Surgical site infections--economic consequences for the health care system

Real-time biofluorescent particle counting compared to conventional air sampling for monitoring airborne contamination in orthopedic implant surgery

Background

Surgical site infection (SSI) following orthopedic surgery is a complication associated with morbidity and economic burden. Transmission of airborne bacteria that settle into surgical wounds constitutes a risk factor for SSIs. However, monitoring microbial contamination inside operating rooms with conventional methods is resource and time-consuming.

Aim

This study aimed to assess correlation between a biofluorescent particle counter (BFPC) and conventional air sampling, to enable real-time monitoring of airborne contamination. Additionally, the study aimed to analyze correlation between particles near the surgical site and particles 1 meter away, to evaluate the feasibility of distance-based measurements.

Methods

Correlation analysis was conducted to compare colony-forming units (CFU) collected using a Sartorius MD8 air sampler with biofluorescent viable particles detected by BioTrak 9510-BD, both positioned near the surgical site. Additionally, correlation between particle counts measured by AeroTrak 6510, positioned 1 meter away, and total particle counts measured by the BioTrak near the surgical site was evaluated. Sampling took place in two operating rooms: one with turbulent mixed airflow (TMA) and one with unidirectional airflow (UDAF).

Results

Negligible to low correlation between biofluorescent particles and CFU was observed, both in UDAF (n = 100) and TMA (n = 22). However, strong correlation was found between BFPC and particle counter measurements of total numbers of particles (Rp = 0.634-0.769, P < .001).

Conclusion

While BFPCs offer real-time monitoring of airborne contamination, their predictive ability for CFU levels remains uncertain. Yet, the strong correlation between particles in the surgical site and particles measured 1 meter away suggests feasibility to conduct future studies with larger cohorts.

Regional variations in incidence of surgical site infection and associated risk factors in women undergoing cesarean section: A systematic review and Meta-Analysis

BACKGROUND

Surgical site infections (SSIs) are the most common postoperative complications after cesarean section (CS), with increased mortality, prolonged hospital stays, and increased healthcare costs.

OBJECTIVE

To systematically estimate the global incidence and identify the risk factors associated with SSI, focusing on the variation between high- and low-income countries.

SEARCH STRATEGY AND SELECTION CRITERIA

Observational studies reporting on the incidence of SSI after CS were systematically searched in PubMed, Embase and SCOPUS.

DATA COLLECTION AND ANALYSIS

Multiple authors independently screened, extracted the data, and assessed therisk of bias. The primary outcome was the incidence of SSI within 30 days. Subgroup and sensitivity analyses and meta-regression examined SSI-related heterogeneity.

MAIN RESULTS

49 cohort studies with 271,954 participants met the inclusion criteria. We found with moderate certainty that the overall SSI incidence in CS patients was 7.0 % (95 % CI: 6.0 %-8.0 %). The SSI incidence in LMICs was 8.0 % (95 % CI: 6.0 %-10.0 %) with moderate certainty, while the incidence in HICs was 5.0 % (95 % CI: 4.0 %-7.0 %) with low certainty. Subgroup analysis indicated a significantly higher incidence in Africa and the Western Pacific. Meta-regression showed a significant decrease in SSI incidence in HICs. Maternal factors, procedural aspects, and care quality were associated with SSI.

CONCLUSIONS

Our findings offer valuable insights into the global incidence of SSIs following CS and provide a reliable estimate for benchmarking and quality improvement. This study adds to the evidence on SSI determinants and highlights the need for targeted preventative measures across various regional and healthcare settings.

IMPLICATIONS FOR CLINICAL PRACTICE

Higher SSI rates in LMICs call for targeted infection prevention strategies, including improved preoperative preparation, antibiotic prophylaxis, and enhanced antenatal care services. In HICs, addressing lifestyle factors, managing comorbidities, and refining surgical protocols can further mitigate risks, emphasizing the need for region-specific, evidence-based interventions.

Vancomycin-Loaded Sol-Gel System for In Situ Coating of Artificial Bone to Prevent Surgical Site Infections

Surgical site infections (SSIs) related to implants have always been a major challenge for clinical doctors and patients. Clinically, doctors may directly apply antibiotics into the wound to prevent SSIs. However, this strategy is strongly associated with experience of doctors on the amount and the location of antibiotics. Herein, an in situ constructable sol-gel system is developed containing antibiotics during surgical process and validated the efficacy against SSIs in beagles. The system involves chitosan (CS), β-glycerophosphate (β-GP) and vancomycin (VAN), which can be adsorbed onto porous hydroxyapatite (HA) and form VAN-CS/β-GP@HA hydrogel in a short time. The VAN concentration from VAN-CS/β-GP@HA hydrogel is higher than minimum inhibitory concentration (MIC) against Staphylococcus aureus (S. aureus) at the 21st day in vitro. In an in vivo canine model for the prevention of SSIs in the femoral condyle, VAN-CS/β-GP@HA exhibits excellent biocompatibility, antimicrobial properties, and promotion of bone healing. In all, the CS/β-GP instant sol-gel system is able to in situ encapsulate antibiotics and adhere on artificial bone implants during the surgery, effectively preventing SSIs related to implants.

The prophylactic use of negative-pressure wound therapy after cardiac surgery: a meta-analysis

Surgical site infections (SSIs) pose a frequent complication in cardiac surgery patients and lead to increased patient discomfort and extended hospitalization. This meta-analysis aimed to evaluate the protective role of single-use negative-pressure wound therapy (sNPWT) devices on closed surgical wounds after cardiac surgery, and explored their potential preventive application across all cardiac surgery patients. A comprehensive literature search was conducted on ScienceDirect, focusing on studies related to "negative pressure wound therapy" or "PICO negative pressure wound therapy" combined with "cardiac surgery" or "sternotomy," published between 2000 and 2022. Inclusion criteria encompassed case-control studies comparing sNPWT with traditional dressings on closed cardiac surgical incisions in adult patients undergoing median sternotomy without immediate postoperative infective complications, with available details on SSIs. A retrospective analysis of cases treated with sNPWT in our centre was also performed. The meta-analysis revealed a protective role of sNPWT, indicating a 44% risk reduction in overall SSIs (odds ratio 0.56) and a 40% risk reduction in deep wound infections (odds ratio 0.60). Superficial wound infections, however, showed non-significant protective effects. A single-centre study aligned with the meta-analysis findings, confirming the efficacy of sNPWT and was included in the meta-analysis. In conclusion, the meta-analysis and the single-centre study collectively support the protective role of negative pressure wound therapy against overall and deep SSIs, suggesting its potential prophylactic use on all cardiac surgery populations.

Hospital infections and health-related quality of life after cardiac surgery: a multicenter survey

BACKGROUND

Recent research suggested that hospital infections are a predictive marker for physical non-recovery one year after cardiothoracic surgery. The purpose of this study was to explore whether this risk factor is etiologic. Additional, the influence of a potential effect modifying factor, diabetes mellitus, was investigated.

METHODS

In this multicenter study, patients underwent elective or urgent cardiothoracic surgery between 01-01-2015 and 31-12-2019, and completed pre- and one year post-operative Short Form Health Survey 36/12 quality of life questionnaires. A binary logistic regression model, in which the inverse of the propensity score for infection risk was included as a weight variable, was used. Second, this analysis was stratified for diabetes mellitus status.

RESULTS

8577 patients were included. After weighing for the propensity score, the standardized mean differences of all variables decreased and indicated sufficient balance between the infection and non-infection groups. Hospital infections were found to be a risk factor for non-recovery after cardiothoracic surgery in the original and imputed dataset before weighting. However, after propensity score weighing, hospital infections did not remain significantly associated with recovery (OR for recovery = 0.79; 95% CI [0.60-1.03]; p = 0.077). No significant interaction between diabetes mellitus and hospital infections on recovery was found (p = 0.845).

CONCLUSIONS

This study could not convincingly establish hospital infections as an etiologic risk factor for non-improvement of physical recovery in patients who underwent cardiothoracic surgery. In addition, there was no differential effect of hospital infections on non-improvement of physical recovery for patients with and without diabetes mellitus. Trial registration International Clinical Trials Registry Platform ID NL9818; date of registration, 22-10-2021 ( https://trialsearch.who.int/ ).

A predictive nomogram for surgical site infection in patients who received clean orthopedic surgery: a retrospective study

BACKGROUND

Surgical site infection (SSI) is a common and serious complication of elective clean orthopedic surgery that can lead to severe adverse outcomes. However, the prognostic efficacy of the current staging systems remains uncertain for patients undergoing elective aseptic orthopedic procedures. This study aimed to identify high-risk factors independently associated with SSI and develop a nomogram prediction model to accurately predict the occurrence of SSI.

METHODS

A total of 20,960 patients underwent elective clean orthopedic surgery in our hospital between January 2020 and December 2021, of whom 39 developed SSI; we selected all 39 patients with a postoperative diagnosis of SSI and 305 patients who did not develop postoperative SSI for the final analysis. The patients were randomly divided into training and validation cohorts in a 7:3 ratio. Univariate and multivariate logistic regression analyses were conducted in the training cohort to screen for independent risk factors of SSI, and a nomogram prediction model was developed. The predictive performance of the nomogram was compared with that of the National Nosocomial Infections Surveillance (NNIS) system. Decision curve analysis (DCA) was used to assess the clinical decision-making value of the nomogram.

RESULTS

The SSI incidence was 0.186%. Univariate and multivariate logistic regression analysis identified the American Society of Anesthesiology (ASA) class (odds ratio [OR] 1.564 [95% confidence interval (CI) 1.029-5.99, P = 0.046]), operative time (OR 1.003 [95% CI 1.006-1.019, P < 0.001]), and D-dimer level (OR 1.055 [95% CI 1.022-1.29, P = 0.046]) as risk factors for postoperative SSI. We constructed a nomogram prediction model based on these independent risk factors. In the training and validation cohorts, our predictive model had concordance indices (C-indices) of 0.777 (95% CI 0.672-0.882) and 0.732 (95% CI 0.603-0.861), respectively, both of which were superior to the C-indices of the NNIS system (0.668 and 0.543, respectively). Calibration curves and DCA confirmed that our nomogram model had good consistency and clinical predictive value, respectively.

CONCLUSIONS

Operative time, ASA class, and D-dimer levels are important clinical predictive indicators of postoperative SSI in patients undergoing elective clean orthopedic surgery. The nomogram predictive model based on the three clinical features demonstrated strong predictive performance, calibration capabilities, and clinical decision-making abilities for SSI.

Comparison of abdominal depth with subcutaneous fat thickness in predicting surgical site infection among patients undergoing hepatopancreatobiliary surgery: a prospective observational study

Introduction

Surgical site infection (SSI) is a significant cause of postoperative morbidity resulting in an increased hospital stay and cost. Various measures have been used to predict SSI such as subcutaneous fat thickness (SCFT) and abdominal depth (AD) in case of abdominal surgeries. The objective of the study was to compare SCFT with AD to predict SSI in HPB surgeries.

Methods

A prospective observational study was conducted from February 2020 to February 2021, which included 76 patients who underwent elective open hepatopancreatobiliary surgeries. SCFT and AD at the level of the umbilicus were measured preoperatively using the computed tomography abdomen. The occurrence of SSI was evaluated in correlation with SCFT and AD. SCFT and AD were compared using the receiver operating characteristic curve for prediction of SSI.

Results

Twenty-five (32.3%) patients who underwent elective HPB surgeries developed SSI. 72% of the SSI were superficial. In multivariate analysis, only SCFT was associated with SSI, which was statistically significant. It was compared with AD using the receiver operating characteristic curve where SCFT proved to be better at predicting SSI (AUC=0.884) with cut-off =2.13 cm, sensitivity 84%, and specificity 86%), compared to AD with an AUC of 0.449.

Conclusion

SSI is the common cause of increased morbidity following hepato-pancreato-biliary surgeries with risk factors including SCFT and AD. Approximately one-third of patient developed SSI, with most the common being superficial SSI. SCFT at the incision site was associated with an increased rate of SSI and the better predictor for SSI as compared with the AD.

Mortality and Case Fatality Rates Associated With Surgical Site Infections: A Retrospective Surveillance Study

Background: Surgical site infections (SSIs) have been associated with increases in terms of costs, hospital stay, morbidity, and mortality. We aimed to assess trends in SSIs monitored through 10 years of surveillance activities in our region, and to describe mortality attributable to SSIs in the two most frequently monitored surgical procedures: colorectal surgery and hip arthroplasty. Methods: A retrospective cohort study was conducted among the 42 hospitals participating in the surveillance network of our region in northern Italy. All colorectal and hip arthroplasty procedures performed between January 1st, 2010, and December 31st, 2019, and monitored through the surveillance system were included in the study. Surgical site infection rates, overall mortality, case fatality rates (CFR), and mortality attributable to SSIs were evaluated overall and by year of participation in the surveillance program. Results: In total, 11,417 colon surgery and 20,804 hip arthroplasty procedures were included. Among colon surgery procedures, SSI rates decreased from 9.21% in 2010 to 5.7% in 2019. A significant decreasing trend was found for overall mortality (p = 0.008), which progressively decreased from 4.96% in 2010 to 2.96% in 2019. Among hip arthroplasty procedures, no significant trend emerged for SSI and mortality rates. Considering the 10-year period, the CFR was 6.62% and 3.7% for SSIs after colon surgery and hip arthroplasty procedures, respectively. Conclusions: The impact of SSIs on the clinical outcomes of patients undergoing surgery highlights the importance of SSI surveillance.

Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis

BACKGROUND

Surgical site infection (SSI) is a health-threatening complication following caesarean section (CS); however, to the authors' knowledge, there is no worldwide estimate of the burden of post-CS SSIs. Therefore, this systematic review and meta-analysis aimed to estimate the global and regional incidence of post-CS SSIs and associated factors.

METHODS

International scientific databases were searched systematically for observational studies published from January 2000 to March 2023, without language or geographical restrictions. The pooled global incidence rate was estimated using a random-effects meta-analysis (REM), and then stratified by World-Health-Organization-defined regions as well as by sociodemographic and study characteristics. Causative pathogens and associated risk factors of SSIs were also analysed using REM. Heterogeneity was assessed with I2.

RESULTS

In total, 180 eligible studies (207 datasets) involving 2,188,242 participants from 58 countries were included in this review. The pooled global incidence of post-CS SSIs was 5.63% [95% confidence interval (CI) 5.18-6.11%]. The highest and lowest incidence rates for post-CS SSIs were estimated for the African (11.91%, 95% CI 9.67-14.34%) and North American (3.87%, 95% CI 3.02-4.83%) regions, respectively. The incidence was significantly higher in countries with lower income and human development index levels. The pooled incidence estimates have increased steadily over time, with the highest incidence rate during the coronavirus disease 2019 pandemic (2019-2023). Staphylococcus aureus and Escherichia coli were the most prevalent pathogens. Several risk factors were identified.

CONCLUSION

An increasing and substantial burden from post-CS SSIs was identified, especially in low-income countries. Further research, greater awareness and the development of effective prevention and management strategies are warranted to reduce post-CS SSIs.

A systematic review with meta-analysis on prophylactic negative pressure wound therapy versus standard dressing for obese women after caesarean section

AIMS

The purpose of this study is to assess the efficacy of prophylactic negative pressure wound therapy (NPWT) in obese women undergoing caesarean section.

DESIGN

An updated review and meta-analysis of randomized controlled trials following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

PubMed, Embase, Medline, Web of Science, and Cochrane Library were searched from inception up to March 2022 without restriction in language. We chose surgical site infection as the primary outcome.

RESULTS

NPWT resulted in a lower surgical site infection rate compared with conventional dressing (risk ratio [RR] = 0.76). The infection rate after low transverse incision was lower comparing the NPWT group with the control group ([RR] = 0.76). No statistically significant difference was detected in blistering([RR] = 2.91). The trial sequential analysis did not support the 20% relative decrease in surgical site infection in the NPWT group. (type II error of 20%).

[Resource conservation from the perspective of infection prevention]

BACKGROUND

Procedures to prevent surgical site infections require a high input of human, technical and natural resources. This paper explores ways to optimize the use of resources in caring for patients who undergo a surgical procedure without compromising patient safety.

METHODS

Review of the contribution of selected procedures for infection prevention in surgical patients considering current evidence and recommendations by comparing current guidelines and results of clinical trials. Analysis of interventions to implement and increase compliance.

RESULTS

Knowledge of current evidence-based recommendations enables not only the identification of procedures with proven effect on infection prevention but also those that are ineffective and thus dispensable. There is still need for further controlled studies, e.g. on the use of antiseptics, that can confirm the evidence level of preventive procedures. Infection surveillance in combination with process and compliance monitoring by infection prevention specialists with a feedback system to healthcare workers are suitable control instruments for infection control management. In the case of increased infection rates, the implementation of evidence-based recommended measures through tailored bundle interventions is successful. Technical measures to maintain environmental conditions must be included in the control process.

CONCLUSION

The reduction of healthcare-associated infections by implementing tailored interventions of infection prevention measures and elimination of ineffective procedures conserves resources and promotes patient safety.

Components of Existing National Surgical Site Infection Surveillance Programs Based on a Case Series of Low- and Middle-Income Countries: Building Blocks for Success and Opportunities for Improvement

Background: Surgical site infection (SSI) surveillance programs are recommended to be included in national infection prevention and control (IPC) programs, yet few exist in low- or middle-income countries (LMICs). Our goal was to identify components of surveillance in existing programs that could be replicated elsewhere and note opportunities for improvement to build awareness for other countries in the process of developing their own national surgical site infection surveillance (nSSIS) programs. Methods: We administered a survey built upon the U.S. Centers for Disease Control and Prevention's framework for surveillance system evaluation to systematically deconstruct logistical infrastructure of existing nSSIS programs in LMICs. Qualitative analyses of survey responses by thematic elements were used to identify successful surveillance system components and recognize opportunities for improvement. Results: Three respondents representing countries in Europe and Central Asia, sub-Saharan Africa, and South Asia designated as upper middle-income, lower middle-income, and low-income responded. Notable strengths described by respondents included use of local paper documentation, staggered data entry, and limited data entry fields. Opportunities for improvement included outpatient data capture, broader coverage of healthcare centers within a nation, improved audit processes, defining the denominator of number of surgical procedures, and presence of an easily accessible, free SSI surveillance training program for healthcare workers. Conclusions: Outpatient post-surgery surveillance, national coverage of healthcare facilities, and training on how to take local SSI surveillance data and integrate it within a broader nSSIS program at the national level remain areas of opportunities for countries looking to implement a nSSIS program.

Negative Pressure Wound Therapy and Traditional Dressing: An Italian Health Technology Assessment Evaluation

This evaluation shows the main advantages related to the introduction of negative pressure wound therapy (NPWT) in Italian clinical practice for the management of incisions in vascular surgery in patients suffering from peripheral arterial disease (PAD) and at risk of postoperative complications, compared to treatment with traditional dressings. A health technology assessment (HTA) activity was conducted assuming the hospital perspective, within a 12-month time horizon. The nine EUnetHTA Core Model dimensions were deeply explored, using scientific evidence on the topic, real-life data, and healthcare professionals' perceptions. The evaluation shows that the use of NPWT has had a positive impact in terms of higher clinical effectiveness and safety profile. The process mapping highlights how NPWT allows a reduction of 2.5 hospitalization days compared with standard dressing, with the consequent benefits considering economic, organizational, and social aspects. A significant economic saving per patient emerged, with an overall optimization of the patient's clinical pathway, impacting positively on the hospital's capacity. The budget impact analysis shows that the higher number of patients treated with NPWT, the higher the economic advantages. Furthermore, assuming the patient's perspective, it would generate an overall reduction in social costs of 28%. In conclusion, the results of this study provide helpful evidence-based information to policymakers through examinations of the relative values of intervention, thus supporting the overall hospital and institutional decision-making process to define appropriate areas of investments, leading to the achievement of not only higher clinical outcomes, but also important social, economic, and organizational advantages.

A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India

Background

Caesarian section is one of the most commonly performed surgeries in India. Determination of the incidence as well as the clinical and financial burden of post caesarian surgical site infection (SSI), is of critical importance for all the stakeholders for rational and fair allocation of resources.

Methods

This study was a prospective observational case-control study. The mean direct and indirect cost of treatment for the cases were compared with the control patients. An unpaired t-test was used to compare the mean between the two groups.

Results

Out of 2024 patients, who underwent caesarian section during the study period, 114 had acquired incisional surgical site infection (ISSI), with the infection incidence being 5.63%. The total cost of illness due to post caesarian ISSI was almost three times higher compared to the non-infected matched control group. (P<0.0001). An average length of hospital stay in the ISSI patient group was 10 days longer than that in the control group (P<0.0001) and importantly total length of antimicrobial therapy(LOT) in patients with ISSI was also almost three times higher than the control group (P<0.0001).

Conclusion

The development of post caesarian SSI imposes a significant clinical as well as a financial burden. The study highlights the necessity of taking effective preventive measures to decrease the incidence of SSI.

Negative Pressure Wound Therapy in Facilitating Wound Healing after Surgical Decompression for Metastatic Spine Disease

BACKGROUND

The risk of wound related complications, including surgical site infections (SSIs), in patients undergoing surgery for metastatic spine disease (MSD) is high. Consequently, patients requiring wound revision surgery face delay in resuming oncological care and incur additional hospitalization. Recent reports suggest that negative pressure wound therapy (NPWT) applied on a closed wound at the time of surgery, significantly reduces post-operative wound complications in degenerative spine disease and trauma setting. Here, we report a single institution experience with incisional NPWT in patients undergoing surgery for MSD.

METHODS

We compared rates of wound complications requiring surgical revision in a surgical cohort of patients with or without NPWT from 2015 to 2020. Adult patients with radiographic evidence of MSD with mechanical instability and/or accelerated neurological decline were included in the study. NPWT was applied on a closed wound in the operating room and continued for 5 days or until discharge, whichever occurred first.

RESULTS

A total of 42 patients were included: 28 with NPWT and 14 without. Patient demographics including underlying comorbidities were largely similar. NPWT patients had higher rates of prior radiation to the surgical site (36% vs. 0%, p = 0.017) and longer fusion constructs (6.7 vs. 3.9 levels, p < 0.001). Three patients (21%) from control group and none from NPWT group contracted SSI requiring wound washout (p = 0.032).

CONCLUSIONS

Our data suggests that SSI and wound dehiscence are significantly reduced with the addition of incisional NPWT in in this vulnerable population.

Risk factors for surgical site infection in pediatric posterior fossa tumors

PURPOSE

Posterior fossa tumors are the most frequent pediatric solid tumor. Its main treatment is a surgical resection. Being a frequent procedure does not mean that it is exempt from complications, such as surgical site infections (SSI). The main objective of this paper is to study the risk factors associated with SSI following a resection of posterior fossa tumors in a purely pediatric population.

METHODS

A retrospective case-control study including all posterior fossa tumor surgeries performed at our hospital between January 2014 and December 2019 was conducted. All patients with a diagnosis of a postoperative SSI have been included as cases, and those who had surgery and no infectious complications have been considered as controls.

RESULTS

When analyzing risk factors, we have found that patients with ventriculoperitoneal shunt (VPS) (p = 0.03) or external ventricular drainage (EVD) (p = 0.005) placement had a greater chance of presenting a postoperative surgical site infection. Prolonged operative time (p < 0.001) and cerebrospinal fluid (CSF) leak through the wound (p = 0.002) also caused an increase in the risk of SSI in the postoperative period. A higher hemoglobin value (p = 0.002) would seem to be a preventive factor.

CONCLUSIONS

Some strategies that could help to reduce the risk of infections are managing hydrocephalus preferably with endoscopic third ventriculostomy, minimizing the needed operative time to perform the procedure, obtaining an adequate serum hemoglobin level, and avoiding CSF leak through the wound.

The Socioeconomic Impact of Surgical Site Infections

Précis: Surgical site infections are an ever-increasing phenomenon worldwide due to different factors. This brief report aimeds to highlight at a glance, for both physicians and political and institutional leaders, the economic burden of surgical site infections.

Objectives: This brief report aimed to highlight the economic burden of surgical site infections (SSIs).

Methods: A narrative review focusing on this subject has been carried out.

Results: Surgical site infections are responsible for generating important costs. In 2017, a French cohort highlighted a mean cost of each SSI treatment to be around €1,814; the same year, the Centers for Disease Control and Prevention guidelines evaluated the mean cost caused by SSI treatment to be from $10,443 to $25,546 per SSI. This cost depends on many factors including the patient himself and the type of surgery.

Conclusions: Prevention of the risk of infection is, therefore, a profitable concept for surgery that must be integrated within all healthcare managements worldwide.

Influence of Internal Thoracic Artery Harvesting on Sternal Osteoblastic Activity and Perfusion

The purpose of this study was to assess the sternal osteoblastic activity and perfusion in the early period after a coronary artery bypass graft (CABG) using single-photon emission computed tomography (SPECT) and three-phasic dynamic scintigraphy (3PDS) with 99mTc methylene diphosphonate (MDP).

METHODS

The study group consisted of 57 male patients that were 57.3 ± 6.6 years of age. Thirty-six of them were randomized into two groups: in group I (n = 18), the internal thoracic artery (ITA) was skeletonized, and in group II (n = 18), the ITA was pedicled. All the patients in groups I and II underwent an off-pump CABG using 1.7 ± 0.3 grafts, including one anastomosis of the ITA to the left anterior descending coronary artery. The control group III (n = 21) consisted of patients that underwent mitral valve repair surgery, in whom the sternotomy without the ITA harvesting was performed. The 3PDS and SPECT of the thorax with 99mTc MDP were performed 2 weeks after surgery.

RESULTS

The sternal phosphates uptake in group I was approximately twice as high as in group II and approximately 1.5 times higher than in group III (p < 0.05). The MDP uptake asymmetry after the ITA skeletonization was the same as in the group with both intact ITAs. In contrast, after the pedicled ITA harvesting, the osteoblastic activity of the ipsilateral side of the sternum was lower than in the contralateral one. There was no statistically significant difference in scintillation count in the xiphoid process between groups I and II (p > 0.05); however, we observed a significant difference in the manubrium and body (p < 0.05).

CONCLUSION

The main factor that improved the sternal perfusion after a CABG was the preservation of branches supplying the sternum using the skeletonization technique of ITA harvesting.

Negative pressure wound therapy (NPWT) on closed incisions to prevent surgical site infection in high-risk patients in hepatopancreatobiliary surgery: study protocol for a randomized controlled trial-the NP-SSI trial

BACKGROUND

Incisional surgical site infections (iSSI) in hepatopancreatobiliary (HPB) surgery usually lead to prolonged hospital stays, consume valuable resources, and impact on patients' outcome. Prophylactic closed incision negative pressure wound therapy (ciNPWT) to decrease wound complications has become available. Owing to an increasing number of studies, evidence for superiority in many indication areas has accumulated; however, in general surgery, there are a few data and those have shown contradictory results.

METHODS

In this monocentric, prospective, randomized, controlled, two-armed study, the influence of ciNPWT on incisional surgical site infection rates after HPB operations will be investigated. A total of 222 patients will be randomized 1:1 to an interventional group (7-day treatment with ciNPWT) or a control group (treated with gauze dressing). The primary parameter to evaluate efficacy is the rate of incisional SSIs within 30 days after surgery. Additionally, several clinically relevant secondary outcomes will be assessed.

DISCUSSION

A reduction in the rate of incisional SSIs would not only lead to a significant cost reduction and shorter postoperative length of stay, but may also improve postoperative quality of life for patients. While earlier publications have shown advantages for ciNPWT, recent studies did not confirm a positive effect regarding iSSI rate. Even if iSSI rate is not reduced, findings obtained from the secondary endpoints may be of clinical relevance, such as reduction of wound complication rates.

TRIAL REGISTRATION

This trial has been registered in the German Clinical Trials Register, DRKS 00015136 . Registered on 19 February 2019 and has been approved by the local ethics committee of the University of Regensburg: 18-1225-101.

Surgical Site Infections and their economic significance in hepatopancreatobiliary surgery: A retrospective incidence, cost, and reimbursement analysis in a German centre of the highest level of care

Surgical site infections (SSI) in open Hepatopancreatobiliary (HPB) surgery are common complications. They worsen patients’ outcomes and prolong hospital stays. Their economic significance in the German diagnosis related groups (DRG) system is mostly unknown. To investigate their economic importance, we evaluated all cases for SSIs as well as clinical and financial parameters undergoing surgery in our centre from 2015 and 2016. Subsequently, we carried out a cost‐revenue calculation by assessing our billing data and the cost matrix of the InEK (German Institute for the Payment System in Hospitals). A total of 13.5% of the patients developed a superficial, 9% a deep incisional, and 2.4% of the patients an organ space SSI. Compared with Patients without SSI, Patients with SSI had more comorbidities, were older, and their average length of stay was extended by 19 days (P < .001). The financial loss per SSI‐case was €‐7035.65 despite increased reimbursement, which resulted in a calculated total loss for the hospital of €‐802 064.62 in 2015 and 2016. Surgical site infections are common complications of open HPB surgery, which lead to a significant increase in the cost per case. Further prevention strategies need to be developed. Besides, an adjustment of revenues must be demanded.

The Impacts of Deep Surgical Site Infections on Readmissions, Length of Stay, and Costs: A Matched Case-Control Study Conducted in an Academic Hospital in the Netherlands

OBJECTIVE

This study aimed to evaluate the impacts of deep surgical site infections (dSSIs) regarding hospital readmissions, prolonged length of stay (LoS), and estimated costs.

PATIENTS AND METHODS

We designed and applied a matched case-control observational study using the electronic health records at the University Medical Center Groningen in the Netherlands. We compared patients with dSSI and non-SSI, matched on the basis of having similar procedures. A prevailing topology of surgeries categorized as clean, clean-contaminated, contaminated, and dirty was applied.

RESULTS

Out of a total of 12,285 patients, 393 dSSI were identified as cases, and 2864 patients without SSIs were selected as controls. A total of 343 dSSI patients (87%) and 2307 (81%) controls required hospital readmissions. The median LoS was 7 days (P25-P75: 2.5-14.5) for dSSI patients and 5 days (P25-P75: 1-9) for controls (p-value: <0.001). The estimated mean cost per hospital admission was €9,016 (SE±343) for dSSI patients and €5,409 (SE±120) for controls (p<0.001). Independent variables associated with dSSI were patient's age ≥65 years (OR: 1.334; 95% CI: 1.036-1.720), the use of prophylactic antibiotics (OR: 0.424; 95% CI: 0.344-0.537), and neoplasms (OR: 2.050; 95% CI: 1.473-2.854).

CONCLUSION

dSSI is associated with increased costs, prolonged LoS, and increased readmission rates. Elevated risks were seen for elderly patients and those with neoplasms. Additionally, a protective effect of prophylactic antibiotics was found.

Prevention of severe infectious complications after colorectal surgery using oral non-absorbable antimicrobial prophylaxis: results of a multicenter randomized placebo-controlled clinical trial

BACKGROUND

Surgical site infections (SSIs) are common complications after colorectal surgery. Oral non-absorbable antibiotic prophylaxis (OAP) can be administered preoperatively to reduce the risk of SSIs. Its efficacy without simultaneous mechanical cleaning is unknown.

METHODS

The Precaution trial was a double-blind, placebo-controlled randomized clinical trial conducted in six Dutch hospitals. Adult patients who underwent elective colorectal surgery were randomized to receive either a three-day course of preoperative OAP with tobramycin and colistin or placebo. The primary composite endpoint was the incidence of deep SSI or mortality within 30 days after surgery. Secondary endpoints included both infectious and non-infectious complications at 30 days and six months after surgery.

RESULTS

The study was prematurely ended due to the loss of clinical equipoise. At that time, 39 patients had been randomized to active OAP and 39 to placebo, which reflected 8.1% of the initially pursued sample size. Nine (11.5%) patients developed the primary outcome, of whom four had been randomized to OAP (4/39; 10.3%) and five to placebo (5/39; 12.8%). This corresponds to a risk ratio in the intention-to-treat analysis of 0.80 (95% confidence interval (CI) 0.23-2.78). In the per-protocol analysis, the relative risk was 0.64 (95% CI 0.12-3.46).

CONCLUSIONS

Observational data emerging during the study provided new evidence for the effectiveness of OAP that changed both the clinical and medical ethical landscape for infection prevention in colorectal surgery. We therefore consider it unethical to continue randomizing patients to placebo. We recommend the implementation of OAP in clinical practice and continuing monitoring of infection rates and antibiotic susceptibilities.

TRIAL REGISTRATION

The PreCaution trial is registered in the Netherlands Trial Register under NL5932 (previously: NTR6113) as well as in the EudraCT register under 2015-005736-17.

Epidemiology and Risk Factors for Superficial Surgical Site Infections after Appendectomy for Acute Appendicitis: A Secondary Data Analysis

Background: The identification of risk factors for superficial surgical site infections (SSSIs) associated with appendectomy is paramount in the management of patients with acute appendicitis (AA). Methods: This study was a secondary data analysis from a prospective multi-center observational study. It included all consecutive hospitalized patients with AA who underwent appendectomy and were monitored for complications at 30 days after the intervention. A case-control approach was used to evaluate risk factors associated with the occurrence of SSSI. Results: Among 2,667 patients, 156 (5.8%) developed an SSSI. The series included 1,449 males (54.3%) and 1,218 females with a median age of 29 years (interquartile range [IQR] 20-45 years). Antimicrobial therapy within the previous 30 days was reported by 170 patients (6.4%), and a C-reactive protein concentration (CRP) >50 mg/L was observed in 609 (22.8%). A total of 960 patients (36.0%) underwent open surgery, 1,699 (63.7%) laparoscopic surgery, and 8 (0.3%) another surgical intervention. In 2,575 patients (95.6%), a pathological appendix was detected during the operation. In 776 patients (29.1%), an intra-operative abdominal drain (IAD) was placed; 125 patients (4.7%) were admitted to the intensive care unit. The median hospital length of stay was 3 days (IQR 2-5 days). The overall mortality rate was 0.11%. Multinomial logistic regression analysis of risk factors demonstrated that statistically significant risk factors independently associated with the occurrence of SSSIs were antimicrobial therapy within the previous 30 days, CRP >50 mg/L, open surgical procedures, presence of IAD, and intra-operative findings of complex appendicitis. Conclusions: Knowledge of five easily recognizable variables, assessable at hospital admission or as soon as the surgical intervention is concluded, might identify patients with a greater risk of developing an SSSI.

Absorbable Polyglactin vs. Non-Cross-linked Porcine Biological Mesh for the Surgical Treatment of Infected Incisional Hernia

BACKGROUND

The use of absorbable meshes during contaminated or infected incisional hernia (IH) repair is associated with high morbidity and recurrence rates. Biological meshes might be more appropriate but have been described in highly heterogeneous series. This study aimed at comparing the efficacy of absorbable vs. biological meshes for the treatment of contaminated or infected IH in a homogeneous series with a standardized technique.

METHODS

Data of all patients operated on between 2008 and 2015 for contaminated or infected IH, using an absorbable (A) Vicryl® or a biological (B) Strattice® mesh, were reviewed. Patient characteristics, infectious complication rates, and recurrence-free outcome (RFO) were compared between the two groups. A propensity score methodology was applied to a Cox regression model to deal with unbalanced characteristics between groups.

RESULTS

Patient demographics in A (n = 57) and in B (n = 24) were similar except that B patients had larger parietal defects (p < 0.001) and higher Center for Disease Control (CDC) wound class (p = 0.034). Patients in A had statistically significantly more postoperative early (61.4% vs. 33.3%, p = 0.03) and late (31.2% vs. 8.3%, p = 0.046) infectious complications. Six-, 12-, and 36-month RFO rates were 77%, 47%, and 24%, and 96%, 87%, and 82% in A and B, respectively, p < 0.001. Raw multivariable Cox regression analysis found that B (HR = 0.1, 95% CI [0.03-0.34], p < 0.001) was independently associated with prolonged RFO (HR = 0.091, 95% CI [0.045-0.180], p < 0.001).

CONCLUSION

Biological meshes seem to be superior to absorbable meshes in patients with contaminated or infected incisional hernia. These results need to be confirmed by prospective randomized trials.

Highlighting the gaps in quantifying the economic burden of surgical site infections associated with antimicrobial-resistant bacteria

Antibiotics are the pillar of surgery from prophylaxis to treatment; any failure is potentially a leading cause for increased morbidity and mortality. Robust data on the burden of SSI especially those due to antimicrobial resistance (AMR) show variable rates between countries and geographical regions but accurate estimates of the incidence of surgical site infections (SSI) due to AMR and its related global economic impact are yet to be determined. Quantifying the burden of SSI treatment is an incentive to sensitize governments, healthcare systems, and the society to invest in quality improvement and sustainable development. However in the absence of a unified epidemiologically sound infection definition of SSI and a well-designed global surveillance system, the end result is a lack of accurate and reliable data that limits the comparability of estimates between countries and the possibility of tracking changes to inform healthcare professionals about the appropriateness of implemented infection prevention and control strategies. This review aims to highlight the reported gaps in surveillance methods, epidemiologic data, and evidence-based SSI prevention practices and in the methodologies undertaken for the evaluation of the economic burden of SSI associated with AMR bacteria. If efforts to tackle this problem are taken in isolation without a global alliance and data is still lacking generalizability and comparability, we may see the future as a race between the global research efforts for the advancement in surgery and the global alarming reports of the increased incidence of antimicrobial-resistant pathogens threatening to undermine any achievement.

A device for measuring sternal bone connectivity using vibration analysis techniques

Objectives:

Stability of bone splitting sternotomy is essential for normal healing after open cardiac surgery. Mechanical vibration transmittance may offer a means for early detection of separation of bone (diastasis) in the sternotomy and prevent further complications. This article describes the technical implementation and validation of vibration analysis–based prototype device built for measuring sternal bone connectivity after sternotomy.

Methods:

An in-house built measurement system, sternal vibration device, consisting of actuator, sensor, and main controller and signal acquisition unit was designed and manufactured. The system was validated, and three different test settings were studied in mockups (polylactide rods in ballistic gel) and in two human sternums: intact, stable wire fixation, and unstable wire fixation with a gap mimicking bone diastasis. The transmittance of vibration stimulus across the median sternotomy was measured.

Results:

The validation showed that the force produced by the actuator was stable, and the sensor could be calibrated to precisely measure the acceleration values. The vibration transmittance response to material cut and sternotomy was evident and detectable in the 20 Hz to 2 kHz band. The transmittance decreased when the connectivity between the sternal halves became unstable. The trend was visible in all the settings.

Conclusion:

Technical solutions and description of validation process were given. The device was calibrated, and the vibration transmittance analysis differentiated intact and cut polylactide rod. In the sternum, intact bone, wire fixation with exact apposition, and with a gap were identified separately. Although further studies are needed to assess the accuracy of the method to detect different levels of diastases, the method appears to be feasible.

Burden of surgical site infections in the Netherlands: cost analyses and disability-adjusted life years

BACKGROUND

Surgical site infections (SSIs) are associated with morbidity, mortality and costs.

AIM

To identify the burden of (deep) SSIs in costs and disability-adjusted life years (DALYs) following colectomy, mastectomy and total hip arthroplasty (THA) in the Netherlands.

METHODS

A retrospective cost-analysis was performed using 2011 data from the national SSI surveillance network PREZIES. Sixty-two patients with an SSI (exposed) were matched to 122 patients without an SSI (unexposed, same type of surgery). Patient records were studied until 1 year after SSI diagnosis. Unexposed patients were followed for the same duration. Costs were calculated from the hospital perspective (2016 price level), and cost differences were tested using linear regression analyses. Disease burden was estimated using the Burden of Communicable Disease in Europe Toolkit of the European Centre for Disease Prevention and Control. The SSI model was specified by type of surgery, with country- and surgery-specific parameters where possible.

FINDINGS

Attributable costs per SSI were €21,569 (THA), €14,084 (colectomy) and €1881 (mastectomy), mainly caused by prolonged length of hospital stay. National hospital costs were estimated at €10 million, €29 million and €0.6 million, respectively. National disease burden was greatest for SSIs following colectomy (3200 DALYs/year, 150 DALYs/100 SSIs), while individual disease burden was highest following THA (1200 DALYs/year, 250 DALYs/100 SSIs). For mastectomy, these DALYs were <1. The total cost of DALYs for the three types of surgery exceeded €88 million.

CONCLUSION

Depending on the type of surgery, SSIs cause a significant burden, both economically and in loss of years in full health. This underlines the importance of appropriate infection prevention and control measures.

Implementation strategies to reduce surgical site infections: A systematic review

BACKGROUND

Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence.

OBJECTIVE

To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs.

DESIGN

Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate).

RESULTS

In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers.

CONCLUSIONS

Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

Cost-effectiveness analysis of single use negative pressure wound therapy dressings (sNPWT) compared to standard of care in reducing surgical site complications (SSC) in patients undergoing coronary artery bypass grafting surgery

Background

There is a growing interest in using negative pressure wound therapy in closed surgical incision to prevent wound complications which continue to persist following surgery despite advances in infection measures.

Objectives

To estimate the cost-effectiveness of single use negative pressure wound therapy (sNPWT) compared to standard of care in patients following coronary artery bypass grafting surgery (CABG) procedure to reduce surgical site complications (SSC) defined as dehiscence and sternotomy infections.

Method

A decision analytic model was developed from the Germany Statutory Health Insurance payer’s perspective over a 12-week time horizon. Baseline data on SSC, revision operations, length of stay, and readmissions were obtained from a prospective observational study of 2621 CABG patients in Germany. Effectiveness data for sNPWT was taken from a randomised open label trial conducted in Poland which randomised 80 patients to treatment with either sNPWT or standard care. Cost data (in Euros) were taken from the relevant diagnostic related groups and published literature.

Results

The clinical study reported an increase in wounds that healed without complications 37/40 (92.5%) in the sNPWT compared to 30/40 (75%) patients in the SC group p = 0.03. The model estimated sNPWT resulted in 0.989 complications avoided compared to 0.952 and the estimated quality adjusted life years were 0.8904 and 0.8593 per patient compared to standard care. The estimated mean cost per patient was €19,986 for sNPWT compared to €20,572 for SC resulting in cost-saving of €586. The findings were robust to a range of sensitivity analyses.

Conclusion

The sNPWT can be considered a cost saving intervention that reduces surgical site complications following CABG surgery compared to standard care. We however recommend that additional economic studies should be conducted as new evidence on the use of sNPWT in CABG patients becomes available to validate the results of this economic analysis.

Surgical site infection in spinal metastasis: incidence and risk factors

BACKGROUND

Surgical site infection (SSI) in spinal metastasis surgery represents the most common postoperative surgical complication with high morbidity and mortality.

OBJECTIVE

This study aims to evaluate the incidence of SSI in spinal metastasis surgery and its risk factors.

STUDY DESIGN

This is a retrospective analysis of a prospectively collected data.

METHODS

Preoperative, operative, and postoperative data were collected together with the modified Tokuhashi score and Frankel score at all time checkpoints. Surgical site infection was divided into superficial and deep SSI, as well as early (<90 days) and late SSI. Multiple logistic regression analysis was performed to identify independent risk factors, with p<.05 as significance threshold.

RESULTS

A total of 297 patients were included, with an incidence of SSI of 5.1% (superficial SSI: 3.4%; deep SSI: 1.7 %). Cervicothoracic surgery was associated with the highest incidence of SSI, whereas cervical surgery had the lowest incidence. Smoking, higher number of spinal metastasis, elevated body mass index (BMI), and higher ASA (American Society of Anesthesiologist) score were the preoperative factors associated with increased risk of SSI. Increased intraoperative blood loss and increased number of fixed vertebra increased the SSI incidence. SSI increased hospital stay by a mean of 12 days. When all these variables are analyzed in a multiple regression model, only surgical time≥4 hours and ASA≥3 were found to be independent risk factors for the occurrence of SSI.

CONCLUSION

This paper represents the largest series of spinal metastasis with a mean incidence of SSI of 5.1%. Smoking, higher BMI, higher number of spinal metastasis, higher ASA score, higher number of fused vertebra, intraoperative bleeding≥2000 mL, and neurologic deterioration are risk factors for SSI occurrence. Only ASA≥3 and operative duration≥4 hours are independent risk factors for this complication occurrence. Finally, SSI occurrence is associated with increased hospital stay, increased 30-day mortality rate, and decreased survival rates.

Intraoperative Vancomycin Powder Reduces Staphylococcus aureus Surgical Site Infections and Biofilm Formation on Fixation Implants in a Rabbit Model

OBJECTIVES

To evaluate the effectiveness of intraoperative vancomycin powder in prevention of surgical site infection and biofilm formation on implants in a contaminated animal fixation model.

METHODS

We created a rabbit surgical model including fixation implants at a tibial surgical site seeded with methicillin-resistant Staphylococcus aureus. Our study cohort included 18 rabbits. Nine received vancomycin powder at the surgical site, and the other 9 did not. Serum vancomycin levels were measured at scheduled time points over 24 hours. Bone infection and implant biofilm formation were determined based on the number of colony-forming units present 2 weeks after surgery. Radiography, histology, and electron microscopy aided in evaluation.

RESULTS

No bone infection or implant colonization occurred in the vancomycin powder group. Six bone infections and 6 implant biofilm formations (67%; 95% confidence interval, 45%-88%) occurred in the group that did not receive vancomycin powder (P = 0.009). Serum vancomycin levels were detectable at minimal levels at 1 and 6 hours only. Pathological changes occurred in the specimens that were positive for infection.

CONCLUSIONS

Intraoperative vancomycin powder application at the time of fixation decreases risk for bone infection and biofilm formation on implants in a rabbit model, with minimal increase in serum vancomycin levels. The results are encouraging and support the rationale for a clinical trial investigating the use of local vancomycin powder to reduce the rate of surgical site infections.

CLINICAL RELEVANCE

Infection is a common complication of surgery, especially with implants. Simple methods to prevent or decrease the occurrence of infection would benefit the patient and the health care system.

Effect of triclosan-coated sutures on the incidence of surgical site infection after abdominal wall closure in gastroenterological surgery: a double-blind, randomized controlled trial in a single center

BACKGROUND

Surgical site infection is one of the most common postoperative complications after gastroenterologic surgery. This study investigated the effect of triclosan-coated sutures in decreasing the incidence of surgical site infections after abdominal wall closure in gastroenterologic surgery.

METHODS

A prospective, double-blind, randomized, controlled parallel adaptive group-sequential superiority trial was conducted from March 2014 to March 2017 in a single center. Eligible patients were those who underwent gastroenterologic surgery. Patients were allocated randomly to receive either abdominal wall closure with triclosan-coated sutures (the study group) or sutures without triclosan (the control group). The primary end point was the incidence of superficial or deep surgical site infections within 30 days after operation. This study was registered with the University Hospital Medical Information Network-Clinical Trials Registry (http://www.umin.ac.jp/ctr/), identification number UMIN000013054.

RESULTS

A total of 1,013 patients (study group, 508 patients; control group, 505 patients) were analyzed by a modified intention-to-treat approach. The wounds in 990 (97.7%) of the 1,013 patients were classified as clean-contaminated. The primary end point (incidence of superficial or deep surgical site infections) was 35 (6.9%) of 508 patients in the study group and 30 (5.9%) of 505 in the control group. The incidence of surgical site infections did not differ markedly between the 2 groups (95% confidence interval: 0.686-2.010, P = .609). Of the 65 infections, 42 (64.6%) were superficial surgical site infections, with similar frequencies in the 2 groups, and 23 (35.4%) were deep surgical site infections, again with similar frequencies in the 2 groups.

CONCLUSION

Triclosan-coated sutures did not decrease the incidence of surgical site infections after abdominal wall closure in gastroenterologic surgery.

Surgical Site Irrigation in Plastic Surgery

BACKGROUND

The incidence of infection following breast implant reconstruction remains high at the level of 24%. Surgical site irrigation is commonly used for its prevention. However, the lack of evidence-based guidelines for antibiotic prophylaxis in breast implant surgery necessitates research for optimal irrigation technique.

OBJECTIVES

composition and exposure time of irrigation solution for surgical site infection (SSI) prophylaxis using an in vitro model of a surgical site.

METHODS

The study design was an in vitro model to assess antibiotic irrigation of a surgical site. Strains of Staphylococcus aureus, Methicillin-resistant Staphylococcus aureus, Group A Streptococcus, and Pseudomonas aeruginosa were seeded on blood agar growth medium and irrigated with various antibiotic and antiseptic solutions under different exposure times. The presence and quantity of the colonies grown were estimated after 24-hour incubation. Repetition of the studies for 5 times with each investigated irrigation solution and microorganism was performed. Optimal irrigation agents were chosen based on the ability to achieve sterility with minimal tissue toxicity.

RESULTS

The optimal wound irrigation agents for SSI prophylaxis in our study were found to be 0.05% chlorhexidine or triple antibiotic antibiotic solutions. Adding of vancomycin to the irrigation solutions did not show an increase in their effectiveness. Prolonged irrigation exposure time was necessary to achieve sterility of the in vitro model of a surgical site.

CONCLUSIONS

We recommend 0.05% chlorhexidine or triple antibiotic solution for topical SSI prophylaxis in breast implant surgery. Sufficient time of irrigation can be achieved by maintaining some of the solution in the pocket and delaying drainage for at least 30 minutes.

LEVEL OF EVIDENCE 5

Triclosan-coated sutures and surgical site infection in abdominal surgery: the TRISTAN review, meta-analysis and trial sequential analysis

INTRODUCTION

Surgical site infection (SSI) is a frequent complication of abdominal surgery causing increased morbidity. Triclosan-coated sutures are recommended to reduce SSI. The aim of this systematic review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing the rate of SSI in abdominal surgery when using triclosan-coated or uncoated sutures for fascial closure.

METHODS

A systematic literature search was conducted using Medline, EMBASE, the Cochrane library, CINAHL, Scopus and Web of Science including publications until August 2017. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively.

RESULTS

Eight RCTs on abdominal wall closure were included in the meta-analysis. In an overall comparison including both triclosan-coated Vicryl and PDS sutures for fascial closure, triclosan-coated sutures were superior in reducing the rate of SSI (OR 0.67; 0.46-0.98). When evaluating PDS sutures separately, there was no effect of triclosan-coating on the rate of SSI (OR 0.85; 0.61-1.17). Trial sequential analysis showed that the required information size (RIS) of 797 patients for triclosan-coated Vicryl sutures was almost reached with an accrued information size (AIS) of 795 patients. For triclosan-coated PDS sutures an AIS of 2707 patients was obtained, but the RIS was estimated to be 18,693 patients.

CONCLUSION

Triclosan-coated Vicryl sutures for abdominal fascial closure decrease the risk of SSI significantly and based on the trial sequential analysis further RCTs will not change that outcome. There was no effect on SSI rate with the use of triclosan-coated PDS sutures for abdominal fascial closure, and it is unknown whether additional RCTs will change that.

Surgical Wound Classification and Surgical Site Infections in the Orthopaedic Patient

INTRODUCTION

The Centers for Disease Control and Prevention created a surgical wound classification system (SWC: I, clean; II, clean/contaminated; III, contaminated; and IV, dirty) to preemptively identify patients at risk of surgical site infection (SSI). The validity of this system is yet to be demonstrated in orthopaedic surgery. We hypothesize a poor association between the SWC and the rate of subsequent SSI in orthopaedic trauma cases.

METHODS

Nine hundred fifty-six orthopaedic cases were reviewed. Wounds were risk stratified intraoperatively using the SWC grades (I-IV). SSI was diagnosed clinically or with objective markers. The SWC was compared with SSI rates using a Fisher exact test. Significance was set at P < 0.05.

RESULTS

Four hundred patients met the selection criteria. The rate of infection was not significantly different across the SWC grades (P = 0.270). There was a significantly higher risk of SSI among patients with diabetes (P = 0.028).

CONCLUSIONS

The Centers for Disease Control and Prevention SWC showed poor utility in predicting and risk stratifying postoperative SSIs in orthopaedic surgical cases.

Patients at High-Risk for Surgical Site Infection

BACKGROUND

Surgical site infections (SSIs) are a significant healthcare quality issue, resulting in increased morbidity, disability, length of stay, resource utilization, and costs. Identification of high-risk patients may improve pre-operative counseling, inform resource utilization, and allow modifications in peri-operative management to optimize outcomes.

METHODS

Review of the pertinent English-language literature.

RESULTS

High-risk surgical patients may be identified on the basis of individual risk factors or combinations of factors. In particular, statistical models and risk calculators may be useful in predicting infectious risks, both in general and for SSIs. These models differ in the number of variables; inclusion of pre-operative, intra-operative, or post-operative variables; ease of calculation; and specificity for particular procedures. Furthermore, the models differ in their accuracy in stratifying risk. Biomarkers may be a promising way to identify patients at high risk of infectious complications.

CONCLUSIONS

Although multiple strategies exist for identifying surgical patients at high risk for SSIs, no one strategy is superior for all patients. Further efforts are necessary to determine if risk stratification in combination with risk modification can reduce SSIs in these patient populations.

Vancomycin microspheres reduce postoperative spine infection in an in vivo rabbit model

Background

Surgical site infections are common and devastating complications after implants related surgeries. Staphylococcus aureus contamination is a leading cause of surgical site infections. This study aims at assessing the effect of vancomycin microspheres on reducing Staphylococcus aureus infection in an in vivo rabbit model.

Methods

Sixty surgical sites of 20 New Zealand White rabbits underwent spinal implant were randomly divided to three groups: the control group, the vancomycin group and vancomycin microspheres group. The surgical sites were incubated with 100 μl 1 × 10⁷ CFU S. aureus ATCC 25923. Prior to closure, vancomycin and vancomycin microspheres were placed into the wounds of the rabbits in the vancomycin group and the vancomycin microspheres group, respectively. The rabbits were killed on postoperative day 7. Standard quantification techniques were used to analyze biomaterial centered and soft tissue bacterial growth. The bacteria were further confirmed by PCR with primers from the thermostable nuclease gene of S. aureus.

Results

All the rabbits survived the surgery and no postoperative wound complications or systemic illness occurred. Results showed that the bacterial cultures were 76.9, 30.8, and 15.4% in the control group, vancomycin group, and vancomycin microspheres group. Vancomycin microspheres treatments significantly decreased the infection rate compared to the control group (p < 0.05).

Conclusion

Vancomycin microspheres combined with preoperative ceftriaxone is effective to reduce postoperative S. aureus infection compared with the control group.

The cost of infection in hip arthroplasty: a matched case-control study

OBJECTIVE

Surgical site infection (SSI) represents 30% of all causes of health care-associated infection (HAI) and is one of the most dreaded complications in surgical patients. We estimated the excess direct costs of SSI using a matched nested case-control study in acute-term care at Ramon y Cajal University Hospital in Spain.

MATERIAL AND METHOD

Cases were patients who developed a first episode of SSI according to the criteria established by the CDC's National Healthcare Safety Network. Controls were matched to cases in 1:1 ratio taking into account the American Society of Anesthesiologists score, age, sex, surgery date, and principal diagnosis.

RESULTS

This study found that infection in hip replacement increased direct costs by 134%. Likewise, the excess cost due to the infections caused by methicillin resistant Staphylococcus aureus was 69% higher than the excess cost attributable to infections caused by other microorganisms.

CONCLUSIONS

SSI after hip replacement continues to be a costly complication from the hospital perspective. Costs due to SSI can be used to prioritise preventive interventions to monitor and control HAI.

Outcomes following the implementation of a quality control campaign to decrease sternal wound infections after coronary artery by-pass grafting

Background

Coronary artery by-pass grafting (CABG) remains the optimal strategy in achieving complete revascularization in patients with complex coronary artery disease. However, sternal wound infections (SWI), especially deep SWI are potentially severe complications to the surgery. At the department of cardiothoracic surgery in Uppsala University Hospital a gradual increase in all types of SWI occurred, which peaked in 2009. This prompted an in-depth revision of the whole surgical process. To monitor the frequency of post-operative infections all patients receive a questionnaire that enquires whether any treatment for wound infection has been carried out.

Methods

All patients operated with isolated CABG between start of 2006 and end of 2012 were included in the study. 1515 of 1642 patients answered and returned the questionnaire (92.3 %). The study period is divided into the time before the intervention program was implemented (2006-early 2010) and the time after the intervention (early 2010- end 2012). To assess whether potential differences in frequency of SWI were a consequence of change in the characteristics of the patient population rather than an effect of the intervention a retrospective assessment of medical records was performed, where multiple of the most known risk factors for developing SWI were studied.

Results

We noticed a clear decrease in the frequency of SWI after the intervention. This was not a consequence of a healthier population.

Conclusions

Our results from implementing the intervention program are positive in that they reduce the number of SWI. As several changes in the perioperative care were introduced simultaneously we cannot deduce which is the most effective.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-015-0148-4) contains supplementary material, which is available to authorized users.

Intrasite vancomycin powder for the prevention of surgical site infection in spine surgery: a systematic literature review

BACKGROUND CONTEXT

Deep surgical site infections (SSIs) following spinal surgery are a significant burden to the patient, patient's family, and the health-care system. Because of increasing pressures to reduce SSIs and control costs, some spine surgeons have begun placing lyophilized vancomycin powder directly into the surgical wound at the conclusion of the procedure. However, the literature supporting this practice remains limited.

PURPOSE

To review the current literature examining the use of prophylactic intrasite vancomycin powder to control SSIs in spinal surgery and determine if any standard recommendations can be made.

STUDY DESIGN

A systematic review.

METHODS

Ovid Medline and PubMed were searched to identify English language articles.

RESULTS

No current guidelines are available for the use of intrasite vancomycin powder in preventing SSIs, and no standard dosage for the drug exists. Based on the limited literature and evidence currently available, there appears to be a protective effect of intrasite vancomycin powder on the incidence of SSI, without evidence of side effects. However, case reports do exist describing the systemic side effects after intrasite vancomycin powder during spine surgery.

CONCLUSIONS

The interpretation of the available evidence supporting the use of intrasite vancomycin powder in surgical wounds is limited, and its extrapolation should be performed with caution. Despite the lack of significant high-quality evidence available in the literature, many surgeons have adopted this practice; anecdotally, it continues to provide protection from infection without apparent significant risk of side effects.

The Italian national surgical site infection surveillance programme and its positive impact, 2009 to 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Nosocomial infections within the first month of solid organ transplantation

Infections remain a common complication of solid organ transplantation. Early postoperative infections remain a significant cause of morbidity and mortality in solid organ transplant (SOT) recipients. Although significant effort has been made to understand the epidemiology and risk factors for early nosocomial infections in other surgical populations, data in SOT recipients are limited. A literature review was performed to summarize the current understanding of pneumonia, urinary tract infection, surgical-site infection, bloodstream infection, and Clostridium difficult colitis, occurring within the first 30 days after transplantation.

Multicentred surgical site infection surveillance using partitioning analysis

BACKGROUND

Surgical site infection (SSI) is an ongoing major public health problem throughout the world that increases healthcare costs. Utilizing a methodology that can help clinicians to continuously collect data about SSIs, analyse it and implement the feedback into routine hospital practice has been identified as a top national priority in Japan.

AIM

To conduct an intervention study through 'operations research' using partitioning at multiple facilities, and to reduce the incidence and consequences of SSI.

METHODS

The Setouchi SSI Surveillance Group, which consists of seven institutes, started SSI surveillance in 2006. Until May of 2008, there were four surveillance periods (A-D). In all, 3089 patients underwent gastrointestinal surgery and were followed up for 30 days after their operations. Twenty-six factors that have been reported to be related to SSI were evaluated for all patients. The top three factors from each surveillance period were determined and then actual practice improvements were planned for each subsequent period.

FINDINGS

The total SSI occurrence was 6.9% for period A, 6.3% for period B, 6.4% for period C and 3.9% for period D. Comparing periods A and D, there was a statistical significance in the decrease of SSI occurrence (P = 0.012).

CONCLUSION

Using the results and partitioning analysis of active SSI surveillance to contribute to action plans for improving clinical practice was effective in significantly reducing SSIs.