Risk factors for surgical infection

Optimizing Dual Antiplatelet Therapy in the Perioperative Period for Spine Surgery After Recent Percutaneous Coronary Intervention: A Comprehensive Review, Synthesis, and Catalyst for Protocol Formulation

The increased incidence of spine surgery within the past decade has highlighted the importance of robust perioperative management to improve patient outcomes overall. Coronary artery disease is a common medical comorbidity present in the population of individuals who receive surgery for spinal pathology that is often treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Discontinuation of DAPT before surgical intervention is typically indicated; however, contradictory evidence exists in the literature regarding the timing of DAPT use and discontinuation in the perioperative period. We review the most recent cardiac and spine literature on the intricacies of percutaneous coronary intervention and its associated risks in the postoperative period. We further propose protocols for DAPT use after both elective and urgent spine surgery to optimize perioperative care.

Determination of risk factors associated with surgical site infection in patients undergoing preperitoneal pelvic packing for unstable pelvic fracture

Background

Several recent studies have shown that preperitoneal pelvic packing (PPP) effectively produces hemostasis in patients with unstable pelvic fractures. However, few studies have examined the rate of surgical site infections (SSIs) in patients undergoing PPP following an unstable pelvic fracture. The purpose of the present study was to evaluate factors associated with SSI in such patients.

Methods

We retrospectively reviewed the medical charts of 188 patients who developed hemorrhagic shock due to pelvic fracture between April 2012 and May 2021. Forty-four patients were enrolled in this study.

Results

SSI occurred in 15 of 44 patients (34.1%). The SSIs occurred more frequently in cases of repacking during the second-look surgery (0 vs. 4 [26.7%], P=0.010) and combined bladder-urethra injury (1 [3.4%] vs. 4 [26.7%], P=0.039). The incidence of SSIs was not significantly different between patients undergoing depacking within or after 48 hours (12 [41.4%] vs. 5 [33.3%], P=0.603). The mean time to diagnosis of SSI was 8.1±3.9 days from PPP. The most isolated organism was Staphylococcus epidermidis.

Conclusions

Repacking and combined bladder-urethra injury are potential risk factors for SSI in patients with unstable pelvic fracture. Close observation is recommended for up to 8 days in patients with these risk factors. Further, 48 hours after PPP, removing the packed gauze on cessation of bleeding and not performing repacking can help prevent SSI. Additional analyses are necessary with a larger number of patients with the potential risk factors identified in this study.

Is sterile exposure in perianal procedures necessary? A single-institution experience and results from a national survey

BACKGROUND

Surgical site infections (SSI) are the most common postoperative complications. To minimize the risk of SSI, there is a strict asepsis policy in the operating theatre. The aim of this study was to evaluate the risk and cost-saving benefit of performing perianal surgery in a non-sterile setting.

METHODS

All patients who had perianal surgery at our institution between January 2014 and December 2017 in a sterile (S) or non-sterile (NS) setting for an infectious or non-infectious cause were included. The primary outcome was the 30-day SSI rate. The secondary outcome was the reintervention rate. A questionnaire was sent to surgeons in the Netherlands to assess current policy with regard to asepsis in perianal procedures. Finally, a cost analysis was performed.

RESULTS

In total, 376 patients were included. The rate of SSI in infectious procedures was 13% (S) versus 14% (NS, p = 0.853) and 5.1% (S) versus 0.9% (NS) in non-infectious procedures (p = 0.071). Reintervention rates in infectious procedures were 3.4% (S) versus 8.6% (NS, p = 0.187) and 1.3% (S) versus 0.0% (NS) in non-infectious procedures (p = 0.227). The questionnaire revealed that most surgeons perform perianal surgery in a sterile setting although they did not consider this useful. The potential national cost-saving benefit of a non-sterile setting is €124.61 per patient.

CONCLUSIONS

This study suggests that it is safe to perform perianal surgery in a non-sterile setting with regard to the SSI and reintervention rate. Adjustment of the current practice will contribute to a reduction in healthcare expenses.

Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial

IMPORTANCE

Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee.

OBJECTIVE

To evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants from 19 hospitals (17 teaching and 2 academic) in the Netherlands (November 2014-September 2016), with a follow-up of 6 months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy.

INTERVENTIONS

A single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242).

MAIN OUTCOMES AND MEASURES

Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction.

RESULTS

Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7-16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, -1.7 [95% CI, -8.0 to 4.6], P = .60).

CONCLUSIONS AND RELEVANCE

Among patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with saline did not reduce the risk of surgical site infection within 30 days following implant removal.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02225821.

Review of Subcutaneous Wound Drainage in Reducing Surgical Site Infections after Laparotomy

Purpose. Surgical site infections (SSIs) remain a significant problem after laparotomies. The aim of this review was to assess the evidence on the efficacy of subcutaneous wound drainage in reducing SSI. Methods. MEDLINE database was searched. Studies were identified and screened according to criteria to determine their eligibility for meta-analysis. Meta-analysis was performed using the Mantel-Haenszel method and a fixed effects model. Results. Eleven studies were included with two thousand eight hundred and sixty-four patients. One thousand four hundred and fifty patients were in the control group and one thousand four hundred and fourteen patients were in the drain group. Wound drainage in all patients shows no statistically significant benefit in reducing SSI incidence. Use of drainage in high risk patients, contaminated wound types, and obese patients appears beneficial. Conclusion. Using subcutaneous wound drainage after laparotomy in all patients is unnecessary as it does not reduce SSI risk. Similarly, there seems to be no benefit in using it in clean and clean contaminated wounds. However, there may be benefit in using drains in patients who are at high risk, including patients who are obese and/or have contaminated wound types. A well designed trial is needed which examines these factors.

Antimicrobial efficacy of preoperative skin antisepsis and clonal relationship to postantiseptic skin-and-wound flora in patients undergoing clean orthopedic surgery

Nosocomial surgical site infections (SSI) are still important complications in surgery. The underlying mechanisms are not fully understood. The aim of this study was to elucidate the possible role of skin flora surviving preoperative antisepsis as a possible cause of SSI. We conducted a two-phase prospective clinical trial in patients undergoing clean orthopedic surgery at a university trauma center in northern Germany. Quantitative swab samples were taken from pre- and postantiseptic skin and, additionally, from the wound base, wound margin, and the suture of 137 patients. Seventy-four patients during phase I and 63 during phase II were investigated. Microbial growth, species spectrum, and antibiotic susceptibility were analyzed. In phase two, the clonal relationship of strains was additionally analyzed. 18.0 % of the swab samples were positive for bacterial growth in the wound base, 24.5 % in the margin, and 27.3 % in the suture. Only 65.5 % of patients showed a 100 % reduction of the skin flora after antisepsis. The microbial spectrum in all postantiseptic samples was dominated by coagulase-negative staphylococci (CoNS). Clonally related staphylococci were detected in ten patients [nine CoNS, one methicillin-susceptible Staphylococcus aureus (MSSA)]. Six of ten patients were suspected of having transmitted identical clones from skin flora into the wound. Ethanol-based antisepsis results in unexpected high levels of skin flora, which can be transmitted into the wound during surgery causing yet unexplained SSI. Keeping with the concept of zero tolerance, further studies are needed in order to understand the origin of this flora to allow further reduction of SSI.

Preoperative skin antiseptics for preventing surgical wound infections after clean surgery

BACKGROUND

Surgical site infection rates in the month following clean surgery vary from 0.6% (knee prosthesis) to 5% (limb amputation). Due to the large number of clean surgical procedures conducted annually the costs of these surgical site infections (SSIs) can be considerable in financial and social terms. Preoperative skin antisepsis using antiseptics is performed to reduce the risk of SSIs by removing soil and transient organisms from the skin where a surgical incision will be made. Antiseptics are thought to be toxic to bacteria and therefore aid their mechanical removal. The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however, it is unclear whether preoperative skin antisepsis actually reduces postoperative wound infection, and, if so, which antiseptic is most effective.

OBJECTIVES

To determine whether preoperative skin antisepsis immediately prior to surgical incision for clean surgery prevents SSI and to determine the comparative effectiveness of alternative antiseptics.

SEARCH METHODS

For this third update we searched just the Cochrane Wounds Group Specialised Register (searched 27 January 2015); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 12).

SELECTION CRITERIA

Randomised controlled trials evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. There was no restriction on the inclusion of reports based on language of publication, date or publication status.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of risk of bias were undertaken independently by two review authors.

MAIN RESULTS

There were no new studies added to the review in the third updateThirteen studies were included in this review (2,623 participants). These evaluated several different types of skin antiseptics - leading to 11 different comparisons being made. Although the antiseptics evaluated differed between studies, all trials involved some form of iodine. Iodine in alcohol was compared to alcohol alone in one trial; one trial compared povidone iodine paint (solution type not reported) with soap and alcohol. Six studies compared different types of iodine-containing products with each other and five compared iodine-containing products with chlorhexidine-containing products.There was evidence from one study suggesting that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits led to a reduced risk of SSI compared with an alcohol based povidone iodine solution: RR 0.47 (95% CI 0.27 to 0.82). However, it is important to note that the trial does not report important details regarding the interventions (such as the concentration of povidone iodine paint used) and trial conduct, such that risk of bias was unclear.There were no other statistically significant differences in SSI rates in the other comparisons of skin antisepsis. Overall the risk of bias in included studies was unclear.A mixed treatment comparison meta-analysis was conducted and this suggested that alcohol-containing products had the highest probability of being effective - however, again the quality of this evidence was low.

AUTHORS' CONCLUSIONS

A comprehensive review of current evidence found some evidence that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of SSIs following clean surgery than alcohol-based povidone iodine paint. However this single study was poorly reported. Practitioners may therefore elect to consider other characteristics such as costs and potential side effects when choosing between alternatives.The design of future trials should be driven by the questions of high priority to decision makers. It may be that investment in at least one large trial (in terms of participants) is warranted in order to add definitive and hopefully conclusive data to the current evidence base. Ideally any future trial would evaluate the iodine-containing and chlorhexidine-containing solutions relevant to current practice as well as the type of solution used (alcohol vs. aqueous).

Is there an evidence-based argument for embracing an antimicrobial (triclosan)-coated suture technology to reduce the risk for surgical-site infections?: A meta-analysis

BACKGROUND

It has been estimated that 750,000 to 1 million surgical-site infections (SSIs) occur in the United States each year, causing substantial morbidity and mortality. Triclosan-coated sutures were developed as an adjunctive strategy for SSI risk reduction, but a recently published systematic literature review and meta-analysis suggested that no clinical benefit is associated with this technology. However, that study was hampered by poor selection of available randomized controlled trials (RCTs) and low patient numbers. The current systematic review involves 13 randomized, international RCTs, totaling 3,568 surgical patients.

METHODS

A systematic literature search was performed on PubMed, Embase/Medline, Cochrane database group (Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Health Economic Evaluations Database/Database of Health Technology Assessments), and www.clinicaltrials.gov to identify RCTs of triclosan-coated sutures compared with conventional sutures and assessing the clinical effectiveness of antimicrobial sutures to decrease the risk for SSIs. A fixed- and random-effects model was developed, and pooled estimates reported as risk ratio (RR) with a corresponding 95% confidence interval (CI). Publication bias was assessed by analyzing a funnel plot of individual studies and testing the Egger regression intercept.

RESULTS

The meta-analysis (13 RCTs, 3,568 patients) found that use of triclosan antimicrobial-coated sutures was associated with a decrease in SSIs in selected patient populations (fixed effect: RR = 0.734; 95% CI: 0.590-0.913; P = .005; random-effect: RR = 0.693; 95% CI: 0.533-0.920; P = .011). No publication bias was detected (Egger intercept test: P = .145).

CONCLUSION

Decreasing the risk for SSIs requires a multifaceted "care bundle" approach, and this meta-analysis of current, pooled, peer-reviewed, randomized controlled trials suggests a clinical effectiveness of antimicrobial-coated sutures (triclosan) in the prevention of SSIs, representing Center for Evidence-Based Medicine level 1a evidence.

Preoperative skin antiseptics for preventing surgical wound infections after clean surgery

BACKGROUND

Surgical site infection rates in the month following clean surgery vary from 0.6% (knee prosthesis) to 5% (limb amputation). Due to the large number of clean surgical procedures conducted annually the costs of these surgical site infections (SSIs) can be considerable in financial and social terms. Preoperative skin antisepsis using antiseptics is performed to reduce the risk of SSIs by removing soil and transient organisms from the skin where a surgical incision will be made. Antiseptics are thought to be toxic to bacteria and therefore aid their mechanical removal. The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however, it is unclear whether preoperative skin antisepsis actually reduces postoperative wound infection, and, if so, which antiseptic is most effective.

OBJECTIVES

To determine whether preoperative skin antisepsis immediately prior to surgical incision for clean surgery prevents SSI and to determine the comparative effectiveness of alternative antiseptics.

SEARCH METHODS

For this second update we searched the The Cochrane Wounds Group Specialised Register (searched 7 August 2012), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), Ovid MEDLINE  (1950 to July Week 4 2012), Ovid MEDLINE (In-Process & Other Non-Indexed Citations August 06, 2012), Ovid EMBASE (1980 to 2012 Week 31), EBSCO CINAHL (2007 to 3 August 2012).

SELECTION CRITERIA

Randomised controlled trials evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. There was no restriction on the inclusion of reports based on language of publication, date or publication status.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of risk of bias were undertaken independently by two review authors.

MAIN RESULTS

Thirteen studies were included in this review (2,623 participants). These evaluated several different types of skin antiseptics - leading to 11 different comparisons being made. Although the antiseptics evaluated differed between studies, all trials involved some form of iodine. Iodine in alcohol was compared to alcohol alone in one trial; one trial compared povidone iodine paint (solution type not reported) with soap and alcohol. Six studies compared different types of iodine-containing products with each other and five compared iodine-containing products with chlorhexidine-containing products.There was evidence from one study suggesting that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits led to a reduced risk of SSI compared with an alcohol based povidone iodine solution: RR 0.47 (95% CI 0.27 to 0.82). However, it is important to note that the trial does not report important details regarding the interventions (such as the concentration of povidone iodine paint used) and trial conduct, such that risk of bias was unclear.There were no other statistically significant differences in SSI rates in the other comparisons of skin antisepsis. Overall the risk of bias in included studies was unclear.A mixed treatment comparison meta-analysis was conducted and this suggested that alcohol-containing products had the highest probability of being effective - however, again the quality of this evidence was low.

AUTHORS' CONCLUSIONS

A comprehensive review of current evidence found some evidence that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of SSIs following clean surgery than alcohol-based povidone iodine paint. However this single study was poorly reported. Practitioners may therefore elect to consider other characteristics such as costs and potential side effects when choosing between alternatives.The design of future trials should be driven by the questions of high priority to decision makers. It may be that investment in at least one large trial (in terms of participants) is warranted in order to add definitive and hopefully conclusive data to the current evidence base. Ideally any future trial would evaluate the iodine-containing and chlorhexidine-containing solutions relevant to current practice as well as the type of solution used (alcohol vs. aqueous).

Correlation of risk and postoperative assessment methods in wound surveillance

BACKGROUND

Various surveillance methods have been described for surveillance of surgical site infections (SSI). The aim of this study was to examine practicality of SSI risk assessment methods (Study on the Efficacy of Nosocomial Infection Control [SENIC] and National Nosocomial Infections Surveillance [NNIS]) with a postoperative wound monitoring scale (ASEPSIS) as an outcome assessment measure.

MATERIALS AND METHODS

Patients were followed with a prospective data chart from January 1, 2003, to December 31, 2005. Correlation of SENIC and NNIS together with ASEPSIS were performed.

RESULTS

During the study period, 222 SSI occurred. SSIs were determined within the 21-d period after operations. Correlation between SENIC with ASEPSIS (r(s) = 0.47, P < 0.001) was found better than that for NNIS with ASEPSIS (r(s) = 0.41, P < 0.001). Type of operation (emergency versus elective), body mass index, operation class, and American Society of Anesthesiologists scores were found independently predictive factors for SSI.

CONCLUSIONS

This study indicates weak but significant correlation between preoperative risk assessment methods for SSI and ASEPSIS.

American Society of Anesthesiologists classification of physical status as a predictor of wound infection

BACKGROUND

Wound infection occurs when bacterial contamination overcomes the hosts' defences against bacterial growth. Wound categories are a measurement of wound contamination. The American Society of Anesthesiologists (ASA) classification of physical status may be an effective indirect measurement of the hosts' defence against infection. This study examines the association between the ASA score of physical status and wound infection.

METHODS

A retrospective review of a prospective study of antibiotic prophylaxis was carried out. Patients with a documented ASA score who received optimal prophylactic antibiotics were included. The anaesthetist scored the ASA classification of physical status in theatre. Other risk factors for wound infection were also documented. Patients were assessed up to 30 days postoperatively.

RESULTS

Of 1013 patients there were 483 with a documented ASA score. One hundred and one may not have received optimal prophylaxis, leaving a database of 382 patients. There were 36 wound infections (9.4%). Both the ASA classification of physical status (P = 0.002) and the wound categories (P = 0.034) significantly predicted wound infection. The duration of surgery, patient's age, acuteness of surgery and the organ system being operated on did not predict wound infection. On logistic regression analysis the ASA score was the strongest predictor of wound infection.

CONCLUSION

When effective prophylactic antibiotics were used the ASA classification of physical status was the most significant predictor of wound infection.

Preoperative skin antiseptics for preventing surgical wound infections after clean surgery

BACKGROUND

Approximately 15% of elective surgery patients and 30% of patients receiving contaminated or dirty surgery are estimated to develop post-operative wound infections. The costs of surgical wound infection can be considerable in financial as well as social terms. Preoperative skin antisepsis is performed to reduce the risk of post-operative wound infections by removing soil and transient organisms from the skin. Antiseptics are thought to be both toxic to bacteria and aid their mechanical removal. The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however it is unclear whether preoperative skin antisepsis actually reduces post-operative wound infection and if so which antiseptic is most effective.

OBJECTIVES

To determine whether preoperative skin antisepsis reduces post-operative surgical wound infection.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Trials Register and the Cochrane Central Register of Controlled Trials in April 2004. In addition we handsearched journals, conference proceedings and bibliographies.

SELECTION CRITERIA

Randomised controlled trials evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. There were no restrictions based on language, date or publication status.

DATA COLLECTION AND ANALYSIS

Three reviewers independently undertook data extraction and assessment of study quality. Pooling was inappropriate and trials are discussed in a narrative review.

MAIN RESULTS

We identified six eligible RCTs evaluating preoperative antiseptics. There was significant heterogeneity in the comparisons and the results could not be pooled. In one study, infection rates were significantly lower when skin was prepared using chlorhexidine compared with iodine. There was no evidence of a benefit in four trials associated with the use of iodophor impregnated drapes.

REVIEWERS' CONCLUSIONS

There is insufficient research examining the effects of preoperative skin antiseptics to allow conclusions to be drawn regarding their effects on post-operative surgical wound infections. Further research is needed.

The surgical error examination is a novel method for objective technical knowledge assessment

BACKGROUND

Objective analysis of surgical skill is necessary. A novel method of assessment using simple error analysis in synthetic models is examined for construct validity.

METHODS

Two examination protocols were devised using synthetic models. These contained either a purpose made error or were representative of good surgical practice. Protocol one contained models of skin closure and minor operations. Protocol two in addition more complex procedures. Face validity was established by the approval of senior surgeons. Junior surgeons were recruited to undertake the assessment. A p value of less than 0.05 was deemed to be significant.

RESULTS

Eighty-nine surgeons were recruited. Both protocol one and two were able to discriminate between groups at statistically significant levels.

CONCLUSIONS

Construct validity has been established by showing that error analysis is able to distinguish surgeons with varying levels of experience.

The cytokine response to physical activity and training

Cytokines are soluble glycoproteins that are produced by and mediate communication between and within immune and nonimmune cells, organs and organ systems throughout the body. Pro- and anti-inflammatory mediators constitute the inflammatory cytokines, which are modulated by various stimuli, including physical activity, trauma and infection. Physical activity affects local and systemic cytokine production at different levels, often exhibiting striking similarity to the cytokine response to trauma and infection. The present review examines the cytokine response to short term exercise stress, with an emphasis on the balance between pro- and anti-inflammatory mechanisms and modulation of both innate and specific immune parameters through cytokine regulation. The effects of long term exercise on cytokine responses and the possible impact on various facets of the immune system are also discussed, with reference to both cross-sectional and longitudinal studies of exercise training. Finally, the validity of using exercise as a model for trauma and sepsis is scruti- nised in the light of physiological changes, symptomatology and outcome, and limitations of the model are addressed. Further studies, examining the effect of exercise, trauma and infection on novel cytokines and cytokine systems are needed to elucidate the significance of cytokine regulation by physical activity and, more importantly, to clarify the health implications of short and long term physical activity with respect to overall immune function and resistance to infection.

Prevalence of hospital-acquired infections in Italy

A one-day prevalence survey was conducted in Calabria (Italy) to estimate the prevalence of hospital-acquired infections (HAI) and the effect of different variables on HAI in 888 patients present in a ward for at least 24 hours and not due for discharge or transfer on the day of the survey. The overall prevalence of HAI was 1.7% and urinary tract and surgical wounds were the most frequent sites (each four patients, 26.7%). In only eight (53.3%) of the fifteen HAI detected, had a microbiological examination been requested and the only two positive culture results involved Pseudomonas aeruginosa (surgical site) and Escherichia coli (urinary tract). Results of multiple logistic regression analysis indicated that HAI differed significantly in prevalence between age groups, ward, and was higher in patients with urinary catheters and in those receiving antibiotics.

Controversies in the prevention of neurosurgical infection

Amongst post-operative infections, those associated with neurosurgery are of particular significance in view of their proximity to, or location within, the central nervous system. Superficial surgical site infections may be complicated by osteomyelitis of the calvarium and deeper extension to the meninges and cerebral parenchyma. The prevention, diagnosis and management of infections associated with implant devices provide similar challenges to those faced in orthopaedic and cardiac surgery. Whilst some consensus exists regarding the need for antimicrobial prophylaxis in the latter two disciplines, its place in neurosurgery remains controversial. When prophylaxis is considered, choice of antimicrobial agents should take account of up-to-date local information in relation to the relevant microbial ecology in hospitals and in the community setting. The potential for spread of blood-borne virus infections and transmissible spongiform encephalopathies in relation to neurosurgery must also be considered and it should be ensured that appropriate preventive strategies are in place.

Nurses and hospital infection control: knowledge, attitudes and behaviour of Italian operating theatre staff

This study examined the disinfection and sterilization practices used by hospital operating theatres and evaluated the knowledge, attitude and behaviour of nursing staff with regard to infection control. Of the 216 nurses responding, knowledge concerning such practices was not consistent since 10% did not believe that items should be rinsed in water after contact with glutaraldehyde and more than 25% thought that 10 min contact time provided sterilization. Almost all were aware that improper practices increased the risk of nosocomial infections in patients. Nurses in orthopaedic surgery had a significantly lower level of knowledge compared with others. The great majority of nurses agreed that guidelines for disinfection and sterilization practice should be maintained and applied. With regard to the use of surgical instruments, the majority used steam or dry heat sterilizers for the appropriate time and temperature. Glutaraldehyde was used by 95% to sterilize endoscopes, but at different temperatures and times of exposure. Similar procedures were reported as used for laryngoscopes, though a higher percentage used heat sterilization. Only 38% routinely used all barrier techniques (gloves, masks, and protective eye-wear). Predictors for the routine use of all barrier techniques included attendance at continuing education courses on nosocomial infections, and nurses who were male and those involved in orthopaedic operations. Data support the need for finding and implementing interventions related to the prevention of hospital infection activities, in order to motivate nurses to use the correct procedures as a routine.

Prospective, randomized, double-blind study of prophylactic antibiotics in axillary lymph node dissection

BACKGROUND

Antibiotic prophylaxis is controversial in patients undergoing axillary lymph node dissection (ALND). We determined whether preoperative antibiotics decreased incidence or treatment cost of infectious complications following ALND.

METHODS

Two hundred patients entered this prospective, randomized, double-blind trial. Patients received either placebo or cefonicid preoperatively. Loco-regional signs of infection were monitored for 4 weeks postoperatively.

RESULTS

There was a trend toward fewer infections in the prophylactic group (placebo 13% versus cefonicid 6%; P = 0.080). Cefonicid significantly decreased severe infections requiring hospitalization (placebo 8% versus cefonicid 1%; P = 0.033). Cefonicid also decreased the treatment cost of infection per patient ($49.80 versus $364.87).

CONCLUSIONS

We demonstrated a trend toward fewer overall infections and significantly fewer severe infections in patients given prophylactic antibiotics, which translated into a decrease in the cost of treatment for infectious complications. These findings support antibiotic prophylaxis for patients undergoing ALND.

The simple excision

Elliptical excisional surgery offers several advantages over other cutaneous surgical techniques (i.e., shave excision, saucerization) which require healing by second intention. In general, an elliptical excision exhibits faster healing, better cosmesis, and yields a specimen for histologic exam and review of margins, and with proper attention to the details of cutaneous anatomy, familiarity with instrumentation, local anesthetics, suture materials, and observance of meticulous surgical technique, is performed with relative ease in the dermatology outpatient office setting.

The epidemiology of methicillin-resistant Staphylococcus aureus: surgical relevance 20 years on

Despite vigorous attempts at eradication over the last 20 years, methicillin-resistant Staphylococcus aureus (MRSA) continues to be a major nosocomial pathogen in Australian acute care institutions. The epidemiology of hospital spread is now well characterized; infected and colonized patients provide the primary reservoirs, and transmission is mainly via hospital staff. The MRSA remains endemic in most of Australia's large urban teaching hospitals; occasional outbreak also occur, especially in intensive care areas. The level of MRSA infection is often indicative of the total rate of nosocomial infection within an institution and may reflect overcrowding, heavy workloads and under-staffing of wards. Standard precautions, isolation and cohorting of infected and colonized patients, screening of staff, hand washing campaigns, nasal eradication policies and increased staff education have all been tried, with variable success. There is no universal formula; local problems require local solutions plus commitment of local resources. Preventing surgical infection with MRSA requires the application of surgical first principles, and the routine use of vancomycin for prophylaxis is not recommended.