection Post Cardiac Surgery: A Review of the Literature. Cureus 2023; 15:e33678. [PMID: 36793816 PMCID: PMC9924705 DOI: 10.7759/cureus.33678] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 01/15/2023] Open
Abstract
Sternal wound infections after cardiac surgery are associated with high rates of morbidity and mortality. One of the known risk factors of sternal wound infection is Staphylococcus aureus colonisation. Intranasal mupirocin decolonisation therapy implemented pre-operatively appears to be an effective preventative measure in reducing sternal wound infections post-cardiac surgery. Therefore, the main aim of this review is to evaluate the current literature regarding the use of intranasal mupirocin before cardiac surgery and its impact on sternal wound infection rates.
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23
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Garcia R, Barnes S, Boukidjian R, Goss LK, Spencer M, Septimus EJ, Wright MO, Munro S, Reese SM, Fakih MG, Edmiston CE, Levesque M. Recommendations for change in infection prevention programs and practice. Am J Infect Control 2022; 50:1281-1295. [PMID: 35525498 PMCID: PMC9065600 DOI: 10.1016/j.ajic.2022.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 01/25/2023]
Abstract
Fifty years of evolution in infection prevention and control programs have involved significant accomplishments related to clinical practices, methodologies, and technology. However, regulatory mandates, and resource and research limitations, coupled with emerging infection threats such as the COVID-19 pandemic, present considerable challenges for infection preventionists. This article provides guidance and recommendations in 14 key areas. These interventions should be considered for implementation by United States health care facilities in the near future.
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Affiliation(s)
- Robert Garcia
- Department of Healthcare Epidemiology, State University of New York at Stony Brook, Stony Brook, NY,Address correspondence to Robert Garcia, BS, MT(ASCP), CIC, FAPIC, Department of Healthcare Epidemiology, State University of New York at Stony Brook, 100 Nicolls Rd, Stony Brook, NY, 11580
| | - Sue Barnes
- Infection Preventionist (Retired), San Mateo, CA
| | | | - Linda Kaye Goss
- Department of Infection Prevention, The Queen's Health System, Honolulu, HI
| | | | | | | | - Shannon Munro
- Department of Veterans Affairs Medical Center, Research and Development, Salem, VA
| | - Sara M. Reese
- Quality and Patient Safety Department, SCL Health System Broomfield, CO
| | - Mohamad G. Fakih
- Clinical & Network Services, Ascension Healthcare and Wayne State University School of Medicine, Grosse Pointe Woods, MI
| | | | - Martin Levesque
- System Infection Prevention and Control, Henry Ford Health, Detroit, MI
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Zukowska A, Zukowski M. Surgical Site Infection in Cardiac Surgery. J Clin Med 2022; 11:jcm11236991. [PMID: 36498567 PMCID: PMC9738257 DOI: 10.3390/jcm11236991] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
Surgical site infections (SSIs) are one of the most significant complications in surgical patients and are strongly associated with poorer prognosis. Due to their aggressive character, cardiac surgical procedures carry a particular high risk of postoperative infection, with infection incidence rates ranging from a reported 3.5% and 26.8% in cardiac surgery patients. Given the specific nature of cardiac surgical procedures, sternal wound and graft harvesting site infections are the most common SSIs. Undoubtedly, DSWIs, including mediastinitis, in cardiac surgery patients remain a significant clinical problem as they are associated with increased hospital stay, substantial medical costs and high mortality, ranging from 3% to 20%. In SSI prevention, it is important to implement procedures reducing preoperative risk factors, such as: obesity, hypoalbuminemia, abnormal glucose levels, smoking and S. aureus carriage. For decolonisation of S. aureus carriers prior to cardiac surgery, it is recommended to administer nasal mupirocin, together with baths using chlorhexidine-based agents. Perioperative management also involves antibiotic prophylaxis, surgical site preparation, topical antibiotic administration and the maintenance of normal glucose levels. SSI treatment involves surgical intervention, NPWT application and antibiotic therapy.
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Affiliation(s)
- Agnieszka Zukowska
- Department of Infection Control, Regional Hospital Stargard, 73-110 Stargard, Poland
| | - Maciej Zukowski
- Department of Anesthesiology, Intensive Care and Acute Intoxication, Pomeranian Medical University, 70-204 Szczecin, Poland
- Correspondence: ; Tel.: +48-504-451-924
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25
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Chung WTG, Shafi H, Seah J, Purnima P, Patun T, Kam KQ, Seah VXF, Ong RYL, Lin L, Choo RSM, Lingegowda P, Lim CLL, Chung JS, Chua NGSY, Lee TH, Yap MY, Ng TM, Somani J. National surgical antibiotic prophylaxis guideline in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Institutional surgical antibiotic prophylaxis (SAP) guidelines are in place at all public hospitals in Singapore, but variations exist and adherence to guidelines is not tracked consistently. A national point prevalence survey carried out in 2020 showed that about 60% of surgical prophylactic antibiotics were administered for more than 24 hours. This guideline aims to align best practices nationally and provides a framework for audit and surveillance.
Method: This guideline was developed by the National Antimicrobial Stewardship Expert Panel’s National Surgical Antibiotic Prophylaxis Guideline Development Workgroup Panel, which comprises infectious diseases physicians, pharmacists, surgeons and anaesthesiologists. The Workgroup adopted the ADAPTE methodology framework with modifications for the development of the guideline. The recommended duration of antibiotic prophylaxis was graded according to the strength of consolidated evidence based on the scoring system of the Singapore Ministry of Health Clinical Practice Guidelines.
Results: This National SAP Guideline provides evidence-based recommendations for the rational use of antibiotic prophylaxis. These include recommended agents, dose, timing and duration for patients undergoing common surgeries based on surgical disciplines. The Workgroup also provides antibiotic recommendations for special patient population groups (such as patients with β-lactam allergy and patients colonised with methicillin-resistant Staphylococcus aureus), as well as for monitoring and surveillance of SAP.
Conclusion: This evidence-based National SAP Guideline for hospitals in Singapore aims to align practices and optimise the use of antibiotics for surgical prophylaxis for the prevention of surgical site infections while reducing adverse events from prolonged durations of SAP.
Keywords: Antibiotic prophylaxis duration, antimicrobial resistance, antimicrobial stewardship, hospital-acquired infection, surgical site infections
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Affiliation(s)
| | | | | | | | | | | | | | | | - Li Lin
- Ng Teng Fong General Hospital, Singapore
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Latha T, Bhat AK, Hande HM, Mukhopadhyay C, Devi ES, Nayak BS, George A. Effectiveness of Extended Infection Control Measures on Methicillin-Resistant Staphylococcus aureus Infection Among Orthopaedic Patients. Indian J Orthop 2022; 56:1804-1812. [PMID: 36187590 PMCID: PMC9485330 DOI: 10.1007/s43465-022-00713-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/28/2022] [Indexed: 02/04/2023]
Abstract
Purpose The purpose of the study was to find the effectiveness of Extended Infection Control Measures (EICM) in reducing the rate of methicillin-resistant Staphylococcus aureus (MRSA) infection among orthopaedic surgery patients. Methods The study adopted a quasi-experimental design and was conducted in the orthopaedic units of a tertiary care hospital. This study recruited 168 orthopaedic patients and 154 healthcare professionals (HCPs). EICM included hand hygiene, decolonizing the patients and HCPS, staff education, feedback of surveillance data, treatment of high-risk and MRSA-infected patients, having separate equipment for MRSA-infected patients, and appropriate cleaning of patient's unit. Results The EICM effectively reduced MRSA infection from 21.2 to 6% (p < 0.001). It also resulted in improving the knowledge of HCPs in the prevention and management of MRSA infection (p < 0.001), and all colonized HCPs were successfully (100%) decolonized. Conclusion EICM is a promising intervention to combat MRSA infection among orthopaedic wards. Hence, it can be executed in orthopaedic wards, thereby improving the treatment quality and reducing the infection-related consequences. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-022-00713-5.
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Affiliation(s)
- T. Latha
- College of Nursing, All India Institute of Medical Sciences, Kalyani, West Bengal India
- Manipal-McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - Anil K. Bhat
- Department of Orthopedics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
- Manipal-McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - H. Manjunatha Hande
- Department of Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - Chiranjay Mukhopadhyay
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka India
- Manipal-McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - Elsa Sanatombi Devi
- Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - Baby S. Nayak
- Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka India
| | - Anice George
- Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka India
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27
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Staphylococcus Aureus Swabbing and Decolonization Before Neuromodulation Procedures: A Systematic Review and Meta-analysis. Neuromodulation 2022:S1094-7159(22)01227-2. [DOI: 10.1016/j.neurom.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/04/2022] [Accepted: 07/07/2022] [Indexed: 11/06/2022]
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Smith BB, Bosch W, O'Horo JC, Girardo ME, Bolton PB, Murray AW, Hirte IL, Singbartl K, Martin DP. Surgical Site Infections During the Covid-19 Era: A Retrospective, Multicenter Analysis. Am J Infect Control 2022; 51:607-611. [PMID: 36162605 PMCID: PMC9500048 DOI: 10.1016/j.ajic.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/28/2022]
Abstract
Background Surgical site infections (SSIs) are an undesired perioperative outcome. Recent studies have shown increases in hospital acquired infections during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate postoperative SSIs in the COVID-19-era compared to a historical cohort at a large, multicenter, academic institution. Methods A retrospective review of all patients who underwent National Health and Safety Network (NHSN) inpatient surgical procedures between January 1, 2018 and December 31, 2020. Patients from the COVID-19-era (March-December 2020) were compared and matched 1:1 with historical controls (2018/2019) utilizing the standardized infection ratio (SIR) to detect difference. Results/Discussion During the study period, 29,904 patients underwent NHSN procedures at our institution. When patients from the matched cohort (2018/2019) were compared to the COVID-19-era cohort (2020), a decreased risk of SSI was observed following colorectal surgery (RR = 0.94, 95% CI [0.65, 1.37], P = .76), hysterectomy (RR = 0.88, 95% CI [0.39, 1.99], P = .75), and knee prothesis surgery (RR = 0.95, 95% CI [0.52, 1.74], P = .88), though not statistically significant. An increased risk of SSI was observed following hip prosthesis surgery (RR 1.09, 95% CI [0.68, 1.75], P = .72), though not statistically significant. Conclusions The risk of SSI in patients who underwent NHSN inpatient surgical procedures in 2020 with perioperative COVID-19 precautions was not significantly different when compared to matched controls at our large, multicenter, academic institution.
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Affiliation(s)
- Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054.
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, 4500 San Pablo Rd; Jacksonville, FL 32224
| | - John C O'Horo
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, 200 1(st) St. SW; Rochester, MN 55905; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St. SW; Rochester, MN 55905
| | - Marlene E Girardo
- Department of Quantitative Health Sciences, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - Patrick B Bolton
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - Andrew W Murray
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - Ingrid L Hirte
- Mayo Clinic Alix School of Medicine, 13400 E. Shea Blvd. Scottsdale, AZ 85259
| | - Kai Singbartl
- Division of Critical Care Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st St. SW; Rochester, MN 55905
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Santana DC, Klika AK, Jin Y, Emara AK, Piuzzi NS. Preoperative Colonization With Staphylococcus Aureus in THA Is Associated With Increased Length of Stay. Clin Orthop Relat Res 2022; 480:1504-1514. [PMID: 35130192 PMCID: PMC9278920 DOI: 10.1097/corr.0000000000002136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Staphylococcus aureus is a common organism implicated in prosthetic joint infection after THA and TKA, prompting preoperative culturing and decolonization to reduce infection rates. It is unknown whether colonization is associated with other noninfectious outcomes of THA or TKA. QUESTIONS/PURPOSES (1) What is the association between preoperative S. aureus colonization (methicillin-sensitive S. aureus [MSSA] and methicillin-resistant S. aureus [MRSA]) and the noninfectious outcomes (discharge destination, length of stay, Hip/Knee Disability and Osteoarthritis Outcome Score [HOOS/KOOS] pain score, HOOS/KOOS physical function score, 90-day readmission, and 1-year reoperation) of THA and TKA? (2) What factors are associated with colonization with S. aureus ? METHODS Between July 2015 and March 2019, 8078 patients underwent primary THA in a single healthcare system, and 17% (1382) were excluded because they were not tested preoperatively for S. aureus nasal colonization, leaving 6696 patients in the THA cohort. Between June 2015 and March 2019, 9434 patients underwent primary TKA, and 12% (1123) were excluded because they were not tested for S. aureus colonization preoperatively, leaving 8311 patients in the TKA cohort. The goal of the institution's standardized care pathways is to test all THA and TKA patients preoperatively for S. aureus nasal colonization; the reason the excluded patients were not tested could not be determined. Per institutional protocols, all patients were given chlorhexidine gluconate skin wipes to use on the day before and the day of surgery, and patients with positive S. aureus cultures were instructed to use mupirocin nasal ointment twice daily for 3 to 5 days preoperatively. Adherence to these interventions was not tracked, and patients were not rescreened to test for S. aureus control. The minimum follow-up time for each outcome and the percentage of the cohort lost for each was: for discharge destination, until discharge (0 patients lost); for length of stay, until discharge (0.06% [4 of 6696] lost in the THA group and 0.01% [1 of 8311] lost in the TKA group); for HOOS/KOOS pain score, 1 year (26% [1734 of 6696] lost in the THA group and 24% [2000 of 8311] lost in the TKA group); for HOOS/KOOS physical function, 1 year (33% [2193 of 6696] lost in the THA group and 28% [2334 of 8311] lost in the TKA group); for 90-day readmission, 90 days (0.06% [4 of 6696] lost in the THA group and 0.01% [1 of 8311] lost in the TKA group); and for 1-year reoperation, 1 year (30% [1984 of 6696] lost in the THA group and 30% [2475 of 8311] lost in the TKA group). Logistic regression models were constructed to test for associations between MSSA or MRSA and nonhome discharge, length of stay greater than 1 day, improvement in the HOOS/KOOS pain subscale (≥ the minimum clinically important difference), HOOS/KOOS physical function short form (≥ minimum clinically important difference), 90-day readmission, and 1-year reoperation. We adjusted for patient-related and hospital-related factors, such as patient age and hospital site. Variable significance was assessed using the likelihood ratio test with a significance level of p < 0.05. To assess factors associated with S. aureus colonization, we constructed a logistic regression model with the same risk factors. RESULTS Among the THA cohort, after controlling for potentially confounding variables such as patient age, smoking status, and BMI, S. aureus colonization was associated with length of stay greater than 1 day (MSSA: odds ratio 1.32 [95% CI 1.08 to 1.60]; MRSA: OR 1.88 [95% CI 1.24 to 2.85]; variable p < 0.001 by likelihood ratio test) but not the other outcomes of THA. Male sex (OR 1.26 [95% CI 1.09 to 1.45]; p = 0.001) and BMI (OR 1.02 for a one-unit increase over median BMI [95% CI 1.01 to 1.03]; p = 0.003) were patient-related factors associated with S. aureus colonization, whereas factors associated with a lower odds were older age (OR 0.99 [95% CI 0.98 to 0.99]; p < 0.001) and Black race compared with White race (OR 0.64 [95% CI 0.50 to 0.82]; p < 0.001). Among the TKA cohort, S. aureus colonization was associated with 90-day readmission (MSSA: OR 1.00 [95% CI 0.99 to 1.01]; MRSA: OR 1.01 [95% CI 1.00 to 1.01]; variable p = 0.007 by likelihood ratio test). Male sex (OR 1.19 [95% CI 1.05 to 1.34]; p = 0.006) was associated with S. aureus colonization, whereas factors associated with a lower odds of colonization were older age (OR 0.99 [95% CI 0.98 to 0.99]; p < 0.001), Veterans RAND-12 mental component score (OR 0.99 [95% CI 0.99 to 1.00]; p = 0.027), Black race compared with White race (OR 0.70 [95% CI 0.57 to 0.85]; p < 0.001), and being a former smoker (OR 0.86 [95% CI 0.75 to 0.97]; p = 0.016) or current smoker (OR 0.70 [95% CI 0.55 to 0.90]; p = 0.005) compared with those who never smoked. CONCLUSION After controlling for the variables we explored, S. aureus colonization was associated with increased length of stay after THA and 90-day readmission after TKA, despite preoperative decolonization. Given that there is little causal biological link between colonization and these outcomes, the association is likely confounded but may be a proxy for undetermined social or biological factors, which may alert the surgeon to pay increased attention to outcomes in patients who test positive. Further study of the association of S. aureus colonization and increased length of stay after THA and readmission after TKA may be warranted to determine what the confounding variables are, which may be best accomplished using large cohorts or registry data. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Daniel C. Santana
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Yuxuan Jin
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Chen C, Gao Y, Zhao D, Ma Z, Su Y, Mo R. Deep sternal wound infection and pectoralis major muscle flap reconstruction: A single-center 20-year retrospective study. Front Surg 2022; 9:870044. [PMID: 35903265 PMCID: PMC9314736 DOI: 10.3389/fsurg.2022.870044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundOne of the most drastic complications of median sternal incision is deep sternal wound infection (DSWI), as it can lead to prolonged hospitalization, increased expected costs, re-entry into the ICU and even reoperation. Since the pectoralis major muscle flap (PMMF) technique was proposed in the 1980s, it has been widely used for sternal reconstruction after debridement. Although numerous studies on DSWI have been conducted over the years, the literature on DSWI in Chinese population remains limited. The purpose of this study was to investigate the clinical characteristics of DSWI in patients and the clinical effect of the PMMF at our institution.MethodsThis study retrospectively analyzed all 14,250 consecutive patients who underwent cardiac surgery in the Department of Cardiothoracic Surgery of Drum Tower Hospital from 2001 to 2020. Ultimately, 134 patients were diagnosed with DSWI.,31 of whom had recently undergone radical debridement and transposition of the PMMF in the cardiothoracic surgery or burns and plastic surgery departments because of DSWIs, while the remaining patients had undergone conservative treatment or other methods of dressing debridement.ResultsIn total, 9,824 patients were enrolled in the study between 2001 and 2020, of whom 134 met the DSWI criteria and 9690 served as controls. Body mass index (OR = 1.08; P = 0.02; 95% CI, 1.01∼1.16) and repeat sternotomy (OR = 5.93; P < 0.01; 95% CI, 2.88∼12.25) were important risk factors for DSWI. Of the 134 patients with DSWI, 31 underwent the PMMF technique, and the remaining 103 served as controls. There were significant differences in coronary artery bypass grafting (CABG) (P < 0.01), valve replacement (P = 0.04) and repeat sternotomy (P < 0.01) between the case group and the control group. The postoperative extubation time (P < 0.001), ICU time (P < 0.001), total hospitalization time (P < 0.001) and postoperative hospitalization time (P < 0.001) in the PMMF group were significantly lower than those in the control group. The results of multivariate regression analysis showed that PMMF surgery was an important protective factor for the postoperative survival of DSWI patients (OR = 0.12; P = 0.04; 95% CI, 0.01∼0.90).ConclusionsStaphylococcus aureus was the most common bacteria causing DSWI, which was associated with BMI and reoperation, and can be validly treated with PMMF.
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Affiliation(s)
- Chen Chen
- Department of Nutrition, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yu Gao
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Demei Zhao
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhouji Ma
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yunyan Su
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Correspondence: Ran Mo Yunyan Su
| | - Ran Mo
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Correspondence: Ran Mo Yunyan Su
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Zenga J, Atkinson S, Yen T, Massey B, Stadler M, Bruening J, Peppard W, Reuben M, Hayward M, Mesich B, Buchan B, Ledeboer N, Sanchez JL, Fraser R, Lin CW, Holtz ML, Awan M, Wong SJ, Puram SV, Salzman N. A phase 2 trial of a topical antiseptic bundle in head and neck cancer surgery: Effects on surgical site infection and the oral microbiome. EBioMedicine 2022; 81:104099. [PMID: 35671624 PMCID: PMC9168040 DOI: 10.1016/j.ebiom.2022.104099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 11/27/2022] Open
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Effectiveness and acceptability of intranasal povidone-iodine decolonization among fracture fixation surgery patients to reduce Staphylococcus aureus nasal colonization. Infect Control Hosp Epidemiol 2022:1-3. [DOI: 10.1017/ice.2022.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
We evaluated povidone-iodine (PVI) decolonization among 51 fracture-fixation surgery patients. PVI was applied twice on the day of surgery. Patients were tested for S. aureus nasal colonization and surveyed. Mean S. aureus concentrations decreased from 3.13 to 1.15 CFU/mL (P = .03). Also, 86% of patients stated that they felt neutral or positive about their PVI experience.
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Obremskey W, Alman B, Vail TP, Suk M, Russell G. How to Assess Quality in an Increasingly Diverse Health-Care System: AOA Critical Issues Symposium. J Bone Joint Surg Am 2022; 104:e51. [PMID: 35041622 DOI: 10.2106/jbjs.21.00307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- William Obremskey
- Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ben Alman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Thomas Parker Vail
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Michael Suk
- Musculoskeletal Institute & Department of Orthopaedic Surgery, Geisinger Health System and Geisinger Commonwealth School of Medicine, Danville, Pennsylvania
| | - George Russell
- Department of Orthopedics, University of Mississippi, Jackson, Mississippi
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Long JC, Sarkies MN, Francis Auton E, Nguyen HM, Pomare C, Hardwick R, Braithwaite J. Conceptualising contexts, mechanisms and outcomes for implementing large-scale, multisite hospital improvement initiatives: a realist synthesis. BMJ Open 2022; 12:e058158. [PMID: 35589340 PMCID: PMC9126051 DOI: 10.1136/bmjopen-2021-058158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 04/26/2022] [Indexed: 12/15/2022] Open
Abstract
DESIGN Realist synthesis. STUDY BACKGROUND Large-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context-mechanism-outcome interactions. OBJECTIVES To review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts. METHODS An iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies' mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context-mechanism-outcome hypotheses. Data was drawn from searches (March-May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts. INCLUSION CRITERIA reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed. RESULTS Concepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top-down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context-mechanism-outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory's tenets. CONCLUSION This paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.
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Affiliation(s)
- Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Mitchell N Sarkies
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Emilie Francis Auton
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Hoa Mi Nguyen
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Chiara Pomare
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | | | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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A bundle of infection control measures reduces post-operative sternal wound infection due to Staphylococcus aureus but not Gram-negative bacteria: a retrospective analysis of 6,903 patient episodes. J Hosp Infect 2022; 126:21-28. [PMID: 35341810 DOI: 10.1016/j.jhin.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/02/2022] [Accepted: 03/10/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Prevention of cardiac surgical site infection has largely focused on reducing infection due to Staphylococcus aureus although other bacteria also play an important role in this complication. AIM We assess the impact of an evolving infection control program on the incidence of sternal wound infection (SWI) and the changing incidence of non-staphylococcal infections. METHODS We conducted a retrospective cohort study of all patients who underwent primary sternotomy at a single UK centre between September 2010 and May 2018. Data were collated from two-years prior to the stepwise introduction of a broad-ranging infection control program, including S. aureus decolonisation. FINDINGS 6,903 primary sternotomies were performed of which 2.6% (n=178) were complicated by SWI. Gram-negative bacteria (GNB) and S. aureus were most commonly identified as causative pathogens (45.5% and 30.3% respectively). Following program introduction there was a reduction in the rate of SWI from 3.9 to 1.8 cases/100 patients/month. This was mainly due to a sustained reduction in S. aureus infected cases with no discernible impact on GNB. Multivariable logistic regression analysis identified coronary artery bypass grafting, procedural urgency and procedures performed in the 3rd quarter as independent risk factors for post-operative infection. CONCLUSION A multifaceted infection control program was successful at reducing the rate of SWI primarily due to a reduction in S. aureus infections. GNB also play an important role in SWI and traditional preventative measures fail to address these. Future intervention and impact assessments should consider Gram negative infection when measuring effectiveness.
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Ingall EM, Grisdela PT, Bejarano-Pineda L, DiGiovanni CW. To Screen or Not to Screen. . . Who Nose? Foot Ankle Int 2022; 43:453-456. [PMID: 34794341 DOI: 10.1177/10711007211052294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Eitan M Ingall
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
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Baker NF, Brown O, Hart AM, Danko D, Stewart CM, Thompson PW. Preventing Infection in Implant-based Breast Reconstruction: Evaluating the Evidence for Common Practices and Standardized Protocols. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4208. [PMID: 35350150 PMCID: PMC8939924 DOI: 10.1097/gox.0000000000004208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/22/2022] [Accepted: 01/25/2022] [Indexed: 12/14/2022]
Abstract
Infection following implant-based breast reconstruction (IBBR) results in increased rates of hospital readmission, reoperation, patient and hospital expenses, and reconstructive failure. IBBR is a complex, multistep procedure, and there is a relative lack of high-quality plastic surgery evidence regarding "best practices" in the prevention of implant infections. In the absence of strong data, standardizing procedures based on available evidence can reduce error and improve efficacy and outcomes. Methods We performed a focused literature review of the available evidence supporting specific interventions for infection prevention in the preoperative, intraoperative, and postoperative phases of care that are applicable to IBBR. In addition, we examined previously published standardized perioperative protocols for implant reconstruction. Results Preoperative, intraoperative, and postoperative planning and organization is crucial in IBBR. Preoperative planning involves skin decolonization in advance of surgery with either chlorhexidine gluconate or mupirocin. Intraoperative methods that have shown potential benefit include double-gloving, breast pocket irrigation, separate closing instruments, and the utilization of "no-touch" techniques. In the postoperative period, the duration of drain removal and postoperative antibiotic administration play an important role in the prevention of surgical site infection. Conclusions There is a crucial need to establish an evidence-based set of "best practices" for IBBR, and there exists a paucity of evidence in the breast literature. These data can be utilized to develop a standardized protocol as part of a rigorous quality improvement methodology.
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Affiliation(s)
| | - Owen Brown
- Emory Department of Surgery, Division of Plastic Surgery, Atlanta, Ga
| | - Alexandra M. Hart
- Emory Department of Surgery, Division of Plastic Surgery, Atlanta, Ga
| | - Dora Danko
- From the Emory University School of Medicine, Atlanta, Ga
| | | | - Peter W. Thompson
- Emory Department of Surgery, Division of Plastic Surgery, Atlanta, Ga
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38
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Hu QL, Ko CY. Prevention of Perioperative Surgical Site Infection. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Xiong GX, Greene NE, Hershman SH, Schwab JH, Bono CM, Tobert DG. Nasal screening for methicillin-resistant Staphylococcus aureus does not reduce surgical site infection after primary lumbar fusion. Spine J 2022; 22:113-125. [PMID: 34284131 DOI: 10.1016/j.spinee.2021.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/07/2021] [Accepted: 07/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Preoperative methicillin-resistant Staphylococcus aureus (MRSA) testing and decolonization has demonstrated success for arthroplasty patients in surgical site infections (SSIs) prevention. Spine surgery, however, has seen varied results. PURPOSE The purpose of this study was to determine the impact of nasal MRSA testing and operative debridement rates on surgical site infection after primary lumbar fusion. STUDY DESIGN/SETTING Retrospective cohort study and/or Consolidated medical enterprise PATIENT SAMPLE: Adult patients undergoing primary instrumented lumbar fusions from January 2015 to December 2019 were reviewed. OUTCOME MEASURES The primary outcome was incision and drainage performed in the operating room within 90 days of surgery. METHODS MRSA testing <90-day's before surgery, mupirocin prescription <30-day's before surgery, perioperative antibiotics, and Elixhauser comorbidity index were collected for each subject. Bivariate analysis used Wilcoxon rank-sum testing and logistic regression modeling Multivariable logistic regression modeling assessed for associations with MRSA testing, intravenous vancomycin use, and I&D rate. RESULTS The study included 1,884 patients for analysis, with mean age of 63.1 (SE 0.3) and BMI 29.5 (SE 0.1). MRSA testing was performed in 755 patients (40.1%) and was more likely to be performed in patients with lower Elixhauser index scores (OR 0.98, 95% CI 0.96-0.99, p=.021) on multivariable analysis. Vancomycin use increased significantly over time (OR 1.49 and/or year, 95% CI 1.3-1.8, p<.001) despite no change in mupirocin or I&D rates. MRSA testing, mupirocin prescriptions, perioperative parenteral vancomycin use, and intrawound vancomycin powder use had no impact on I&D rates. I&D risk was associated with higher BMI (OR 1.06, 95% CI 1.02-1.12, p=.009) and higher number of blood product units transfused (OR 1.23, 95% CI 1.03-1.46, p=.022). CONCLUSIONS The present study demonstrates no impact on surgical I&D rates from the use of preoperative MRSA testing. Increased BMI and transfusions were associated with operative I&D rates for surgical site infection. As a result of the hospital directive, vancomycin use increased over time with no associated change in infection rates, underscoring the need for focused interventions, and engagement with antibiotic stewardship programs.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Boston, MA, USA
| | | | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Dayani L, Taheri A, Taymouri S, Najafi RB, Esmaeilian F. Preparation and in vitro evaluation of Vancomycin loaded Montmorillonite-Sodium Alginate topical gel for wound infection. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e21034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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41
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Hockett Sherlock S, Goedken CC, Balkenende EC, Dukes KC, Perencevich EN, Reisinger HS, Forrest GN, Pfeiffer CD, West KA, Schweizer M. Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration. FRONTIERS IN HEALTH SERVICES 2022; 2:920830. [PMID: 36925849 PMCID: PMC10012655 DOI: 10.3389/frhs.2022.920830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022]
Abstract
As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion. Trial registration ClinicalTrials.gov, identifier: NCT02216227.
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Affiliation(s)
- Stacey Hockett Sherlock
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Cassie Cunningham Goedken
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States
| | - Erin C Balkenende
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Kimberly C Dukes
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
| | - Heather Schacht Reisinger
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States.,Institute for Clinical and Translational Science, The University of Iowa, Iowa City, IA, United States
| | - Graeme N Forrest
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL, United States
| | - Christopher D Pfeiffer
- Department of Hospital and Specialty Medicine, VA Portland Health Care System, Portland, OR, United States.,Department of Medicine, Oregon Health & Sciences University, Portland, OR, United States
| | - Katelyn A West
- VA Portland Healthcare System, Portland, OR, United States
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation (CADRE), VA Iowa City Health Care System, Iowa City, IA, United States.,Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA, United States
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Coia JE, Wilson JA, Bak A, Marsden GL, Shimonovich M, Loveday HP, Humphreys H, Wigglesworth N, Demirjian A, Brooks J, Butcher L, Price JR, Ritchie L, Newsholme W, Enoch DA, Bostock J, Cann M, Wilson APR. Joint Healthcare Infection Society (HIS) and Infection Prevention Society (IPS) guidelines for the prevention and control of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities. J Hosp Infect 2021; 118S:S1-S39. [PMID: 34757174 DOI: 10.1016/j.jhin.2021.09.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/03/2021] [Accepted: 09/13/2021] [Indexed: 12/28/2022]
Affiliation(s)
- J E Coia
- Department of Clinical Microbiology, Hospital South West Jutland, Esbjerg, Denmark; Department of Regional Health Research IRS, University of Southern Denmark, Denmark; Healthcare Infection Society, London, UK
| | - J A Wilson
- Richard Wells Research Centre, University of West London, London, UK; Infection Prevention Society, Seafield, UK
| | - A Bak
- Healthcare Infection Society, London, UK.
| | | | - M Shimonovich
- Healthcare Infection Society, London, UK; MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - H P Loveday
- Richard Wells Research Centre, University of West London, London, UK; Infection Prevention Society, Seafield, UK
| | - H Humphreys
- Healthcare Infection Society, London, UK; Department of Clinical Microbiology, The Royal College of Surgeons, Ireland; Department of Microbiology, Beaumont Hospital, Dublin, Ireland
| | - N Wigglesworth
- Infection Prevention Society, Seafield, UK; East Kent Hospitals University, NHS Foundation Trust, Canterbury, UK
| | - A Demirjian
- Healthcare-associated Infection and Antimicrobial Resistance, Public Health England, London, UK; Paediatric Infectious Diseases and Immunology, Evelina London Children's Hospital, London, UK; Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - J Brooks
- Infection Prevention Society, Seafield, UK; University Hospital Southampton NHS Foundation Trust, UK
| | - L Butcher
- Infection Prevention Society, Seafield, UK; Oxford University Hospitals NHS Foundation Trust, UK
| | - J R Price
- Healthcare Infection Society, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - L Ritchie
- Healthcare Infection Society, London, UK; NHS England and NHS Improvement, London, UK
| | - W Newsholme
- Healthcare Infection Society, London, UK; Guy's and St Thomas' NHS Foundation Trust, UK
| | - D A Enoch
- Healthcare Infection Society, London, UK; Clinical Microbiology & Public Health Laboratory, Public Health England, Addenbrooke's Hospital, Cambridge, UK
| | | | - M Cann
- Lay Member, UK; MRSA Action UK, Preston, UK
| | - A P R Wilson
- Healthcare Infection Society, London, UK; University College London Hospitals NHS Foundation Trust, UK.
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Surgical site infection prevention through bundled interventions in hip replacement surgery: A systematic review. Int J Surg 2021; 95:106149. [PMID: 34687953 DOI: 10.1016/j.ijsu.2021.106149] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bundles have shown to improve patient outcomes in several settings. Surgical site infections (SSIs) following joint replacement surgery are associated with severe outcomes. We aimed to determine the effectiveness of non-pathogen specific bundled interventions in reducing SSIs after hip arthroplasty procedures. MATERIALS AND METHODS A systematic review and meta-analysis were conducted according to the PRISMA statement guidelines (PROSPERO registration number CRD42020203031). PubMed, Embase and Cochrane databases were searched for studies evaluating SSI prevention bundles in hip replacement surgery, excluding studies evaluating pathogen-specific bundles. Records were independently screened by two authors. The primary outcome was the SSI rate in intervention and control groups or before and after bundle implementation. Secondary outcomes of interest were bundle compliance and the number and type of bundle components. A meta-analysis was conducted using raw data, by calculating pooled relative risk (RR) SSI estimates to assess the impact of bundled interventions on SSI reduction. RESULTS Eleven studies were included in the qualitative review and four studies comprising over 20 000 patients were included in the quantitative synthesis. All included studies found bundles were associated with reduced SSI rates. The pooled RR estimated from the fixed-effects model was 0.76 (95% confidence interval 0.61-0.96, p 0.022) with 49.8% heterogeneity. CONCLUSIONS Results support the effectiveness of non-pathogen specific bundled interventions in preventing SSIs following hip arthroplasty. A "core" group of evidence-based elements for bundle development were identified.
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Dinic D, Milojevic M, Paunic N, Cirkovic A, Peric M, Bojic M, Otasevic P. Implementation of Best Practice Guidelines as an Effort in Reducing Hospital Readmission following Coronary Artery Bypass Surgery. Eur Surg Res 2021; 63:55-63. [PMID: 34569485 DOI: 10.1159/000518403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/08/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The present study aimed to identify significant causes of readmission within 30 days following coronary artery bypass graft (CABG) surgery and compare readmission incidence related to surgical site infections (SSIs) before and after implementing international recommendations for antibiotic prophylaxis. METHODS We analyzed 2,225 CABG patients who received either guideline-directed antibiotic prophylaxis (GDAP = 568) or institutional antibiotic prophylaxis (non-GDAP = 1,657) between January 2017 and December 2019. The primary outcome was a composite of sternal wound infection (SWI) or harvest SWI. Secondary outcomes consisted of the individual components of composite end point, the incidence of in-hospital SSIs, and prolonged postoperative length of hospital stay (LOS) (>7 days). Propensity matching was used to select pairs for final comparison. RESULTS Before implementing GDAP, the most frequent reason for readmission were SSIs, causing 58.2% of all readmissions within 30 days. Of 429 matched pairs, 48 patients in the GDAP group and 67 patients in the non-GDAP group were readmitted to a hospital within 30 days for any cause (11.2 vs. 15.6%, p = 0.048). We found a decreased readmission incidence for reasons related to SSIs, although these differences did not reach statistical significance (7.4 vs. 10.0%, p = 0.069). Adherence to GDAP was associated with reduced in-hospital risks of SSIs and prolonged postoperative LOS (19.6 vs. 26.6%, p = 0.015). CONCLUSIONS In this contemporary clinical practice study, the adherence to GDAP was an insufficient measure to decrease rehospitalization due to SSIs. The present findings warrant further investigation on factors that may contribute to SSIs development after hospital discharge.
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Affiliation(s)
- Dragana Dinic
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Natasa Paunic
- Department of Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Andja Cirkovic
- Department for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miodrag Peric
- Department of Cardiac Surgery, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Milovan Bojic
- Department of Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Petar Otasevic
- Department of Cardiology, Dedinje Cardiovascular Institute, Belgrade, Serbia
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Dellinger EP, Villaflor-Camagong D, Whimbey E. Gradually Increasing Surgical Site Infection Prevention Bundle with Monitoring of Potentially Preventable Infections Resulting in Decreasing Overall Surgical Site Infection Rate. Surg Infect (Larchmt) 2021; 22:1072-1076. [PMID: 34382872 DOI: 10.1089/sur.2021.183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Objective: Reduction of surgical site infection. Methods: Retrospective evaluation of a surgical infection prevention program consisting of the gradual introduction of specific infection prevention methods and a surveillance system identifying and reporting on potentially preventable surgical site infections as defined by the omission of a preventive method. Setting: A university tertiary referral medical center. Results: The sequential introduction of infection prevention elements in the bundle resulted in a fluctuating rate of potentially preventable surgical site infections simultaneously with a slow, gradual reduction of the clean wound SSI rate. Conclusions: Change in a complex, multidisciplinary environment such as an inpatient surgical unit happens gradually and requires focused attention and input from all involved professionals.
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Affiliation(s)
- E Patchen Dellinger
- Department of Surgery, University of Washington, University of Washington Medical Center, Seattle, Washington, USA
| | | | - Estella Whimbey
- University of Washington, Department of Medicine: Allergy and Infectious Diseases, University of Washington Medical Center, Seattle, Washington, USA
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46
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Evidence of the medical and economic benefits of implementing hygiene measures by a prevention link physician in trauma surgery: Study protocol for a biphasic multicenter prospective interventional pre-post cohort study using a structured intervention bundle development and tools of behavior change management. Contemp Clin Trials Commun 2021; 23:100815. [PMID: 34286158 PMCID: PMC8274293 DOI: 10.1016/j.conctc.2021.100815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 06/22/2021] [Accepted: 06/27/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction The German Commission for Hospital Hygiene and Infection Prevention recommends nominating one authorized medical specialist in every medical department as an infection prevention link physician (PLP). It has been roughly described that a PLP serves as a link between the infection prevention team and the respective clinical departments. No detailed evidence about the contribution made by PLPs to the decrease of infection rates is available in Germany. The “HygArzt” project aims to demonstrate the medical and economic benefits of the implementation of hygiene measures by PLP in trauma surgery/orthopedics. Methods A multicenter interventional pre/post cohort study design was chosen. The study will run for a three-year period, including a pre-, post-, and an intervention phase, in four different hospitals, one of which will serve as pilot. A complex intervention containing evidence-based infection control measures will be developed and implemented by a PLP to proof efficacy. After the successful implementation of the preventive measures in the pilot hospital, the concept will be transposed to the three remaining trauma and orthopedic departments to confirm the transferability and generalizability. To enable the PLPs of the non-pilot departments, a subject-specific training program will be developed based on the study results of the pilot hospital and offered to the PLPs. Discussion Data are intended to provide evidence that and, if so, to which extent the implementation of specific preventive measures by a medical department-specific PLP is possible and results in a reduction of nosocomial infections in orthopedic surgery and traumatology. Contribution to the literature The present study describes a novel complex study design to prove the effectiveness of intervention measures for infection prevention. The study design and newly developed methodological approach could serve as a model for similar studies on infection prevention in the future. For the first time, the presented research project “HygArzt” focuses on the implementation of hygiene measures by an infection prevention link physician (PLP) and investigates whether nosocomial infections, especially surgical site infections, can be reduced by the measures implemented. Trial registration German clinical Trials register DRKS-ID:00013,296. Registered on March 5, 2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013296.
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Narulita L, Suharjono, Kuntaman, Akram M. Analysis of the use of antibiotics profile and factors of surgical site infections study on digestive and oncology surgeries. J Basic Clin Physiol Pharmacol 2021; 32:693-700. [PMID: 34214340 DOI: 10.1515/jbcpp-2020-0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/16/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The incision method operation with a high risk of infection in a clean and clean-contaminated operation requires the use of prophylactic antibiotics to minimize the risk of infection. This study was designed to analyze the effectiveness of prophylactic antibiotics in patients with digestive and oncology surgeries. METHODS The statistical method used was chi-square to determine the risk factors for infection at surgical site infections (SSI) in patients with digestive and oncology surgeries. This study had received ethical approval from the Ethics Committee of Dr. H. Slamet Martodirdjo Hospital, Pamekasan. RESULTS There were 67 patients consisted of 48 digestive surgeries (71.6%) and 19 oncology surgeries (28.4%). The criteria of observation on day 30 showed that as 1 (1.5%) SSI patient experienced purulence, inflammation, and erythema around the surgical wound so an analysis of p>0.05 was carried out so that there was no association with the incidence of SSI during hospitalization, but other factors originating from the patient, such as a lack of personal hygiene at home and lack of nutritious food intake was measured in temperature, pulse, respiration, and white blood cells examination before surgery and 24 h after surgery, all within normal ranges. The qualitative analysis of prophylactic antibiotics using the Gyssen method showed that 31 (46.3%) rationales needed an improvement process. CONCLUSIONS The widely used prophylactic antibiotics, namely cefazolin and cefuroxime are recommended antibiotics used in incision surgery and rationale used.
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Affiliation(s)
- Lisa Narulita
- Master of Clinical Pharmacy Program, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
| | - Suharjono
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia
| | - Kuntaman
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Mohammad Akram
- Department of Surgery, Dr. H. Slamet Martodirdjo Hospital, Pamekasan, Indonesia
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Nicolas R, Carricajo A, Morel J, Rigaill J, Grattard F, Guezzou S, Audoux E, Campisi S, Favre JP, Berthelot P, Verhoeven PO, Botelho-Nevers E. Evaluation of effectiveness and compliance with the mupirocin nasal ointment part of Staphylococcus aureus decolonization in real life using UPLC-MS/MS mupirocin quantification. J Antimicrob Chemother 2021; 75:1623-1630. [PMID: 32097475 DOI: 10.1093/jac/dkaa025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/16/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preoperative decolonization is recommended in Staphylococcus aureus nasal carriers scheduled for cardiac surgery. We aimed to evaluate the effectiveness of and compliance with mupirocin use in nasal S. aureus carriers in a real-life setting. METHODS Prospective study including consecutive patients scheduled for cardiac surgery screened for S. aureus nasal carriage at preoperative consultation. Carriers were prescribed mupirocin nasal ointment, chlorhexidine shower and mouthwash. Effectiveness of decolonization was evaluated with a postoperative nasal sample. Compliance was evaluated objectively by determination of nasal mupirocin concentration using UPLC-MS/MS and self-reported by questionnaire. RESULTS Over 10 months, 361 patients were included, 286 had preoperative screening, 75 (26.2%) were S. aureus nasal carriers and 19 of them (25.3%) failed to be effectively decolonized. No resistance to mupirocin was documented. Preoperative and postoperative strains were identical in all cases. Declared good compliance was associated with decolonization success (OR = 24; 95% CI 4-143, P < 0.0001). Mupirocin detection was significantly associated with the level of compliance. Mupirocin was detected in 52.2% (24/46) of patients effectively decolonized and in 12.5% (2/16) of patients with decolonization failure (P < 0.01). In 2/19 patients, failure of decolonization was not associated with a compliance issue. Postoperative carriage was associated with an increased risk of S. aureus infection (OR = 9.8; 95% CI 1.8-53, P < 0.01). CONCLUSIONS In real life, decolonization is not always effective, hence there is a persisting risk of S. aureus endogenous infection. Mupirocin concentration measurement may help to understand compliance issues and failures in decolonization.
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Affiliation(s)
- Roxane Nicolas
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France.,GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France
| | - Anne Carricajo
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France.,Laboratory of Infectious Agents and Hygiene, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Jérôme Morel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Josselin Rigaill
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France.,Laboratory of Infectious Agents and Hygiene, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Florence Grattard
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France.,Laboratory of Infectious Agents and Hygiene, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Salim Guezzou
- Laboratory of Infectious Agents and Hygiene, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Estelle Audoux
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France
| | - Salvatore Campisi
- Cardiac Surgery Department, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Jean-Pierre Favre
- Cardiac Surgery Department, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Philippe Berthelot
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France.,Laboratory of Infectious Agents and Hygiene, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France.,Infectious Diseases Department, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Paul O Verhoeven
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France.,Laboratory of Infectious Agents and Hygiene, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
| | - Elisabeth Botelho-Nevers
- GIMAP (Groupe Immunité des Muqueuses et Agents Pathogènes), University of Lyon, St-Etienne, France.,Infectious Diseases Department, University Hospital of St-Etienne, 42055 St-Etienne Cedex 02, France
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Yuan W, Gu Y, Zhang K, Liang T, Wang P, Zhang J, Xu Y, Fu Q, Song L. Postoperative Infection of Male Posterior Urethral Stenosis with Pelvic Fracture: A Retrospective Study from a Chinese Tertiary Teferral Center. Urology 2021; 154:294-299. [PMID: 33940048 DOI: 10.1016/j.urology.2021.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the risk factors for postoperative infection, including systemic inflammatory response syndrome, sepsis and surgical site infection, after posterior urethral anastomosis for the treatment of male posterior urethral stenosis with pelvic fractures. METHODS We retrospectively analyzed data from patients who underwent transperineal end-to-end anastomotic urethroplasty between January 2016 and December 2018. Descriptive statistics were used to analyze patient characteristics and perioperative features. Univariate analysis was performed to identify prognostic factors associated with postoperative infection. Multivariate analysis was used to identify independent risk factors for postoperative infection. RESULTS Among 261 patients included in the analysis, 16.48% had SIRS, 3.83% had sepsis, and 8.05% had SSI. The primary results suggested that penile septum separation, inferior pubic resection, operating duration, preoperative urine culture result, preoperative waiting time, urethral stenosis length, and draining method were significant predictors of postoperative infections. Multivariate analysis revealed that more complex surgical procedures, operating duration and positive urine culture results were independent risk factors for SIRS and preoperative positive urine culture result was an independent risk factor for sepsis and SSI. CONCLUSIONS Positive preoperative urine culture was the main risk factor for postoperative infections. More complex surgical procedures, such as penile septum separation and inferior pubic resection, and longer operating duration were more likely to be associated with postoperative SIRS.
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Affiliation(s)
- Wei Yuan
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Yubo Gu
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Kaile Zhang
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Tao Liang
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Ping Wang
- Department of Urology, Shanghai Electric Power Hospital, Shanghai, 200233, China
| | - Jiong Zhang
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Yuemin Xu
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Qiang Fu
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China
| | - Lujie Song
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai Oriental Institute for Urologic Reconstruction, Shanghai, 200233, China.
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Hadaya J, Downey P, Tran Z, Sanaiha Y, Verma A, Shemin RJ, Benharash P. Impact of Postoperative Infections on Readmission and Resource Use in Elective Cardiac Surgery. Ann Thorac Surg 2021; 113:774-782. [PMID: 33882295 DOI: 10.1016/j.athoracsur.2021.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/06/2021] [Accepted: 04/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efforts to reduce postoperative infections have garnered national attention, leading to practice guidelines for cardiac surgical perioperative care. The present study characterized the impact of healthcare-acquired infection (HAI) on index hospitalization costs and post-discharge healthcare utilization. METHODS Adults undergoing elective coronary artery bypass grafting (CABG) and/or valve operations were identified in the 2016-2018 Nationwide Readmissions Database. Infections were categorized into bloodstream, gastrointestinal, pulmonary, surgical site, or urinary tract infections. Generalized linear or flexible hazard models were used to assess associations between infections and outcomes. Observed-to-expected (O/E) ratios were generated to examine inter-hospital variation in HAI. RESULTS Of an estimated 444,165 patients, 8.0% developed HAI. Patients with HAI were older, had a greater burden of chronic diseases, and more commonly underwent CABG/valve or multi-valve operations (all p<0.001). HAI was independently associated with mortality (odds ratio 4.02, 95% CI 3.67-4.40), non-home discharge (3.48, 95% CI 3.21-3.78), and a cost increase of $23,000 (95% CI 20,900-25,200). At 90 days, HAI was associated with greater hazard of readmission (1.29, 95% CI 1.24-1.35). Pulmonary infections had the greatest incremental impact on patient-level ($24,500, 95% CI 23,100-26,00) and annual cohort costs ($121.8 million, 95% CI 102.2-142.9 million). Significant hospital level variation in HAI was evident, with O/E ranging from 0.17 to 4.3 for cases performed in 2018. CONCLUSIONS Infections following cardiac surgery remain common and are associated with inferior outcomes and increased resource use. The presence of inter-hospital variation in this contemporary cohort emphasizes the ongoing need for systematic approaches in their prevention and management.
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Affiliation(s)
- Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peter Downey
- Department of Cardiovascular & Thoracic Surgery, University of Kansas Health System, Kansas City, Kansas
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Richard J Shemin
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California.
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