Timing of surgical antimicrobial prophylaxis: a phase 3 randomised controlled trial

Prevention of infection in aortic or aortoiliac peripheral arterial reconstruction

BACKGROUND

Peripheral arterial disease (PAD) results from the narrowing of arteries. Aortic aneurysms - abnormal dilatations in artery walls - are a related concern. For severe cases, arterial reconstruction surgery is the treatment option. Surgical site infections (SSIs) are a feared and common complication of vascular surgery. These infections have a significant global healthcare impact. Evaluating the effectiveness of preventive measures is essential.

OBJECTIVES

To assess the effects of pharmacological and non-pharmacological interventions, including antimicrobial therapy, antisepsis, and wound management, for the prevention of infection in people undergoing any open or hybrid aortic or aortoiliac peripheral arterial reconstruction.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform, LILACS, and ClinicalTrials.gov up to 11 November 2024.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a parallel (e.g. cluster or individual) or split-body design, and quasi-RCTs, which assessed any intervention to reduce or prevent infection following aortic or aortoiliac procedures for the treatment of aneurysm or PAD. There were no limitations regarding age and sex.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third review author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 21 RCTs with 4952 participants. Fifteen studies were assessed as having a high risk of bias in at least one domain, and 19 studies had an unclear risk of bias in at least one domain. We analysed 10 different comparisons for eight different outcomes. The comparisons were antibiotic versus placebo or no treatment; short-duration antibiotics (≤ 24 hours) versus long-duration antibiotics (> 24 hours); different types of systemic antibiotics (one versus another); antibiotic-bonded implant versus standard implant; Dacron graft versus stretch polytetrafluoroethylene graft; prophylactic closed suction drainage versus undrained wound; individualised goal-directed therapy (IGDT) versus fluid therapy based on losses, standard haemodynamic parameters and arterial blood gas values (standard care); comprehensive geriatric assessment versus standard preoperative care; percutaneous versus open-access technique; and negative pressure wound therapy (NPWT) versus standard dressing. The primary outcomes were graft infection rate and SSI rate. The secondary outcomes included all-cause mortality, arterial reconstruction failure rate, re-intervention rate, amputation rate, pain resulting from the intervention, and adverse events resulting from the interventions to prevent infection. We did not assess all the outcomes across the different comparisons. The main findings are presented below. Antibiotic versus placebo or no treatment (five studies) Very low-certainty evidence from five included studies suggests that antibiotic prophylaxis reduces SSI (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.15 to 0.71; 5 studies, 583 participants; number needed to treat for an additional beneficial outcome (NNT) 9). With very low- to low-certainty evidence, there was little or no difference between the groups in the other assessed outcomes (graft infection rate, all-cause mortality, re-intervention rate, and amputation rate). We did not quantitatively assess other outcomes in this comparison. Short duration antibiotics (≤ 24 hours) versus long duration antibiotics (> 24 hours) (three studies) Very low-certainty evidence from three included studies suggests that there is little or no difference in graft infection rate (RR 2.74, 95% CI 0.11 to 65.59; 1 study, 88 participants) or SSI rate (RR 3.65, 95% CI 0.59 to 7.71; 1 study, 88 participants) between short- and long-duration antibiotic prophylaxis. We did not quantitatively assess other outcomes in this comparison. Different types of systemic antibiotics (one versus another) (seven studies) We grouped seven studies comparing one antibiotic to another into three subgroups that compared different classes of antibiotics amongst themselves. We found little or no difference between the groups analysed. Graft infection rate: beta-lactams versus cephalosporins (RR 0.36, 95% CI 0.02 to 8.71; 1 study, 88 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 5.00, 95% CI 0.24 to 103.05; 1 study, 238 participants; low-certainty evidence); one cephalosporin versus another (RR not estimable, CI not estimable; 1 study; 69 participants; very low-certainty evidence); SSI rate: beta-lactams and cephalosporins (RR 0.27, 95% CI 0.03 to 2.53; 2 studies, 229 participants; very low-certainty evidence); glycopeptides versus cephalosporins (RR 2.17, 95% CI 0.65 to 7.23; 2 studies, 312 participants; very low-certainty evidence); and one cephalosporin versus another (RR 1.26, 95% CI 0.21 to 7.45; 3 studies, 625 participants; very low-certainty evidence). We could extract all-cause mortality data for the glycopeptide versus cephalosporin comparison; there was little or no difference between groups (RR 1.33, 95% CI 0.30 to 5.83; 1 study, 238 participants; low-certainty evidence). We did not quantitatively assess other outcomes in this comparison.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that the use of prophylactic antibiotics may prevent SSIs in aortic or aortoiliac peripheral arterial reconstruction. We found no superiority amongst specific antibiotics or differences in extended antibiotic use (over 24 hours) compared with shorter use (up to 24 hours), with low-certainty evidence. For other interventions, very low- to moderate-certainty evidence showed little or no difference across various outcomes. We advise interpreting these conclusions with caution due to the limited number of events in all groups and comparisons.

The impact of antimicrobial stewardship interventions on appropriate use of surgical antimicrobial prophylaxis in low- and middle-income countries: a systematic review

BACKGROUND

Surgical antimicrobial prophylaxis (SAP) is an effective infection prevention strategy used to reduce postoperative surgical site infection. Inappropriate use of SAP is a concern in low-middle-income countries (LMICs) due to increased mortality risks, adverse reactions, re-admission rates and length of hospital stay. Antimicrobial Stewardship Programs (ASP) have been shown to be effective in improving the appropriate use of antibiotics including the use of SAP. The aim of this review was to evaluate the impact of ASP on the appropriate use of SAP and its implication on patient outcomes in LMICs.

METHOD

The protocol for this review was registered in PROSPERO. Studies published between 1st January 2010 and 31st December 2023 were searched electronically from Medline, Central Cochrane Library, web of science, CINAHL and APA PsychInfo databases. Studies were included if they assessed the impact of ASP interventions on SAP use in low- and middle-income countries (LMICs). Studies were evaluated using the Risk of Bias in Non-Randomized Studies-of Interventions (ROBINS-I) tool for non-randomized and before and after studies as well as the Cochrane Risk of Bias 2 (ROB 2) tool for randomized studies. Findings were summarized in tables.

RESULTS

Twenty studies comprising of seventeen before-after studies, two interrupted time series, and one randomized controlled trial were included. Penicillins and cephalosporins were the most commonly used antibiotics for SAP. Most (50%) of the studies were conducted in Asia followed by Africa (45%). While 80% of the studies showed the impact of ASP on compliance to SAP guidelines, only 45% showed an impact on antibiotic utilization. Again, 50% and 60% showed an impact on reducing antibiotic costs and patient length of stay at hospitals respectively. Patient outcomes including rates of surgical site infections and mortality showed no significant change. The studies showed a high risk of bias mainly due to the choice of study designs.

CONCLUSION

ASP interventions in LMICs are effective in improving SAP guideline adherence, antibiotic utilization and their cost. Deliberate effort must be made to improve on the quality of future interventional studies in these settings to guide practice and encourage other LMICs to conduct such studies to assess the influence of different geographical contexts on SAP use.

Predictive factors for postoperative ileus after elective right hemicolectomy performed on over 80% Enhanced Recovery After Surgery-adherent patients: a retrospective cohort study

Purpose

Laparoscopic right hemicolectomy is the standard surgical approach for treatment of right-sided colonic neoplasms. Although performed within a strict Enhanced Recovery After Surgery (ERAS) program, patients still develop postoperative ileus. The aim of this study was to describe the factors responsible for postoperative ileus after right hemicolectomy in a patient population with over 80% ERAS adherence.

Methods

In this retrospective study, we analyzed 499 consecutive patients undergoing elective right-sided colectomy for neoplastic disease in a single high-volume center. All patients followed an updated ERAS program.

Results

The overall median ERAS adherence was 80%. Patients with ≥ 80% adherence (n = 271) were included in further analysis. Their median ERAS adherence was 88.9% (interquartile range, 80-90; range, 80-100). Twenty-four of 271 patients (8.9%) developed postoperative ileus. A univariate regression analysis revealed carcinoma situated in the transverse colon, duration of operation over 200 minutes, and opiate consumption over 10 mg on the second postoperative day (POD) to be associated with a significantly higher risk of postoperative ileus. Multivariate regression analysis revealed that duration of surgery over 200 minutes (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0-5.8; P = 0.045) and opiate consumption over 10 mg on POD 2 (OR, 4.8; 95% CI, 1.6-14.3; P = 0.005) independently predict a higher risk for postoperative ileus. The median length of hospital stay was significantly longer in patients with postoperative ileus (8 days vs. 3 days, P < 0.001). None of the 271 patients died during a 30-day follow-up.

Conclusion

Long duration of surgery, even minor postoperative opiate use, predict a higher risk for postoperative ileus in strictly ERAS-adherent patients undergoing laparoscopic right hemicolectomy.

Association of relative resection volume with patient-reported outcomes applying different levels of oncoplastic breast conserving surgery - A retrospective cohort study

INTRODUCTION

The American Society of Breast Surgeons (ASBrS) recently classified oncoplastic breast conserving surgery (OBCS) into two levels. The association of resection ratio during OBCS with patient-reported outcomes (PRO) is unclear.

MATERIALS AND METHODS

Patients with stage 0-III breast cancer undergoing OBCS between 01/2011-04/2023 at a Swiss university hospital, who completed at least one postoperative BREAST-Q PRO questionnaire were identified from a prospectively maintained institutional database. Outcomes included differences in PROs between patients after ASBrS level I (<20 % of breast tissue removed) versus level II surgery (20-50 %).

RESULTS

Of 202 eligible patients, 129 (63.9 %) underwent level I OBCS, and 73 (36.1 %) level II. Six patients (3.0 %) who underwent completion mastectomy were excluded. The median time to final PROs was 25.4 months. Patients undergoing ASBrS level II surgery were more frequently affected by delayed wound healing (p < 0.001). ASBrS level was not found to independently predict any BreastQ domain. However, delayed wound healing was shown to reduce short-term physical well-being (estimated difference -26.27, 95 % confidence interval [CI] -39.33 to -13.22, p < 0.001). Higher age was associated with improved PROs.

CONCLUSION

ASBrS level II surgery allows the removal of larger tumors without impairing PROs. Preventive measures for delayed wound healing and close postoperative follow-up to promptly treat wound healing disorders may avoid short-term reductions in physical well-being.

Povidone Iodine vs Chlorhexidine Gluconate in Alcohol for Preoperative Skin Antisepsis: A Randomized Clinical Trial

Importance

Preoperative skin antisepsis is an established procedure to prevent surgical site infections (SSIs). The choice of antiseptic agent, povidone iodine or chlorhexidine gluconate, remains debated.

Objective

To determine whether povidone iodine in alcohol is noninferior to chlorhexidine gluconate in alcohol to prevent SSIs after cardiac or abdominal surgery.

Design, Setting, and Participants

Multicenter, cluster-randomized, investigator-masked, crossover, noninferiority trial; 4403 patients undergoing cardiac or abdominal surgery in 3 tertiary care hospitals in Switzerland between September 2018 and March 2020 were assessed and 3360 patients were enrolled (cardiac, n = 2187 [65%]; abdominal, n = 1173 [35%]). The last follow-up was on July 1, 2020.

Interventions

Over 18 consecutive months, study sites were randomly assigned each month to either use povidone iodine or chlorhexidine gluconate, each formulated in alcohol. Disinfectants and skin application processes were standardized and followed published protocols.

Main Outcomes and Measures

Primary outcome was SSI within 30 days after abdominal surgery and within 1 year after cardiac surgery, using definitions from the US Centers for Disease Control and Prevention's National Healthcare Safety Network. A noninferiority margin of 2.5% was used. Secondary outcomes included SSIs stratified by depth of infection and type of surgery.

Results

A total of 1598 patients (26 cluster periods) were randomly assigned to receive povidone iodine vs 1762 patients (26 cluster periods) to chlorhexidine gluconate. Mean (SD) age of patients was 65.0 years (39.0-79.0) in the povidone iodine group and 65.0 years (41.0-78.0) in the chlorhexidine gluconate group. Patients were 32.7% and 33.9% female in the povidone iodine and chlorhexidine gluconate groups, respectively. SSIs were identified in 80 patients (5.1%) in the povidone iodine group vs 97 (5.5%) in the chlorhexidine gluconate group, a difference of 0.4% (95% CI, -1.1% to 2.0%) with the lower limit of the CI not exceeding the predefined noninferiority margin of -2.5%; results were similar when corrected for clustering. The unadjusted relative risk for povidone iodine vs chlorhexidine gluconate was 0.92 (95% CI, 0.69-1.23). Nonsignificant differences were observed following stratification by type of surgical procedure. In cardiac surgery, SSIs were present in 4.2% of patients with povidone iodine vs 3.3% with chlorhexidine gluconate (relative risk, 1.26 [95% CI, 0.82-1.94]); in abdominal surgery, SSIs were present in 6.8% with povidone iodine vs 9.9% with chlorhexidine gluconate (relative risk, 0.69 [95% CI, 0.46-1.02]).

Conclusions and Relevance

Povidone iodine in alcohol as preoperative skin antisepsis was noninferior to chlorhexidine gluconate in alcohol in preventing SSIs after cardiac or abdominal surgery.

Trial Registration

ClinicalTrials.gov Identifier: NCT03685604.

Optimal time window for initiating cefuroxime surgical antimicrobial prophylaxis in spinal fusion surgery: a nested case-control study

BACKGROUND CONTEXT

Surgical site infections (SSI) are one of the common complications following spinal fusion surgery. Unfortunately, several studies had shown conflicting results regarding optimal timing of surgical antimicrobial prophylaxis (SAP) administration. Due to limitations in population homogeneity and sample size, these studies have not provided significant statistical correlations or clear practical recommendations.

PURPOSE

The purpose of the study was to investigate the impact of timing of cefuroxime SAP on the risk of SSI in patients undergoing spinal fusion surgery, and to determine the optimal timing of administration.

DESIGN

Retrospective nested case-control study.

PATIENT SAMPLE

We retrospectively analyzed consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021.

OUTCOME MEASURE

In the current study, the primary outcome measure was SSI.

METHODS

This was a retrospective nested case-control study. All consecutive patients who underwent spinal fusion surgery at our institution between October 2011 and October 2021 formed a retrospective cohort. For each SSI case, 2 controls free of SSI at the time of the index date of their corresponding case were selected, matched by age, sex, and calendar year. Electronic record and radiographic data were reviewed retrospectively in electronic database. SAP related data included timing of administration, preoperative dose, intraoperative second dose, and postoperative use. To examine the effects of mismatched variables, we further adjusted for possible confounding factors using conditional logistic regression models. Subsequently, subgroup analyses were conducted to assess the robustness of the statistical associations.

RESULTS

According to the preplanned statistical scheme and matching factors, we matched 236 controls for these SSI cases, and the subsequent statistical analysis was performed on these 354 patients. After adjusting for confounding factors, the results indicated that the risk of SSI was 70% higher in the group receiving SAP 31 to 60 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=1.732, 95%CI 1.031-2.910, p=.038). Additionally, the risk of SSI was 150% higher in the group receiving SAP 61 to 120 minutes before incision compared to the group receiving SAP 0 to 30 minutes before incision (OR=2.532, 95%CI 1.250-5.128, p=.010). In subgroup analysis, this statistical trend persisted for both deformity surgeries and different SSI classifications.

CONCLUSION

Administering cefuroxime SAP within 30 minutes before skin incision significantly reduces the risk of SSI, whether they are deep or superficial, in spinal fusion surgery. This pattern remains consistent among spinal deformity patients.

Comparison of ciprofloxacin versus fosfomycin versus fosfomycin plus trimethoprim/sulfamethoxazole for preventing infections after transrectal prostate biopsy

BACKGROUND

To evaluate antibiotic prophylaxis in transrectal prostate biopsies due to the recommendation of the European Medicines Agency (EMA): We describe our single center experience switching from ciprofloxacin to fosfomycin trometamol (FMT) alone and to an augmented prophylaxis combining fosfomycin and trimethoprim/sulfamethoxazole (TMP/SMX).

METHODS

Between 01/2019 and 12/2020 we compared three different regimes. The primary endpoint was the clinical diagnosis of an infection within 4 weeks after biopsy. We enrolled 822 men, 398 (48%) of whom received ciprofloxacin (group-C), 136 (16.5%) received FMT (group-F) and 288 (35%) received the combination of TMP/SMX and FMT (group-BF).

RESULTS

Baseline characteristics were similar between groups. In total 37/398 (5%) postinterventional infections were detected, of which 13/398 (3%) vs 18/136 (13.2%) vs 6/288 (2.1%) were detected in group-C, group-F and group-BF respectively. The relative risk of infectious complication was 1.3 (CI 0.7-2.6) for group-C vs. group-BF and 2.8 (CI 1.4-5.7) for group-F vs. group-BF respectively.

CONCLUSION

The replacement of ciprofloxacin by fosfomycin alone resulted in a significant increase of postinterventional infections, while the combination of FMT and TMP/SMX had a comparable infection rate to FQ without apparent adverse events. Therefore, this combined regimen of FMT and TMP/SMX is recommended.

Perioperative Antibiotics and Other Factors Associated with Postcesarean Infections: A Case-Control Study

OBJECTIVE

Our objective was to determine modifiable risk factors associated with surgical site infection (SSI) and postpartum endometritis. We hypothesized that inappropriate surgical antibiotic prophylaxis would be a risk factor for both types of infections.

STUDY DESIGN

This was a single-center case-control study of SSI and endometritis after cesarean delivery over a 2-year period from 2016 to 2017. Cases were identified by International Classification of Diseases, 10th Revision diagnosis codes, infection control surveillance, and electronic medical records search and were subsequently confirmed by chart review. Three controls were randomly selected for each case from all cesareans ± 48 hours from case delivery. Demographic, pregnancy, and delivery characteristics were abstracted. Separate multivariable logistic regression models were used to assess factors associated with SSI and endometritis. Postpartum outcomes, including length of stay and readmission, were also compared.

RESULTS

We identified 141 cases of SSI and endometritis with an overall postpartum infection rate of 4.0% among all cesarean deliveries. In adjusted analysis, factors associated with both SSI and endometritis were intrapartum delivery, classical or other (non-low-transverse) uterine incision, and blood transfusion. Factors associated with SSI only included inadequate antibiotic prophylaxis, public insurance, hypertensive disorder of pregnancy, and nonchlorhexidine abdominal preparation; factors only associated with endometritis included β-lactam allergy, anticoagulation therapy, and chorioamnionitis. Among cases, 34% of those with SSI and 25% of those with endometritis did not receive adequate antibiotic prophylaxis, compared with 12.9 and 13.5% in control groups, respectively. Failure to receive appropriate antibiotic prophylaxis was associated with an increased risk of SSI (adjusted odds ratio [aOR]: 4.4, 95% confidence interval [CI]: 1.3-15.6) but not endometritis (aOR 0.9, 95% CI 0.4-2.0).

CONCLUSION

Inadequate surgical antibiotic prophylaxis was associated with an increased risk of SSI but not postpartum endometritis, highlighting the different mechanisms of these infections and the importance of prioritizing adequate surgical prophylaxis. Additional potentially modifiable factors which emerged included blood transfusion and chlorhexidine skin preparation.

KEY POINTS

· Inadequate antibiotic prophylaxis is associated with a four-fold risk in surgical site infections.. · The most common cause for failure to achieve adequate surgical prophylaxis was inappropriate timing of antibiotics at or after skin incision.. · Blood transfusions are strongly associated (>10-fold risk) with both SSI and endometritis..

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Timing of prophylactic antibiotics administration and suspected systemic infection after percutaneous biliary intervention

BACKGROUND/PURPOSE

Prophylactic antibiotics administration before percutaneous biliary intervention (PBI) is currently recommended, but the underlying evidence is mostly extrapolated from prophylactic antibiotics before surgery. The aim of this study was to evaluate the impact of prophylactic antibiotics administration timing on the incidence of suspected systemic infection after PBI.

METHODS

The incidence of suspected systemic infection after PBI was compared in patients who received prophylactic antibiotics at four different time intervals between antibiotics administration and skin puncture for PBI. Suspected post-intervention systemic infection was assessed according to predetermined clinical criteria.

RESULTS

There were 98 (21.6%) suspected systemic infections after 454 PBIs in 404 patients. There were significant differences among the four groups in the incidence of suspected systemic infection after the intervention (p = .020). Fever was the most common sign of suspected systemic infection. Administration of prophylactic antibiotics more than an hour before PBI was identified as an independent risk factor of suspected systemic infection after adjusting for other relevant factors (adjusted odds ratio = 10.54; 95% confidence interval, 1.40-78.86).

CONCLUSIONS

The incidence of suspected systemic infection after the PBI was significantly lower when prophylactic antibiotics were administered within an hour before the intervention.

Effective Antimicrobial Prophylaxis in Surgery: The Relevance and Role of Pharmacokinetics-Pharmacodynamics

Appropriate surgical antimicrobial prophylaxis (SAP) is an important measure in preventing surgical site infections (SSIs). Although antimicrobial pharmacokinetics-pharmacodynamics (PKPD) is integral to optimizing antibiotic dosing for the treatment of infections, there is less research on preventing infections postsurgery. Whereas clinical studies of SAP dose, preincision timing, and redosing are informative, it is difficult to isolate their effect on SSI outcomes. Antimicrobial PKPD aims to explain the complex relationship between antibiotic exposure during surgery and the subsequent development of SSI. It accounts for the many factors that influence the PKs and antibiotic concentrations in patients and considers the susceptibilities of bacteria most likely to contaminate the surgical site. This narrative review examines the relevance and role of PKPD in providing effective SAP. The dose-response relationship i.e., association between lower dose and SSI in cefazolin prophylaxis is discussed. A comprehensive review of the evidence for an antibiotic concentration-response (SSI) relationship in SAP is also presented. Finally, PKPD considerations for improving SAP are explored with a focus on cefazolin prophylaxis in adults and outstanding questions regarding its dose, preincision timing, and redosing during surgery.

Antibiotic use in spine surgery: A narrative review based in principles of antibiotic stewardship

Background

A growing emphasis on antibiotic stewardship has led to extensive literature regarding antibiotic use in spine surgery for surgical prophylaxis and the treatment of spinal infections.

Purpose

This article aims to review principles of antibiotic stewardship, evidence-based guidelines for surgical prophylaxis and ways to optimize antibiotics use in the treatment of spinal infections.

Methods

A narrative review of several society guidelines and spine surgery literature was conducted.

Results

Antibiotic stewardship in spine surgery requires multidisciplinary investment and consistent evaluation of antibiotic use for drug selection, dose, duration, drug-route, and de-escalation. Developing effective surgical prophylaxis regimens is a key strategy in reducing the burden of antibiotic resistance. For treatment of primary spinal infection, the diagnostic work-up is vital in tailoring effective antibiotic therapy. The future of antibiotics in spine surgery will be highly influenced by improving surgical technique and evidence regarding the role of bacteria in the pathogenesis of degenerative spinal pathology.

Conclusions

Incorporating evidence-based guidelines into regular practice will serve to limit the development of resistance while preventing morbidity from spinal infection. Further research should be conducted to provide more evidence for surgical site infection prevention and treatment of spinal infections.

The American Society of Breast Surgeons classification system for oncoplastic breast conserving surgery independently predicts the risk of delayed wound healing

INTRODUCTION

Oncoplastic breast conserving surgery (OBCS) aims to provide safe and satisfying surgery for breast cancer patients. The American Society of Breast Surgeons (ASBrS) classification system is based on volumetric displacement cut-offs (level I for <20% of breast volume; level II for 20-50%). It aims to facilitate communication among treating physicians and patients. Here, we investigate whether the extent of OBCS as classified by ASBrS independently predicts postoperative complications.

MATERIALS AND METHODS

This retrospective analysis of a prospectively maintained database included patients with stage I-III breast cancer who underwent OBCS between 03/2011 and 12/2020 at a Swiss university hospital. Outcomes included short-term (≤30 days) complications and chronic (>30 days) pain after surgery. Multivariate logistic regression models were used to identify independent predictors.

RESULTS

In total, 439 patients were included, 314 (71.5%) received ASBrS level I surgery, and 125 (28.5%) underwent ASBrS level II surgery. ASBrS level II was found to be an independent predictor of delayed wound healing (odds ratio [OR] 9.75, 95% confidence intervals (CI) 2.96-32.10). However, ASBrS level did not predict chronic postoperative pain (incidence rate ratio [IRR] 1.20, 95%CI 0.85-1.70), as opposed to age (IRR 1.19, 95%CI 1.11-1.27 per 5 years decrease), and weight disorders (underweight [BMI <18.5] vs. normal weight [BMI 18.5 < 25]: IRR 4.02, 95%CI 1.70-9.54; obese [BMI ≥30] vs. normal weight: IRR 2.07, 95%CI 1.37-3.13).

CONCLUSION

ASBrS level II surgery predicted delayed wound healing, warranting close clinical follow-up and prompt treatment to avoid delays in adjuvant therapy.

"A breach in the protocol for no good reason": a surgical antimicrobial prophylaxis experience in an Ethiopian academic medical center

BACKGROUND

An appropriately administered surgical antimicrobial prophylaxis decreases the rate of surgical site infections. Although evidence-based clinical practice guidelines have been published on surgical antimicrobial prophylaxis, the rate of adherence to the protocol and the impact of extending antimicrobial prophylaxis postoperatively is yet to be well elucidated.

METHOD

A total of general surgery and vascular surgery patients with clean and clean contaminated wound undergoing elective surgical procedures were included in the study. The rate of surgical antimicrobial prophylaxis utilization, the proportion of patients whom had their antimicrobial prophylaxis extended beyond 24 h and the rate of surgical site infections across groups were evaluated.

RESULTS

The surgical antimicrobial prophylaxis utilization rate was 90.5%. Of these patients, 12.6% were unnecessarily administered with antibiotics. An "extended" antibiotics administration beyond 24 h after the surgery was found in 40.2%. Gastrointestinal and hepato-pancreatico-biliary surgery patients had 7.9-fold rate of "extended" surgical antimicrobial prophylaxis beyond 24 h, AOR 7.89 (95% CI 3.88-20.715.62, p value < 0.0001). The overall rate of surgical site infection was 15(6.8%). The "extended" regimen of prophylactic antibiotics had no effect on the rate of surgical site infections.

CONCLUSION

Less than half of the patients included here had surgical antimicrobial prophylaxis regimen in accordance with the existing guidelines. The most common protocol violation was noted as extension of antimicrobial prophylaxis for more than 24 h after surgery. The extension of antimicrobial prophylaxis did not decrease the rate of surgical site infections, reaffirming the evidence that prophylactic extension of surgical antimicrobial prophylaxis is unnecessary.

Timing of Cefuroxime Surgical Antimicrobial Prophylaxis and Its Association With Surgical Site Infections

Importance

World Health Organization guidelines recommend administering surgical antimicrobial prophylaxis (SAP), including cefuroxime, within 120 minutes prior to incision. However, data from clinical settings supporting this long interval is limited.

Objective

To assess whether earlier vs later timing of administration of cefuroxime SAP is associated with the occurrence of surgical site infections (SSI).

Design, Setting, and Participants

This cohort study included adult patients who underwent 1 of 11 major surgical procedures with cefuroxime SAP, documented by the Swissnoso SSI surveillance system between January 2009 and December 2020 at 158 Swiss hospitals. Data were analyzed from January 2021 to April 2023.

Exposures

Timing of cefuroxime SAP administration before incision was divided into 3 groups: 61 to 120 minutes before incision, 31 to 60 minutes before incision, and 0 to 30 minutes before incision. In addition, a subgroup analysis was performed with time windows of 30 to 55 minutes and 10 to 25 minutes as a surrogate marker for administration in the preoperating room vs in the operating room, respectively. The timing of SAP administration was defined as the start of the infusion obtained from the anesthesia protocol.

Main Outcomes and Measures

Occurrence of SSI according to Centers for Disease Control and Prevention definitions. Mixed-effects logistic regression models adjusted for institutional, patient, and perioperative variables were applied.

Results

Of 538 967 surveilled patients, 222 439 (104 047 men [46.8%]; median [IQR] age, 65.7 [53.9-74.2] years), fulfilled inclusion criteria. SSI was identified in 5355 patients (2.4%). Cefuroxime SAP was administered 61 to 120 minutes prior to incision in 27 207 patients (12.2%), 31 to 60 minutes prior to incision in 118 004 patients (53.1%), and 0 to 30 minutes prior to incision in 77 228 patients (34.7%). SAP administration at 0 to 30 minutes was significantly associated with a lower SSI rate (adjusted odds ratio [aOR], 0.85; 95% CI, 0.78-0.93; P < .001), as was SAP administration 31 to 60 minutes prior to incision (aOR, 0.91; 95% CI, 0.84-0.98; P = .01) compared with administration 61 to 120 minutes prior to incision. Administration 10 to 25 minutes prior to incision in 45 448 patients (20.4%) was significantly associated with a lower SSI rate (aOR, 0.89; 95% CI, 0.82-0.97; P = .009) vs administration within 30 to 55 minutes prior to incision in 117 348 patients (52.8%).

Conclusions and Relevance

In this cohort study, administration of cefuroxime SAP closer to the incision time was associated with significantly lower odds of SSI, suggesting that cefuroxime SAP should be administrated within 60 minutes prior to incision, and ideally within 10 to 25 minutes.

Epidemiology of postoperative spinal wound infection in the Middle East and North Africa (MENA) region

Background

Despite the extensive literature on postoperative spinal wound infection, yet to our knowledge, there is no previous study containing combined data from several sites in the Middle East and North Africa (MENA) region. This study aimed to estimate the incidence of surgical site infection (SSI) following spine surgeries, its associated factors, and management.

Methods

In a retrospective cohort study, medical records of all patients ≥18 years of age who underwent spine surgery at 6 tertiary referral centers in the MENA region between January 2014 to December 2019 (n=5,872) were examined to collect data on the following: (1) Patient's characteristics, (2) Disease characteristics, (3) Spine surgery approach, and (4) Characteristics of Postoperative SSI. The determinants of postoperative SSI were identified using logistic regression analysis. Receiver operating characteristic (ROC) curve was applied to identify the cut-off of the length of stay in the hospital postoperatively till the infection is likely to occur. Significance was set at p<.05.

Results

The overall incidence of SSI was 4.2% (95% CI: 3.72-4.77), in the form of deep (46.4%), superficial (43.1%), dehiscence (9.3%), and organ space (1.2%) infections. After adjusting for all possible confounders, significant predictors of postoperative SSI were; diabetes (OR=2.12, p<.001), smoking (OR=1.66, p=.002), revision surgery (OR=2.20, p<.001), open surgery (OR=2.73, p<.001), perioperative blood transfusion (OR=1.45, p=.033), ASA class III(OR=2.08, p=.002), and ≥4 days length of stay "LOS" (OR= 1.71, p=.001). A cut-off of 4 days was the optimum LOS above which postoperative SSI is more likely to occur, with 0.70 sensitivity, 0.47 specificity, and 0.61 area under the curve.

Conclusions

This is the first study that highlighted the incidence of postoperative SSI in spine surgery in the MENA region. Incidence figures are comparable to figures in different areas of the world. Identifying predictors of SSI might help high‑risk patients benefit from more intensive wound management.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.

Double blind randomized controlled trial for subjects undergoing surgery receiving surgical antimicrobial prophylaxis at tertiary hospital: the clinical pharmacist's interventions

Background

A surgical site infection (SSI) has significant clinical, humanistic and economic consequences. Surgical antimicrobials prophylaxis (SAP) is a reliable standard to prevent SSIs.

Objective

The objective was to test that the clinical pharmacist's interventions may facilitate the implementation of SAP protocol and subsequent reduction of SSIs.

Methods

This was double blinded randomized controlled interventional hospital-based-study at Khartoum State-Sudan. A total of 226 subjects underwent general surgeries at four surgical units. Subjects were randomized to interventions and controls in a (1:1) ratio where patient, assessors and physician were blinded. The surgical team has received structured educational and behavioral SAP protocol mini courses by way of directed lecturers, workshops, seminars and awareness campaigns delivered by the clinical pharmacist. The clinical pharmacist provided SAP protocol to the interventions group. The outcome measure was the primary reduction in SSIs.

Results

There were (51.8%, 117/226) females, (61/113 interventions versus 56/113 controls), and (48.2%, 109/226) males (52 interventions and 57 controls). The overall rate of SSIs was assessed during 14 days post-operatively and was documented in (35.4%, 80/226). The difference in adherence to locally developed SAP protocol regarding the recommended antimicrobial was significant (P <0.001) between the interventions group (78, 69%) and the controls group (59, 52.2%). The clinical pharmacist's implementation of the SAP protocol revealed significant differences in SSIs with reduction in SSIs from 42.5% to 25.7% versus the controls group from 57.5% to 44.2% respectively, P = 0.001 between the interventions group and the controls group respectively.

Conclusion

The clinical pharmacist's interventions were very effective in sustainable adherence to SAP protocol and subsequent reduction in SSIs within the interventions group.

ERAS failure and major complications in elective colon surgery: Common risk factors

Background

Proper implementation and practice of an Enhanced Recovery After Surgery (ERAS) protocol streamlines perioperative management to its optimum, resulting in fewer complications and lower costs. This study aims to identify potential risk factors for the failure of ERAS and for major postoperative complications in patients with elective colon resection.

Materials and methods

This was a single center retrospective analysis including all consecutive patients for elective colon resection during June 2017 - June 2019. All patients were treated within an upgraded ERAS program.

Results

908 patients were included. Median ERAS compliance was 67%. Over 70% compliance was associated with a significantly lower median complication index and a shorter median hospital stay and was set as threshold in further analyses. In a multivariate regression analysis, male gender, American Society of Anesthesiologists Physical Status (ASA PS) Classification IV, open surgery, and albumin level < 34 independently predicted increased risk for failure of ERAS. Furthermore, multivariate analyses revealed that male gender, cancer in the right hemicolon/transverse colon/splenic flexure, open surgery, failure to mobilize postoperatively, and administration of > 60 mg oxycodone postoperatively, independently predicted increased risk of postoperative ileus. Volvulus as primary diagnosis, conversion of laparoscopy to open surgery, failure to mobilize postoperatively, and preoperative hemoglobin < 100 g/l were found to independently predict increased risk of anastomotic dehiscence.

Conclusions

We suggest that patients of male gender, high ASA class, challenged mobility, and higher risk in open surgery, be managed with powered preoperative counseling, including rigorous physiotherapy, and operated on by two senior colorectal surgeons, in order to diminish the risk of conversion to open surgery and of postoperative complications.

Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation

BACKGROUND

This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low-middle-income countries (LMIC's) for elective abdominal and gynecologic care.

METHODS

The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC's. The group consisted of seven members from the ERAS® Society and eight members from LMIC's. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592-695, Nelson et al in Int J Gynecol Cancer 29(4):651-668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC's and LMIC's were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC's. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC's and determined through discussions and consensus.

RESULTS

In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.

CONCLUSIONS

These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC's.

ACOI Surgical Site Infections Management Academy (ACOISSIMA)

Background:

Surgical site infections (SSIs) are the most common cause of healthcare-associated infections in surgical patients. Many SSIs may be preventable if simple measures are respected. Despite evidence supporting the effectiveness of evidence-based practices in Infection Prevention and Control, many surgeons fail to implement them.

Methods:

To clarify the key issues in the prevention of SSIs, an expert panel designated by the board of directors of Associazione Chirurghi Ospedalieri Italiani—Italian Surgical Association (ACOI) convened in Rome, Italy, on 16 December 2021, for a consensus conference.

Results:

The expert panel approved 11 evidence-based statements regarding the prevention of SSIs. A article was drafted and reviewed by the expert panel, finally obtaining this document that represents the executive summary of the consensus.

Conclusions:

The document aims to disseminate best practices among Italian surgeons and summarizes the ACOI recommendations for the prevention of SSIs.

Antibiotic resistance among bacteria isolated from war-wounded patients at the Weapon Traumatology Training Center of the International Committee of the Red Cross from 2016 to 2019: a secondary analysis of WHONET surveillance data

Background

A substantial body of evidence has recently emphasized the risks associated with antibiotic resistance (ABR) in conflicts in the Middle East. War-related, and more specifically weapon-related wounds can be an important breeding ground for multidrug resistant (MDR) organisms. However, the majority of available evidence comes from the military literature focused on risks and patterns of ABR in infections from combat-related injuries among military personnel. The overall aim of this study is to contribute to the scarce existing evidence on the burden of ABR among patients, including civilians with war-related wounds in the Middle East, in order to help inform the revision of empirical antibiotic prophylaxis and treatment protocols adopted in these settings. The primary objectives of this study are to: 1) describe the microbiology and the corresponding resistance profiles of the clinically relevant bacteria most commonly isolated from skin, soft tissue and bone biopsies in patients admitted to the WTTC; and 2) describe the association of the identified bacteria and corresponding resistance profiles with sociodemographic and specimen characteristics.

Methods

We retrospectively evaluated the antibiograms of all consecutive, non-duplicate isolates from samples taken from patients admitted to the ICRC WTTC between 2016 and 2019, limited to skin and soft tissue samples and bone biopsies. We collected data on socio-demographic characteristics from patient files and data on specimens from the WHONET database. We ran univariate and multivariable logistic regression models to test the association between bacterial and resistance profiles with sociodemographic and specimen characteristics.

Results

Patients who were admitted with war-related trauma to the ICRC reconstructive surgical project in Tripoli, Lebanon, from 2016 to 2019, presented with high proportion of MDR in the samples taken from skin and soft tissues and bones, particularly Enterobacterales (44.6%), MRSA (44.6%) and P. aeruginosa (7.6%). The multivariable analysis shows that the odds of MDR isolates were higher in Iraqi patients (compared to Syrian patients) and in Enterobacterales isolates (compared to S. aureus isolates).

Conclusions

Our findings stress the importance of regularly screening patients who present with complex war-related injuries for colonization with MDR bacteria, and of ensuring an antibiotic-sensitivity testing-guided antimicrobial therapeutic approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07253-1.

Timing and duration of antibiotic prophylaxis is associated with the risk of infection after hip and knee arthroplasty

AIMS

Antibiotic prophylaxis involving timely administration of appropriately dosed antibiotic is considered effective to reduce the risk of surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA). Cephalosporins provide effective prophylaxis, although evidence regarding the optimal timing and dosage of prophylactic antibiotics is inconclusive. The aim of this study is to examine the association between cephalosporin prophylaxis dose, timing, and duration, and the risk of SSI after THA/TKA.

METHODS

A prospective multicentre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKA/THA at one of 19 high-volume Australian public/private hospitals. Data were collected prior to and for one-year post surgery. Logistic regression was undertaken to explore associations between dose, timing, and duration of cephalosporin prophylaxis and SSI. Data were analyzed for 1,838 participants. There were 264 SSI comprising 63 deep SSI (defined as requiring intravenous antibiotics, readmission, or reoperation) and 161 superficial SSI (defined as requiring oral antibiotics) experienced by 249 (13.6%) participants within 365 days of surgery.

RESULTS

In adjusted modelling, factors associated with a significant reduction in any SSI and deep SSI included: correct weight-adjusted dose (any SSI; adjusted odds ratio (aOR) 0.68 (95% confidence interval (CI) 0.47 to 0.99); p = 0.045); commencing preoperative cephalosporin within 60 minutes (any SSI, aOR 0.56 (95% CI 0.36 to 0.89); p = 0.012; deep SSI, aOR 0.29 (95% CI 0.15 to 0.59); p < 0.001) or 60 minutes or longer prior to skin incision (aOR 0.35 (95% CI 0.17 to 0.70); p = 0.004; deep SSI, AOR 0.27 (95% CI 0.09 to 0.83); p = 0.022), compared to at or after skin incision. Other factors significantly associated with an increased risk of any SSI, but not deep SSI alone, were receiving a non-cephalosporin antibiotic preoperatively (aOR 1.35 (95% CI 1.01 to 1.81); p = 0.044) and changing cephalosporin dose (aOR 1.76 (95% CI 1.22 to 2.57); p = 0.002). There was no difference in risk of any or deep SSI between the duration of prophylaxis less than or in excess of 24 hours.

CONCLUSION

Ensuring adequate, weight-adjusted dosing and early, preoperative delivery of prophylactic antibiotics may reduce the risk of SSI in THA/TKA, whereas the duration of prophylaxis beyond 24 hours is unnecessary. Cite this article: Bone Jt Open 2022;3(3):252-260.

Evidence-based Prevention of Surgical Site Infection

Surgical site infection (SSI) remains an important complication of surgery. SSI is estimated to affect 2% to 5% of all surgical patients. Local and national efforts have resulted in significant improvements in the incidence of SSI. Familiarity with evidence surrounding high-quality SSI-reduction strategies is desirable. There exists strong evidence for mechanical and oral antibiotic bowel preparation in colorectal surgery, smoking cessation before elective surgery, prophylactic antibiotics, chlorhexidine-based skin antisepsis, and maintenance of normothermia throughout the perioperative period to reduce SSI. Use of other practices should be determined by the operating surgeon and/or local hospital policy.

The Role of HbA1c as a Positive Perioperative Predictor of Surgical Site and Other Postoperative Infections: An Explorative Analysis in Patients Undergoing Minor to Major Surgery

Background

Patients with diabetes mellitus type 2 (DM2) inhere impaired peripheral insulin action leading to higher perioperative morbidity and mortality rates, with hospital-acquired infections being one important complication. This post hoc, observational study aimed to analyze the impact of surgical and metabolic stress as defined by the surrogate marker hemoglobin A1c (HbA1c), in relation to self-reported DM2, on perioperative infection rates in a subcohort of the Surgical Site Infection (SSI) Trial population.

Methods

All patients of the SSI study were screened for HbA1c levels measured perioperatively for elective or emergency surgery and classified according to the American Diabetes Association HbA1c cutoff values. SSI and nosocomial infections, self-reported state of DM2 and type of surgery (minor, major) were assessed.

Results

HbA1c levels were measured in 139 of 5175 patients (2.7%) of the complete SSI study group. Seventy patients (50.4%) self-reported DM2, while 69 (49.6%) self-reported to be non-diabetic. HbA1c levels indicating pre-diabetes were found in 48 patients (34.5%) and diabetic state in 64 patients (46%). Forty-five patients of the group self-reporting no diabetes (65.2%) were previously unaware of their metabolic derangement (35 pre-diabetic and 10 diabetic). Eighteen infections were detected. Most infections (17 of 18 events) were found in patients with HbA1c levels indicating pre-/diabetic state. The odds for an infection was 3.9-fold (95% CI 1.4 to 11.3) higher for patients undergoing major compared to minor interventions. The highest percentage of infections (38.5%) was found in the group of patients with an undiagnosed pre-/diabetic state undergoing major surgery.

Conclusions

These results encourage investment in further studies evaluating a more generous and specific use of HbA1c screening in patients without self-reported diabetes undergoing major surgery.

Trial registration Clinicaltrials.gov identifier: NCT 01790529

The Role of Endonasal Endoscopic Skull Base Repair in Posttraumatic Tension Pneumocephalus

OBJECTIVES

Information about the endonasal endoscopic approach (EEA) for the management of posttraumatic tension pneumocephalus (PTTP) remains scarce. Concomitant rhinoliquorrhea and posttraumatic hydrocephalus (PTH) can complicate the clinical course.

METHODS

The authors systematically reviewed pertinent articles published between 1961 and December 2020 and identified 6 patients with PTTP treated by EEA in 5 reports. Additionally, the authors share their institutional experience including a seventh patient, where an EEA resolved a recurrent PTTP without rhinoliquorrhea.

RESULTS

Seven PTTP cases in which EEA was used as part of the treatment regime were included in this review. All cases presented with a defect in the anterior skull base, and 3 of them had concomitant rhinoliquorrhea. A transcranial approach was performed in 6/7 cases before EEA was considered to treat PTTP. In 4/7 cases, the PTTP resolved after the first intent; in 2/7 cases a second repair was necessary because of recurrent PTTP, 1 with and 1 without rhinoliquorrhea, and 1/7 case because of recurrent rhinoliquorrhea only. Overall, PTTP treated by EEA resolved with a mean radiological resolution time of 69 days (range 23-150 days), with no late recurrences. Only 1 patient developed a cerebrospinal fluid diversion infection probably related to a first incomplete EEA skull base defects repair. A permanent cerebrospinal fluid diversion was necessary in 3/7 cases.

CONCLUSIONS

Endonasal endoscopic approach repair of air conduits is a safe and efficacious second-line approach after failed transcranial approaches for symptomatic PTTP. However, the strength of recommendation for EEA remains low until further evidence is presented.

Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection: TAPAS, An Observational Cohort Study

OBJECTIVE

To test the hypothesis that surgical site infection (SSI) risk differs, after administration of surgical antibiotic prophylaxis (SAP) within 60-30 or 30-0 minutes before incision.

BACKGROUND

The importance of appropriate timing of SAP before surgery has long been recognized. However, available evidence is contradictive on the best timing within a 60-0 minutes time interval before incision. Here, we aim to evaluate previous contradictions with a carefully designed observational cohort.

METHODS

An observational cohort study was conducted in a Dutch tertiary referral center. For 2 years, consecutive patients with SAP indication undergoing general, orthopedic, or gynecologic surgery were followed for the occurrence of superficial and deep SSI as defined by the Center of Disease Control and Prevention. The association between timing of SAP and SSI was assessed using multivariable logistic regression.

RESULTS

After 3001 surgical procedures, 161 SSIs were detected. In 87% of the procedures, SAP was administered within 60 minutes before incision. Only antibiotics with short infusion time were used. Multivariable logistic regression indicated there was no conclusive evidence of a difference in SSI risk after SAP administration 60-30 minutes or 30-0 minutes before incision [odds ratio: 0.82; 95% confidence interval (0.57-1.19)].

CONCLUSIONS

For SAP with short infusion time no clear superior timing interval within the 60-minute interval before incision could be identified in this cohort. We were unable to reproduce differences in SSI risk found in earlier studies.

How to Prevent Surgical Site Infection in Vascular Surgery: A Review of the Evidence

BACKGROUND

This review aims to identify and review the current evidence for preventing postoperative surgical site infections in abdominal aortic aneurysm surgery or infrainguinal arterial surgery.

METHODS

Extended literature review of clinical trials that examined the prevention of postoperative surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. Searches were conducted on Ovid MEDLINE (1950 - 13 March 2020) using key terms for vascular surgery, surgical site infections and specific preventative techniques. Articles were included if they discussed a relationship between a preventative technique and surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. The GRADE guidelines were used to assess the quality of evidence.

RESULTS

21 techniques and 81 studies were included. Prophylactic antibiotics and negative pressure wound therapy have a high quality of evidence for the prevention of surgical site infections in abdominal aortic aneurysm or infrainguinal arterial surgery. A moderate quality evidence base was identified for gentamicin containing collagen implant (confined to high surgical site infection risk centers). Currently, there is a low or very low quality of evidence to suggest a reduction in the surgical site infection rate for combination therapy, glycaemic control, Methicillin-resistant Staphylococcus aureus screening and absorbable suture. Evidence suggests no beneficial effect for nutritional supplementation, chlorhexidine bath, hair removal therapy, Staphylococcus aureus nasal eradication, cyanoacrylate microsealant, silver grafts, rifampicin bonded grafts, triclosan coated suture and postoperative wound drains. Endoscopic saphenous vein harvest may reduce surgical site infection rate (very low quality of evidence) but may lower long-term patency. Autologous vein grafts may increase surgical site infections (very low quality of evidence) but may provide better long-term patency rates in above-knee infrainguinal bypass surgery. There was no identified evidence for perioperative normothermia, electrosurgical bipolar vessel sealer or Dermabond and Tegaderm for surgical site infection prevention in vascular surgery.

CONCLUSIONS

Prophylactic antibiotics and postoperative negative pressure wound therapy are effective in the prevention of postoperative surgical site infection in abdominal aortic aneurysm or infrainguinal arterial surgery. There exists a significant risk of bias in the literature for many preventative techniques and further studies are required to investigate the efficacy of gentamicin containing collagen implant, and specific combination therapies.

Surgical site infection in a Greek general surgery department: who is at most risk?

OBJECTIVE

Surgical site infections (SSIs) are associated with protracted hospitalisation, antibiotics administration, and increased morbidity and mortality. This work investigated the incidence rate of SSIs in the Department of General Surgery at the University Hospital of Ioannina, Greece, the associated risk factors and pathogens responsible.

METHOD

In this prospective cohort study, patients who underwent elective procedures under general anaesthesia were enrolled. Risk factors monitored included age, sex, body mass index, smoking, alcohol consumption, preoperative length of stay, chemoprophylaxis, intensive care unit (ICU) stay, American Society of Anesthesiology (ASA) score, and the National Nosocomial Infections Surveillance System (NNIS) basic SSI risk index.

RESULTS

Of the 1058 enrolled patients, 80 (7.6%) developed SSIs. Of the total cohort, 62.5% of patients received chemoprophylaxis for >24 hours. A total of 20 different pathogens, each with multiple strains (n=108 in total), were identified, 53 (49.5%) Gram-negative rods, 46 (42%) Gram-positive cocci, and nine (8.4%) fungi (Candida spp.). Escherichia coli was the prevalent microorganism (24.3%). SSI-related risk factors, as defined by univariate analysis, included: ICU stay, ASA score >2 (p<0.001), NNIS score >0, and wound classes II, III, and IV. Also, serum albumin levels <3.5g/dl were associated with increased rate of SSIs. The multivariate model identified an NNIS score of >0 and wound classes II, III, and IV as independent SSI-related risk factors.

CONCLUSION

This study showed high SSI rates. Several factors were associated with increased SSI rates, as well as overuse of prophylactic antibiotics. The results of the present study could be a starting point for the introduction of a system for recording and actively monitoring SSIs in Greek hospitals, and implementation of specific guidelines according to risk factors.

Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial

OBJECTIVE

To assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery.

DESIGN

Phase III, randomised, double blind, placebo controlled trial.

SETTING

34 centres in France, December 2017 to March 2019.

PARTICIPANTS

1222 adults (>50 years) requiring major non-cardiac surgery with an expected duration of more than 90 minutes. The anticipated time frame for recruitment was 24 months.

INTERVENTIONS

Participants were randomised to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Randomisation was stratified on the two prespecified criteria of cancer and thoracic procedure.

MAIN OUTCOMES MEASURES

The primary outcome was a composite of postoperative complications or all cause mortality within 14 days after surgery, assessed in the modified intention-to-treat population (at least one treatment administered).

RESULTS

Of the 1222 participants who underwent randomisation, 1184 (96.9%) were included in the modified intention-to-treat population. 14 days after surgery, 101 of 595 participants (17.0%) in the dexamethasone group and 117 of 589 (19.9%) in the placebo group had complications or died (adjusted odds ratio 0.81, 95% confidence interval 0.60 to 1.08; P=0.15). In the stratum of participants who underwent non-thoracic surgery (n=1038), the primary outcome occurred in 69 of 520 participants (13.3%) in the dexamethasone group and 93 of 518 (18%) in the placebo group (adjusted odds ratio 0.70, 0.50 to 0.99). Adverse events were reported in 288 of 613 participants (47.0%) in the dexamethasone group and 296 of 609 (48.6%) in the placebo group (P=0.46).

CONCLUSIONS

Dexamethasone was not found to significantly reduce the incidence of complications and death in patients 14 days after major non-cardiac surgery. The 95% confidence interval for the main result was, however, wide and suggests the possibility of important clinical effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03218553.

Prospective Analysis of Hand Infection Rates in Elective Soft Tissue Procedures of the Hand: The Role of Preoperative Antibiotics

Background: The purpose of this study was to evaluate the efficacy of prophylactic antimicrobial prophylaxis in elective hand surgery in preventing postoperative infection. Methods: Between 2009 and 2012, we performed a multicenter trial in which patients undergoing elective hand surgeries were categorized into an antibiotic or control group depending on the center they were enrolled in. Surgical site infections were defined according to the Centers for Diseases Control and Prevention. Results: In total, 434 patients were included: 257 did not receive antibiotics (control) and 177 received antibiotics at a mean age of 61.0 years. In the control group, comorbidities were more common with 23.7% (61/257) in comparison to the antibiotics group with 14.1% (25/177). Only one surgical site infection in each group was identified. One wound was opened surgically, and an antimicrobial treatment was indicated in both cases. In addition, we observed four complications in the control group and three complications in the antibiotics group which required conservative management. No significant differences in the two cohorts in infection rate (0.006% vs 0.003%, χ² = 0.07, P > .05) and complication rate (2.8% vs 1.6%, χ² = 0.01, P > .05) were found. Conclusions: Our prospective multicenter trial showed no significant difference in infection rate in elective hand surgery whether antibiotics were administered preoperatively or not.

Impact of bodyweight-adjusted antimicrobial prophylaxis on surgical-site infection rates

Background

Antimicrobial prophylaxis (AMP) adjustment according to bodyweight to prevent surgical-site infections (SSI) is controversial. The impact of weight-adjusted AMP dosing on SSI rates was investigated here.

Methods

Results from a first study of patients undergoing visceral, vascular or trauma operations, and receiving standard AMP, enabled retrospective evaluation of the impact of bodyweight and BMI on SSI rates, and identification of patients eligible for weight-adjusted AMP. In a subsequent observational prospective study, patients weighing at least 80 kg were assigned to receive double-dose AMP. Risk factors for SSI, including ASA classification, duration and type of surgery, wound class, diabetes, weight in kilograms, BMI, age, and AMP dose, were evaluated in multivariable analysis.

Results

In the first study (3508 patients), bodyweight and BMI significantly correlated with higher rates of all SSI subclasses (both P < 0.001). An 80-kg cut-off identified patients receiving single-dose AMP who were at higher risk of SSI. In the prospective study (2161 patients), 546 patients weighing 80 kg or more who received only single-dose AMP had higher rates of all SSI types than a group of 1615 who received double-dose AMP (odds ratio (OR) 4.40, 95 per cent c.i. 3.18 to 6.23; P < 0.001). In multivariable analysis including 5021 patients from both cohorts, bodyweight (OR 1.01, 1.00 to 1.02; P = 0.008), BMI (OR 1.01, 1.00 to 1.02; P = 0.007) and double-dose AMP (OR 0.33, 0.23 to 0.46; P < 0.001) among other variables were independently associated with SSI rates.

Conclusion

Double-dose AMP decreases SSI rates in patients weighing 80 kg or more.

Antimicrobial prophylaxis administration after umbilical cord clamping in cesarean section and the risk of surgical site infection: a cohort study with 55,901 patients

Background

The World Health Organization (WHO) recommends administration of surgical antimicrobial prophylaxis (SAP) in cesarean section prior to incision to prevent surgical site infections (SSI). This study aimed to determine whether SAP administration following cord clamping confers an increased SSI risk to the mother.

Methods

Study design: Cohort. Setting: 75 participating Swiss hospitals, from 2009 to 2018. Participants: A total of 55,901 patients were analyzed. Main outcome measures: We assessed the association between SAP administration relative to incision and clamping and the SSI rate, using generalized linear multilevel models, adjusted for patient characteristics, procedural variables, and health-care system factors.

Results

SAP was administered before incision in 26′405 patients (47.2%) and after clamping in 29,496 patients (52.8%). Overall 846 SSIs were documented, of which 379 (1.6% [95% CI, 1.4–1.8%]) occurred before incision and 449 (1.7% [1.5–1.9%]) after clamping (p = 0.759). The adjusted odds ratio for SAP administration after clamping was not significantly associated with an increased SSI rate (1.14, 95% CI 0.96–1.36; p = 0.144) when compared to before incision. Supplementary and subgroup analyses supported these main results.

Conclusions

This study did not confirm an increased SSI risk for the mother in cesarean section if SAP is given after umbilical cord clamping compared to before incision.

Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass

AIMS

The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB).

METHODS

Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated.

RESULTS

A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing.

CONCLUSION

Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.

Impact of changing the surgical team for wound closure on surgical site infection: A matched case-control study

BACKGROUND

Wound closure is performed at the end of the procedure, when the attention of the surgical team may decrease due to tiredness. The aim of this study was to assess the influence of changing the surgical team for wound closure on the rate of surgical site infection (SSI).

METHODS

A two-armed observational monocentric matched case-control study was performed in a time series design. During the baseline period, closure of the abdominal wall was performed by the main surgical team. The intervention consisted of closure of the abdominal wall and skin by an independent surgical team. Matching was based on gender, BMI, length of surgery, type of surgery, elective versus emergency surgery and ASA score. The primary outcome was SSI rate 30 days after surgery.

RESULTS

A total of 72 patients in the intervention group were matched with 72 patients in the baseline group. The SSI rate after 30 days in the intervention group was 10% (n = 7) and in the baseline group 21% (n = 15) (p = 0.064). Redo-Surgery as result of infection (e.g. opening the wound, drainage or reoperation) was significantly higher in the baseline group (19.4% vs 2.7%; p = 0.014). Mortality, length of stay, rehospitalisation and complication rates 30 days after surgery did not differ significantly.

CONCLUSION

Changing the surgical team for wound closure did not reduce the overall rate of SSI, but the rate of redo-surgery as a result of SSI. Despite being potentially beneficial, organizational factors are a main limiting factor of changing the surgical team for the wound closure.

TRIAL REGISTRATION

Clinicaltrial.gov NCT04503642.

Antimicrobial prophylaxis and the prevention of surgical site infection in cardiac surgery: an analysis of 21 007 patients in Switzerland†

OBJECTIVES

Our goal was to determine the optimal timing and choice of surgical antimicrobial prophylaxis (SAP) in patients having cardiac surgery.

METHODS

The setting was the Swiss surgical site infection (SSI) national surveillance system with a follow-up rate of >94%. Participants were patients from 14 hospitals who had cardiac surgery from 2009 to 2017 with clean wounds, SAP with cefuroxime, cefazolin or a vancomycin/cefuroxime combination and timing of SAP within 120 min before the incision. Exposures were SAP timing and agents; the main outcome was the incidence of SSI. We fitted generalized additive and mixed-effects generalized linear models to describe effects predicting SSIs.

RESULTS

A total of 21 007 patients were enrolled with an SSI incidence of 5.5%. Administration of SAP within 30 min before the incision was significantly associated with decreased deep/organ space SSI [adjusted odds ratio (OR) 0.73, 95% confidence interval (CI) 0.54-0.98; P = 0.035] compared to administration of SAP 60-120 min before the incision. Cefazolin (adjusted OR 0.64, 95% CI 0.49-0.84; P = 0.001) but not vancomycin/cefuroxime combination (adjusted OR 1.05, 95% CI 0.82-1.34; P = 0.689) was significantly associated with a lower risk of overall SSI compared to cefuroxime alone. Nevertheless, there were no statistically significant differences between the SAP agents and the risk of deep/organ space SSI.

CONCLUSIONS

The results from this large prospective study provide substantial arguments that administration of SAP close to the time of the incision is more effective than earlier administration before cardiac surgery, making compliance with SAP administration easier. The choice of SAP appears to play a significant role in the prevention of all SSIs, even after adjusting for confounding variables.

Compliance with antibiotic prophylaxis guidelines in surgery: Results of a targeted audit in a large-scale region-based French hospital network

INTRODUCTION

While regional monitoring of antibiotic use has decreased since 2011 by 3.2%, in some healthcare facilities a significant increase (+43%) has occurred. The purpose of this study was to assess regional antibiotic prophylaxis (ABP) compliance with national guidelines.

MATERIAL AND METHODS

In 2015, 26 healthcare facilities, both public and private, were requested to audit five items: utilization of antibiotic prophylaxis, the antimicrobial agent (the molecule) administered, time between injection and incision, initial dose, number of intraoperative and postoperative additional doses. Seven surgical procedures were selected for assessment: appendicectomy (APP), cataract (CAT), cesarean section (CES), colorectal cancer surgery (CCR), hysterectomy (HYS), total hip arthroplasty (THA) and transurethral resection of the prostate (TURP). A statistical analysis of the 2303 records included was carried out.

RESULTS

The general rate of antibiotic prophylaxis compliance was 64%. The antimicrobial agent used and initial dose were in compliance with the guidelines for 93% and 97.4% of cases respectively, and administration of antibiotic prophylaxis was achieved 60minutes before incision in 77.6% of the records included. Regarding gastrointestinal surgery, amoxicillin/clavulanic acid was used in 32% of patients. In 26% of appendectomy files, administration occurred after incision, and one out of two files showed non-complaint perioperative and postoperative consumption.

CONCLUSION

Compliance with nationwide ABP guidelines is in need of pronounced improvement, especially with regard to time interval between injection and incision and the molecule prescribed. An action plan based on specific recommendations addressed to each establishment and an updated regionwide ABP protocol are aimed at achieving better and reduced consumption of antimicrobial agents.

Antimicrobial prophylaxis is considered sufficient to preserve an acceptable surgical site infection rate in clean orthopaedic and neurosurgeries in dogs

Background

Surgical site infections (SSI) are associated with increased morbidity and mortality. To lower the incidence of SSI, antimicrobial prophylaxis is given 30–60 min before certain types of surgeries in both human and veterinary patients. However, due to the increasing concern of antimicrobial resistance, the benefit of antimicrobial prophylaxis in clean orthopaedic and neurosurgeries warrants investigation. The aims of this retrospective cross-sectional study were to review the rate of SSI and evaluate the compliance with antimicrobial guidelines in dogs at a veterinary teaching hospital in 2012–2016. In addition, possible risk factors for SSI were assessed.

Results

Nearly all dogs (377/406; 92.9%) received antimicrobial prophylaxis. Twenty-nine dogs (7.1%) did not receive any antimicrobials and only four (1.1%) received postoperative antimicrobials. The compliance with in-house and national protocols was excellent regarding the choice of prophylactic antimicrobial (cefazolin), but there was room for improvement in the timing of prophylaxis administration. Follow-up data was available for 89.4% (363/406) of the dogs. Mean follow-up time was 464 days (range: 3–2600 days). The overall SSI rate was 6.3%: in orthopaedic surgeries it was 6.7%, and in neurosurgeries it was 4.2%. The lowest SSI rates (0%) were seen in extracapsular repair of cranial cruciate ligament rupture, ulnar ostectomy, femoral head and neck excision, arthrotomy and coxofemoral luxation repair. The highest SSI rate (25.0%) was seen in arthrodesis. Omission of antimicrobials did not increase the risk for SSI (P = 0.56; OR 1.7; CI_95% 0.4–5.0). Several risk factors for SSI were identified, including methicillin-resistant Staphylococcus pseudintermedius carriage (P = 0.02; OR 9.0; CI_95% 1.4–57.9) and higher body temperature (P = 0.03; OR 1.69; CI_95% 1.0–2.7; mean difference + 0.4 °C compared to dogs without SSI).

Conclusions

Antimicrobial prophylaxis without postoperative antimicrobials is sufficient to maintain the overall rate of SSI at a level similar to published data in canine clean orthopedic and neurosurgeries.

Consensus on the Role of Antibiotic Use in SSI Following Spinal Surgery

In July of 2018, the Second International Consensus Meeting (ICM) on Musculoskeletal Infection convened in Philadelphia, PA was held to discuss issues regarding infection in orthopedic patients and to provide consensus recommendations on these issues to practicing orthopedic surgeons. During this meeting, attending delegates divided into subspecialty groups to discuss topics specifics to their respective fields, which included the spine. At the spine subspecialty group meeting, delegates discussed and voted upon the recommendations for 63 questions regarding the prevention, diagnosis, and treatment of infection in spinal surgery. Of the 63 questions, 17 focused on the use of antibiotics in spine surgery, for which this article provides the recommendations, voting results, and rationales.

Teaching in the operating room: A risk for surgical site infections?

BACKGROUND/AIM

To investigate whether teaching procedures and surgical experience are associated with surgical site infection (SSI) rates.

METHODS

This prospective cohort study of patients undergoing general, orthopedic trauma and vascular surgery procedures was done between 2012 and 2015 at two tertiary care hospitals in Switzerland/Europe.

RESULTS

Out of a total of 4560 patients/surgeries, 1403 (30.8%) were classified as teaching operations. The overall SSI rate was 5.1% (n = 233). Teaching operations (OR 0.78, 95% CI 0.57-1.07, p = 0.120), junior surgeons (OR 0.80, 95% CI 0.55-1.15, p = 0.229) and surgical experience (OR 0.997, 95% CI 0.982-1.012, p = 0.676) were overall not independently associated with the odds of SSI. However, for surgeons' seniority and experience, these associations depended on the duration of surgery.

CONCLUSIONS

In procedures of shorter and medium duration, teaching procedures and junior as well as less experienced surgeons are not independently associated with increased odds of SSI.

Physiologically based pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis

Aims

Adequate plasma concentrations of antibiotics during surgery are essential for the prevention of surgical site infections. We examined the pharmacokinetics of 1.5 g cefuroxime administered during induction of anaesthesia with follow‐up doses every 2.5 hours until the end of surgery. We built a physiologically based pharmacokinetic model with the aim to ensure adequate antibiotic plasma concentrations in a heterogeneous population.

Methods

A physiologically based pharmacokinetic model (PK‐Sim^®/MoBi^®) was developed to investigate unbound plasma concentrations of cefuroxime. Blood samples from 25 thoracic surgical patients were analysed with high‐performance liquid chromatography. To evaluate optimized dosing regimens, physiologically based pharmacokinetic model simulations were conducted.

Results

Dosing simulations revealed that a standard dosing regimen of 1.5 g every 2.5 hours reached the pharmacokinetic/pharmacodynamic target for Staphylococcus aureus. However, for Escherichia coli, >50% of the study participants did not reach predefined targets. Effectiveness of cefuroxime against E. coli can be improved by administering a 1.5 g bolus immediately followed by a continuous infusion of 3 g cefuroxime over 3 hours.

Conclusion

The use of cefuroxime for perioperative antibiotic prophylaxis to prevent staphylococcal surgical site infections appears to be effective with standard dosing of 1.5 g preoperatively and follow‐up doses every 2.5 hours. In contrast, if E. coli is relevant in surgeries, this dosing regimen appears insufficient. With our derived dose recommendations, we provide a solution for this issue.

Appropriateness of Surgical Antimicrobial Prophylaxis Practices in Australia

IMPORTANCE

Surgical antimicrobial prophylaxis (SAP) is a common indication for antibiotic use in hospitals and is associated with high rates of inappropriateness.

OBJECTIVE

To describe the SAP prescribing practices and assess hospital, surgical, and patient factors associated with appropriate SAP prescribing.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, national, quality improvement study with retrospective analysis of data collected from Australian hospitals via Surgical National Antimicrobial Prescribing Survey audits from January 1, 2016, to June 30, 2018. Data were analyzed using multivariable logistic regression. Crude estimates of appropriateness were adjusted for factors included in the model by calculating estimated marginal means and presented as adjusted-appropriateness with 95% confidence intervals.

MAIN OUTCOMES AND MEASURES

Adjusted appropriateness and factors associated with inappropriate prescriptions.

RESULTS

A total of 9351 surgical episodes and 15 395 prescriptions (10 740 procedural and 4655 postprocedural) were analyzed. Crude appropriateness of total prescriptions was 48.7% (7492 prescriptions). The adjusted appropriateness of each surgical procedure group was low for procedural SAP, ranging from 33.7% (95% CI, 26.3%-41.2%) for dentoalveolar surgery to 68.9% (95% CI, 63.2%-74.5%) for neurosurgery. The adjusted appropriateness of postprocedural prescriptions was also low, ranging from 21.5% (95% CI, 13.4%-29.7%) for breast surgery to 58.7% (95% CI, 47.9%-69.4%) for ophthalmological procedures. The most common reason for inappropriate procedural SAP was incorrect timing (44.9%), while duration greater than 24 hours was the most common reason for inappropriate postprocedural SAP (54.3%).

CONCLUSIONS AND RELEVANCE

High rates of inappropriate procedural and postprocedural antimicrobial use were demonstrated across all surgical specialties. Reasons for inappropriateness, such as timing and duration, varied according to the type of SAP and surgical specialty. These findings highlight the need for improvement in SAP prescribing and suggest potential targeted areas for action.

The impact of surgical site infections on hospital contribution margin-a European prospective observational cohort study

BACKGROUND

Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.

OBJECTIVE

We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).

METHODS

This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.

RESULTS

Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) -2045 (IQR, -12,800 to 4,848) versus CHF 895 (IQR, -2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.

CONCLUSIONS

Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.

Antimicrobial Prophylaxis Redosing Reduces Surgical Site Infection Risk in Prolonged Duration Surgery Irrespective of Its Timing

BACKGROUND

Long-duration surgery requires repeated administration of antimicrobial prophylaxis (amp). Amp "redosing" reduces incidence of surgical site infections (SSI) but is frequently omitted. Clinical relevance of redosing timing needs to be investigated. Here, we evaluated the effects of compliance with amp redosing and its timing on SSI incidence in prolonged duration surgery.

METHODS

Data from >9000 patients undergoing visceral, trauma, or vascular surgery with elective or emergency treatment in two tertiary referral Swiss hospitals were analyzed. All patients had to receive amp preoperatively and redosing, if indicated. Antibiotics used were cefuroxime (1.5 or 3 g, if weight >80 kg), or cefuroxime and metronidazole (1.5 and 0.5 g, or 3 and 1 g doses, if weight >80 kg). Alternatively, in cases of known or suspected allergies, vancomycin (1 g), gentamicin (4 mg/Kg), and metronidazole or clindamycin (300 mg) with or without ciprofloxacin (400 mg) were used. Association of defined parameters, including wound class, ASA scores, and duration of operation, with SSI incidence was explored.

RESULTS

In the whole cohort, SSI incidence significantly correlated with duration of surgery (ρ = 0.73, p = 0.031). In 593 patients undergoing >240 min long interventions, duration of surgery was the only parameter significantly (p < 0.001) associated with increased SSI risk, whereas wound class, ASA scores, treatment areas, and emergency versus elective hospital entry were not. Redosing significantly reduced SSI incidence as shown by multivariate analysis (OR 0.60, 95% CI 0.37-0.96, p = 0.034), but exact timing had no significant impact.

CONCLUSIONS

Long-duration surgery associates with higher SSI incidence. Irrespective of its exact timing, amp redosing significantly decreases SSI risk.