Surgical site infection following hysterectomy: adjusted rankings in a regional collaborative

Construction and validation of nomogram to predict surgical site infection after hysterectomy: a retrospective study

This study aimed to develop a predictive tool for surgical site infections (SSI) following hysterectomy and propose strategies for their prevention and control. We conducted a retrospective analysis at a tertiary maternity and child specialist hospital in Zhejiang Province, focusing on patients who underwent hysterectomy between January 2018 and December 2023 for gynecological malignancies or benign reproductive system diseases resistant to medical treatment. Risk factors associated with surgical site infections (SSI) following hysterectomy were identified using LASSO regression analysis on data from 2018 to 2022 as the training set. Independent risk factors were then used to develop a nomogram. The model was validated using data from 2023 as the validation set. Model performance was assessed using the area under the receiver operating characteristic curve (ROC), while calibration curves were employed to gauge model accuracy. Furthermore, clinical utility was evaluated through clinical decision curve analysis (DCA) and clinical impact curve analysis (CIC), providing insights into the practical application of the nomogram. Multivariate analysis identified six independent risk factors associated with SSI development after hysterectomy: BMI ≥ 24 kg/m2 (OR: 2.58; 95% CI 1.14-6.19; P < 0.05), hypoproteinaemia diagnosis (OR: 4.99; 95% CI 1.95-13.02; P < 0.05), postoperative antibiotic use for ≥ 3 days (OR: 49.53; 95% CI 9.73-91.01; P < 0.05), history of previous abdominal surgery (OR: 7.46; 95% CI 2.93-20.01; P < 0.05), hospital stay ≥ 10 days (OR: 9.67; 95% CI 2.06-76.46; P < 0.05), and malignant pathological type (OR: 4.62; 95% CI 1.78-12.76; P < 0.05). A nomogram model was constructed using these variables. ROC and calibration curves demonstrated good model calibration and discrimination in both training and validation sets. Analysis with DCA and CIC confirmed the clinical utility of the nomogram. Personalized nomogram mapping for SSI after hysterectomy enables early identification of high-risk patients, facilitating timely interventions to reduce SSI incidence post-surgery.

Health Care Disparities in Patients Undergoing Hysterectomy for Benign Indications: A Systematic Review

OBJECTIVE

To explore how markers of health care disparity are associated with access to care and outcomes among patients seeking and undergoing hysterectomy for benign indications.

DATA SOURCES

PubMed, EMBASE, and ClinicalTrials.gov were searched through January 23, 2022.

METHODS OF STUDY SELECTION

The population of interest included patients in the United States who sought or underwent hysterectomy by any approach for benign indications. Health care disparity markers included race, ethnicity, geographic location, insurance status, and others. Outcomes included access to surgery, patient level outcomes, and surgical outcomes. Eligible studies reported multivariable regression analyses that described the independent association between at least one health care disparity risk marker and an outcome. We evaluated direction and strengths of association within studies and consistency across studies.

TABULATION, INTEGRATION, AND RESULTS

Of 6,499 abstracts screened, 39 studies with a total of 46 multivariable analyses were included. Having a Black racial identity was consistently associated with decreased access to minimally invasive, laparoscopic, robotic, and vaginal hysterectomy. Being of Hispanic ethnicity and having Asian or Pacific Islander racial identities were associated with decreased access to laparoscopic and vaginal hysterectomy. Black patients were the only racial or ethnic group with an increased association with hysterectomy complications. Medicare insurance was associated with decreased access to laparoscopic hysterectomy, and both Medicaid and Medicare insurance were associated with increased likelihood of hysterectomy complications. Living in the South or Midwest or having less than a college degree education was associated with likelihood of prior hysterectomy.

CONCLUSION

Studies suggest that various health care disparity markers are associated with poorer access to less invasive hysterectomy procedures and with poorer outcomes for patients who are undergoing hysterectomy for benign indications. Further research is needed to understand and identify the causes of these disparities, and immediate changes to our health care system are needed to improve access and opportunities for patients facing health care disparities.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021234511.

Risk factors for surgical site infection after abdominal hysterectomy, New York State, 2015-2018

OBJECTIVE

To identify risk factors for surgical site infections (SSIs) after abdominal hysterectomy (HYST) procedures using National Healthcare Safety Network (NHSN) data augmented with diagnosis codes available using administrative data.

METHODS

We analyzed 66,001 HYST procedures in 166 New York State hospitals between January 2015 and December 2018, reported in NHSN, and matched to billing data. Risks factors for SSI after abdominal hysterectomy were identified using logistic regression models.

RESULTS

A total of 66,001 HYST procedures were analyzed. SSI was reported following 1,093 procedures, resulting in an infection rate of 1.66%. Risk factors associated with SSIs were open approach (not laparoscopic) with an adjusted odds ratio (AOR) of 2.72 and 95% confidence interval (CI) of 2.37-3.12, contaminated or dirty wound class (AOR 2.28, 95% CI 1.61-3.24), body mass index ≥30 (AOR 1.78, 95% CI 1.56-2.02), procedures lasting 186 minutes or more (AOR 1.78, 95% CI 1.56-2.02), American Society of Anesthesia (ASA) score ≥3 (AOR 1.74, 95% CI 1.52-1.99), gynecological cancer (AOR 1.54, 95% CI 1.32-1.80), and diabetes mellitus (AOR 1.46, 95% CI 1.24-1.70).

CONCLUSION

Obesity, prolonged procedure duration, diabetes mellitus, wound contamination, open approach, ASA score ≥3, and gynecological cancer were significant independent risk factors associated with SSI after hysterectomy.

Predictors of same-day discharge following benign minimally invasive hysterectomy

BACKGROUND

Same-day discharge following minimally invasive hysterectomy has been shown to be safe and feasible in select populations, but many nonclinical factors influencing same-day discharge remain unexplored.

OBJECTIVE

To develop prediction models for same-day discharge following minimally invasive hysterectomy using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups.

STUDY DESIGN

We performed a retrospective study of patients who underwent elective minimally invasive hysterectomy for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of same-day discharge were determined a priori and placed into 1 of 7 attribute groupings: intraoperative, surgeon, hospital, surgical timing, patient clinical, patient socioeconomic, and patient geographic attributes. To account for clustering of same-day discharge practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all predictors in a composite model. Receiver operator characteristic curves were generated for each model. The Hanley-McNeil test was used for comparisons, 95% confidence intervals for the areas under the receiver operator characteristic curve were calculated, and a P value of <.05 was considered significant.

RESULTS

Of the 23,513 patients in our study, 5062 (21.5%) had same-day discharge. The composite model had an area under the receiver operator characteristic curve of 0.770 (95% confidence interval, 0.763-0.777). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for same-day discharge (area under the receiver operator characteristic curve, 0.720; 95% confidence interval, 0.712-0.727). The models using surgeon and hospital attributes were the second and third most concordant, respectively (area under the receiver operator characteristic curve, 0.678; 95% confidence interval, 0.670-0.685; area under the receiver operator characteristic curve, 0.655; 95% confidence interval, 0.656-0.664). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes had poor predictive ability (all areas under the receiver operator characteristic curve <0.6).

CONCLUSION

Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting same-day discharge following minimally invasive hysterectomy. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest predictive ability. Focusing on these attributes may aid efforts to improve utilization of same-day discharge following minimally invasive hysterectomy.

Development of a Preoperative Clinical Risk Assessment Tool for Postoperative Complications After Hysterectomy

STUDY OBJECTIVE

To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy.

DESIGN

Retrospective analysis.

SETTING

Michigan Surgical Quality Collaborative hospitals.

PATIENTS

Women who underwent hysterectomy for gynecologic indications.

INTERVENTIONS

Development of a nomogram to create a clinical risk assessment tool.

MEASUREMENTS AND MAIN RESULTS

Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who had a complication and those who did not. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program, and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n = 1638). Preoperative factors associated with postoperative complications were sepsis (odds ratio [OR] 7.98; confidence interval [CI], 1.98-32.20), abdominal approach (OR 2.27; 95% CI, 1.70-3.05), dependent functional status (OR 2.20; 95% CI, 1.34-3.62), bleeding disorder (OR 2.10; 95% CI, 1.37-3.21), diabetes with HbA1c ≥9% (OR 1.93; 95% CI, 1.16-3.24), gynecologic cancer (OR 1.86; 95% CI, 1.49-2.31), blood transfusion (OR 1.84; 95% CI, 1.15-2.96), American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46; 95% CI, 1.24-1.73), government insurance (OR 1.3; 95% CI, 1.40-1.90), and body mass index ≥40 (OR 1.25; 95% CI, 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively).

CONCLUSION

We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.

Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis

BACKGROUND

Antiseptic vaginal preparation is recommended before gynecologic surgery; however, there is a lack of data regarding the effectiveness of different agents.

OBJECTIVE

To compare rates of postoperative infectious complications and hospital utilization with preoperative vaginal preparation using povidone-iodine or chlorhexidine before hysterectomy.

STUDY DESIGN

This was a retrospective analysis of patients who underwent hysterectomy for gynecologic indications at 70 hospitals in a statewide surgical collaborative between January 2017 and December 2019. The primary outcome was postoperative infectious complications (including urinary tract infection, surgical site infections involving superficial, deep, or organ space tissues, or cellulitis) within 30 days of surgery. To adjust for confounding, propensity score matching, 1:1 without replacement and with a caliper of.005 was performed to create cohorts that had vaginal preparation with either povidone-iodine or chlorhexidine and did not differ in observable characteristics. We compared the rates of infectious morbidity and hospital utilization (emergency department visits, readmission, reoperation) in the matched cohorts.

RESULTS

In the statewide collaborative, there were 18,184 patients who received povidone-iodine and 3018 who received chlorhexidine. After propensity score matching of 2935 pairs, the povidone-iodine and chlorhexidine groups did not differ in demographics, comorbidities, choice of preoperative antibiotics, benign vs malignant surgical indication, and surgical approach. Povidone-iodine was associated with a lower rate of infectious morbidity (3.0% vs 4.3%; P=.01), urinary tract infection (1.1% vs 1.7%; P=.03) and emergency department visits (7.9% vs 9.7%; P=.01) than with chlorhexidine. There were nonsignificant trends of lower rates of surgical site infection (2.0% vs 2.7%; P=.07) and reoperation (1.6% vs 2.1%; P=.18).

CONCLUSION

This propensity score matched analysis provides evidence that povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative.

Surgical site infections in gynecology: the latest evidence for prevention and management

PURPOSE OF REVIEW

Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount.

RECENT FINDINGS

Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies.

SUMMARY

Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.

Hospital variation in responses to safety warnings about power morcellation in hysterectomy

BACKGROUND

Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes.

OBJECTIVE

This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy.

STUDY DESIGN

This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions.

RESULTS

Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72).

CONCLUSION

Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.

Hysterectomy Complications Relative to HbA1c Levels: Identifying a Threshold for Surgical Planning

STUDY OBJECTIVE

To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA_1c) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA_1c level past which we should consider delaying surgery owing to increased risk of complications.

DESIGN

Retrospective cohort study.

SETTING

Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017.

PATIENTS

Women with and without a diabetes diagnosis.

INTERVENTIONS

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Data on demographics, preoperative HbA_1c values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA_1c level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA_1c value; group 2: no diabetes diagnosis, with HbA_1c levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA_1c value or HbA_1c levels <9%; and group 4: diabetes diagnosis with HbA_1c levels ≥9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA_1c level ≥9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA_1c levels ≥9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA_1c levels <9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery.

CONCLUSION

Diabetes diagnosis and measurement of preoperative HbA_1c levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA_1c level ≥9%.

Surgical-Site Infection Prevention After Hysterectomy: Use of a Consensus Bundle to Guide Improvement

Hysterectomy is one of the most commonly performed surgeries in women. Surgical-site infections (SSI) after hysterectomy can lead to increased morbidity and mortality as well as readmission, which is associated with increased costs for health systems. The aim of the project was to improve standardization of preoperative education on infection prevention and incorporate the use of preoperative chlorhexidine (CHG) bathing for patients undergoing hysterectomy to decrease rates of SSI. Data on SSI after hysterectomy were reviewed. Tracer methodology was used to identify gaps in the preoperative process by comparing the current process to the Council on Patient Safety in Women's Health Care Patient Safety Bundle "Prevention of Surgical Site Infection after Gynecologic Surgery." After implementation, survey data were collected on adherence to the washing protocol, and SSI data were monitored. Survey results reflected high compliance with the CHG washing protocol, provision of patient education, and overall patient satisfaction with the process. Before implementation in 2016, we reported 8 deep or organ/space SSI to the National Healthcare Safety Network. After implementation in 2018, we reported 3 deep or organ/space SSI. Standardizing infection prevention processes to align with safety bundles improves the quality of care provided to patients.

Importance of Estimated Blood Loss in Resource Utilization and Complications of Hysterectomy for Benign Indications

OBJECTIVE

To identify the variation in estimated blood loss at the time of hysterectomy for benign indications and to analyze how blood loss is associated with measures of resource utilization and complications.

METHODS

We conducted a retrospective cohort study and analyzed hysterectomy for benign indications at hospitals in the Michigan Surgical Quality Collaborative between January 1, 2013, and May 30, 2015. A sensitivity analysis was performed to identify how estimated blood loss was associated with measures of utilization (transfusion, readmission, reoperation, and length of stay) and postoperative complications. A hierarchical logistic regression model was used to identify patient level factors independently associated with estimated blood loss greater than 400 mL and to calculate a risk- and reliability-adjusted rate for each hospital.

RESULTS

There were 18,033 hysterectomies for benign indications from 61 hospitals included for analysis. The median estimated blood loss was 100 mL, and the 90th percentile estimated blood loss was 400 mL. A sensitivity analysis demonstrated increased risks of transfusion, readmission, reoperation, length of stay, and major postoperative complications with estimated blood loss greater than 400 mL. The proportion of hysterectomies at hospitals in the collaborative with estimated blood loss greater than 400 mL ranged from 3.5% to 16.9% after risk and reliability adjustments. The risk factors with the highest adjusted odds for estimated blood loss greater than 400 mL included abdominal surgery compared with laparoscopic hysterectomy (adjusted odds ratio [aOR] 2.8, CI 2.3-3.5), surgical time longer than 3 hours (aOR 3.9, CI 3.3-4.5), and specimen weight greater than 250 g compared with less than 100 g (aOR 4.8, CI 3.9-5.8). Adhesive disease, low surgeon volume, being younger than 40 years of age, having a body mass index greater than 35, and the need for a preoperative transfusion were also statistically significantly associated with estimated blood loss greater than 400 mL.

CONCLUSION

There is fivefold variation in the hospital rate of hysterectomies with an estimated blood loss greater than 400 mL (90th percentile)-a threshold associated with significantly higher rates of health care utilization and complications. Avoidance of abdominal hysterectomy when possible may reduce intraoperative blood loss and associated sequelae.

Safety Bundles in Gynecology

Patient safety bundles and checklists have been shown to improve outcomes in medicine, surgery, and obstetrics. Until recently, there has been less study into their use in the gynecology setting. Here, we review the available evidence and examples of successful checklist and bundle implementation in gynecology and encourage more robust implementation and standardization in our field going forward.

Postoperative infections in women undergoing hysterectomy for benign indications: a cohort study

BACKGROUND

There is limited data on the incidence of postoperative infections following hysterectomy by route of surgery. We hypothesize that vaginal hysterectomy has lower rates of postoperative infection than laparoscopic and abdominal hysterectomies.

METHODS

A retrospective cohort study and independent hand review of charts of participants undergoing hysterectomy at five hospitals from September 2011 through May 2015 was performed. Cases were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes and were reviewed by the investigators. The primary outcome was the development of Clostridium difficile infection, urinary tract infection, surgical site infection, or yeast vaginitis within 60 days following surgery.

RESULTS

In total, 2742 women underwent hysterectomy: abdominal 17.5% (AH), laparoscopic 65.8% (LH), and vaginal 16.7% (VH). The composite postoperative infection rate for the four specified variables was 8.5% (232). In comparing surgical route, AH was most commonly associated with CDI (0.6%, p <0.001), SSI (6.0%, P=0.001), and yeast vaginitis (1.9%, p <0.001), while VH was most commonly associated with UTI (8.1%, P=0.002). After controlling for demographic and operative factors, multivariable analysis showed that hysterectomy route was not associated with infection. Independent predictors for postoperative infection were increasing age, American Society of Anesthesiologists physical status classification, operative time, and hospital type.

CONCLUSIONS

Infectious complications after hysterectomy are uncommon, accounting for 8.5% of cases. Multivariable analysis showed that demographic and operative variables were more likely to serve as independent predictors of development of infection than hysterectomy route.

Quality Measures in Hernia Surgery

With growing pressures to formulate easily interpreted quality metrics, potential pitfalls exist that deleteriously affect the ultimate outcome of patients. This article defines what quality means in hernia surgery, how it is measured, who measures it, and how it is reported. Key governmental organizations responsible are highlighted. Although striving for high quality seems relatively straightforward, it is a challenge to account for all variables. Most definitions of quality are based on products and derived from minimum standards. This transition to basing it on health care delivery is ongoing, challenging, and incredibly important for the future of patients.

Reducing surgical site infections after hysterectomy: metronidazole plus cefazolin compared with cephalosporin alone

BACKGROUND

Organisms that are isolated from vaginal cuff infections and pelvic abscesses after hysterectomy frequently include anaerobic vaginal flora. Metronidazole has outstanding coverage against nearly all anaerobic species, which is superior to both cefazolin and second-generation cephalosporins. Cefazolin plus metronidazole has been demonstrated to reduce infectious morbidity compared with either cefazolin or second-generation cephalosporins in other clean-contaminated procedures, which include both as colorectal surgery and cesarean delivery.

OBJECTIVE

The purpose of this study was to evaluate whether the combination of cefazolin plus metronidazole before hysterectomy was more effective in the prevention of surgical site infection than existing recommendations of cefazolin or second-generation cephalosporin.

STUDY DESIGN

This was a retrospective cohort study of patients in the Michigan Surgical Quality Collaborative from July 2012 through February 2015. The primary outcome was surgical site infection. Patients who were >18 years old and who underwent abdominal, vaginal, laparoscopic, or robotic hysterectomy for benign or malignant indications were included if they received 1 of the following prophylactic antibiotic regimens: cefazolin, second-generation cephalosporin, or cefazolin plus metronidazole. Multivariate logistic regression modeling was performed to evaluate the independent effect of an antibiotic regimen, and propensity score matching was used to validate the findings.

RESULTS

The study included 18,255 hysterectomies. The overall rate of surgical site infection was 1.8% (n=329). The unadjusted rate of surgical site infection was 1.8% (n=267) for cefazolin, 2.1% (n=49) for second-generation cephalosporin, and 1.4% (n=13) for cefazolin plus metronidazole. After adjustment for differences in patient and operative factors among the antibiotic cohorts, compared with cefazolin plus metronidazole, we found the risk of surgical site infection was significantly higher for patients who received cefazolin (odds ratio, 2.30; 95% confidence interval, 1.06-4.99) or second-generation cephalosporin (odds ratio, 2.31; 95% confidence interval, 1.21-4.41).

CONCLUSION

In this large cohort, the use of prophylactic cefazolin plus metronidazole resulted in lower surgical site infection rates after hysterectomy compared with cefazolin or second-generation cephalosporin.

Incidence and risk factors for surgical site infections in obstetric and gynecological surgeries from a teaching hospital in rural India

BACKGROUND

Surgical site infections (SSI) are one of the most common healthcare associated infections in the low-middle income countries. Data on incidence and risk factors for SSI following surgeries in general and Obstetric and Gynecological surgeries in particular are scare. This study set out to identify risk factors for SSI in patients undergoing Obstetric and Gynecological surgeries in an Indian rural hospital.

METHODS

Patients who underwent a surgical procedure between September 2010 to February 2013 in the 60-bedded ward of Obstetric and Gynecology department were included. Surveillance for SSI was based on the Centre for Disease Control (CDC) definition and methodology. Incidence and risk factors for SSI, including those for specific procedure, were calculated from data collected on daily ward rounds.

RESULTS

A total of 1173 patients underwent a surgical procedure during the study period. The incidence of SSI in the cohort was 7.84% (95% CI 6.30-9.38). Majority of SSI were superficial. Obstetric surgeries had a lower SSI incidence compared to gynecological surgeries (1.2% versus 10.3% respectively). The risk factors for SSI identified in the multivariate logistic regression model were age (OR 1.03), vaginal examination (OR 1.31); presence of vaginal discharge (OR 4.04); medical disease (OR 5.76); American Society of Anesthesia score greater than 3 (OR 12.8); concurrent surgical procedure (OR 3.26); each increase in hour of surgery, after the first hour, doubled the risk of SSI; inappropriate antibiotic prophylaxis increased the risk of SSI by nearly 5 times. Each day increase in stay in the hospital after the surgery increased the risk of contacting an SSI by 5%.

CONCLUSIONS

Incidence and risk factors from prospective SSI surveillance can be reported simultaneously for the Obstetric and Gynecological surgeries and can be part of routine practice in resource-constrained settings. The incidence of SSI was lower for Obstetric surgeries compared to Gynecological surgeries. Multiple risk factors identified in the present study can be helpful for SSI risk stratification in low-middle income countries.

Timing of and Reasons for Unplanned 30-Day Readmission After Hysterectomy for Benign Disease

OBJECTIVE

To characterize timing and reasons associated with unplanned 30-day readmissions after hysterectomy for benign indications.

METHODS

We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Project database files from 2012 to 2013. We identified patterns of 30-day readmission after benign hysterectomy for all surgical approaches (abdominal, laparoscopic, vaginal). Readmission timing was determined from discharge date and readmission diagnoses were tabulated. Statistical analyses included χ tests and multivariable logistic regression.

RESULTS

The 30-day readmission rate was 2.8% (1,118/40,580 hysterectomies). Readmissions complicated 3.7% (361/9,869) of abdominal, 2.6% (576/22,266) of laparoscopic, and 2.1% (181/8,445) of vaginal hysterectomies. Readmissions were more likely when hysterectomy was performed abdominally (adjusted odds ratio [OR] 1.45, 95% confidence interval [CI] 1.2-1.76) but not laparoscopically (adjusted OR 1.1, 95% CI 0.9-1.4) compared with a vaginal approach. Eighty-two percent of readmissions occurred within 15 days of discharge. The shortest median time to readmission was associated with pain (3 days), and the longest was associated with noninfectious wound complications (10 days). Surgical site infection was the most common diagnosis (abdominal 36.6%, laparoscopic 28.3%, vaginal 32.6%). Surgical site infections, surgical injuries, and wound complications combined accounted for 51.5% of abdominal, 51.9% of laparoscopic, and 50.8% of vaginal hysterectomy readmissions. Medical complications such as cardiovascular events and venous thromboembolism were responsible for 5.8% of abdominal, 6.9% of laparoscopic, and 8.8% of vaginal hysterectomy readmissions. Surgical injuries were responsible for more readmissions after laparoscopic (unadjusted OR 2.3, 95% CI 1.48-3.65) and vaginal hysterectomies (unadjusted OR 2.3, 95% CI 1.29-3.97) than abdominal cases.

CONCLUSION

Readmissions after hysterectomy tend to occur shortly after discharge. Most readmissions are related to surgical issues, most commonly surgical site infection. Medical complications, including venous thromboembolism, account for less than 10% of readmissions. Readmission reduction efforts should focus on early postdischarge follow-up, preventing infectious complications, and determining preventability of surgical-related reasons for readmission.