Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update

Systematic Review of Surgical Site Infection Prevention Guideline Recommendations for Maintenance of Homeostasis in the Perioperative Period

Surgical site infections are common, result in increased patient morbidity and mortality, and increase the economic burden to society. Anesthesiologists play a key role in perioperative infection prevention, with data suggesting that evidence-based measures can significantly reduce the incidence of these infections. This systematic review aimed to identify and compare current recommendations for the maintenance of homeostasis in surgical site infection prevention guidelines. Eight surgical site infection prevention guidelines published in the past 10 yr were identified. There was broad consensus regarding the importance of optimizing intraoperative homeostasis to reduce infections. However, there was substantial heterogeneity in both the studies cited and the specific recommendations provided regarding maintenance of oxygenation, normovolemia, normothermia and glycemic targets. High-quality randomized controlled trials are required to close existing knowledge gaps, with adaptive platform trials likely to play a key role in improving the current evidence base for preventing surgical site infection.

Sustainability and spread of best practices for peri-operative antimicrobial stewardship following discontinuation of mandatory public reporting: perceptions from the Society for Healthcare Epidemiology in America research network

BACKGROUND

A Joint Commission national program, the surgical care improvement project (SCIP), supported the adoption of evidence-based peri-operative antimicrobial use practices, including administration of antimicrobials prior to incision and early discontinuation after skin closure. With high compliance, in 2015, the public reporting requirement that provided external pressure to support practice improvements was discontinued. Since discontinuation, few studies have assessed the sustainment of best antimicrobial use practices and what procedures were developed to maintain improvements within facilities.

OBJECTIVE

The aim of this study was to measure perceptions among antimicrobial stewardship experts about which policies and practices have been important and effective for sustainment.

DESIGN

A 15-min survey was administered to the Society for Hhealthcare Epidemiology in America (SHEA) research network over the summer of 2023. The survey included questions about different SCIP measures such as prophylactic antibiotic use pre and post-surgery and about local policies and procedures that were implemented to support best practices. Simple descriptive statistics were utilized to analyze results.

RESULTS

The survey was distributed to 112 members of the SHEA research network, with a 41% response rate. Most respondents perceived high rates of ongoing compliance with both pre- and post-operative prophylaxis guidelines, although ongoing surveillance and measurement is limited. Respondents perceived that the most important internal factors associated with ongoing compliance were electronic order sets, facility policies, time outs, and automatic stop orders. Substantial spread of best practices (eg, to surgical procedures and specialties not covered until the SCIP program) was reported.

CONCLUSIONS

Despite discontinuation of mandated reporting, antimicrobial stewards perceived ongoing compliance with SCIP measures. Local policies and procedures implemented to support initial uptake of best practices have supported ongoing sustainment of practice improvements.

The role of antimicrobial prophylaxis in brachytherapy for prostate, breast and gynaecological cancer: a narrative review

Proper antimicrobial prophylaxis is critical for reducing the risk of infection during interventional procedures. Brachytherapy, a highly effective radiation therapy for various malignancies, allows for precise radiation delivery; however, the use of foreign material as instrumentation for brachytherapy potentially increases the risk of infection. Understanding infectious complications and proper antimicrobial use in this case is essential for successful outcomes and patient safety. The aim of this review is to provide insights and summarize existing information on the infectious complications of brachytherapy in prostate, breast and gynaecological (cervical and endometrial) cancer, as well as on the potential benefit, if any, of administering antimicrobial prophylaxis. Infectious complication rates in prostate, breast and gynaecological cancer brachytherapy remain low with diverse prophylactic regimens, emphasizing the need to identify risk factors for tailored practices. The choice of the antimicrobial regimen, type of device and modality influences the probability of infectious complications. There is minimal overlap of existing brachytherapy guidelines with surgical prophylaxis guidelines. Infectious outcomes and antimicrobial resistance are underreported, and guidance for antimicrobial-resistant organisms is scarce. When indicated, prophylaxis for less than 24 h is efficient. More studies oriented towards antimicrobial prophylaxis on this specific population are needed.

Implementation of surgical site infection prophylaxis in children - a cross sectional prospective study

BACKGROUND

Surgical Site Infections (SSI) are a common cause for morbidity and mortality in both adults and children. In paediatric surgery, evidence on specific prevention measures is lacking and practice mainly depends on local guidelines and treating team's preferences. Aim We aimed to investigate current practice for children undergoing surgery with respect to SSI prevention using a standardized surveillance tool.

METHODS

Nine Swiss paediatric surgery centres participated in a standard period prevalence study. SSI prevention measures were recorded in these hospitals during seven consecutive days in October 2022 for any paediatric surgical procedure resulting in a surgical wound. The SSI prevention measures of interest were drawn from the most recent WHO guidelines. Findings 351 procedures were included. All Swiss language regions were represented. Traumatologic/orthopaedic surgeries were most common. Surgical antibiotic prophylaxis was administered in 161/351 (46%) of all cases, though in 33/161 (21%) of cases, there was no indication for the administration of antibiotics. Alcohol-based or iodine-based solutions were most often used for surgical skin preparation. Antimicrobial-coated sutures were only used in 84/351 (24%) of cases. Regional differences in prevention measures were noted between participating centres for skin preparation solution, suture material, wound dressing, and implementation of warming devices.

CONCLUSION

This study provides an overview of current SSI prevention practices in Swiss paediatric surgery centers, identifies targets for improvement, and highlights areas of clinical uncertainty requiring further investigation. The findings underscore the need for standardized guidelines to ensure consistent and evidence-based SSI prevention strategies in paediatric surgery.

Food Insecurity and Clinical Outcomes in Surgical Trauma Patients

Importance

Food insecurity, which is the lack of consistent access to sufficient and nutritious food, impacts over 1.3 billion individuals worldwide. The impact of food insecurity on primary care and medical subspecialties is recognized, but its influence on surgical outcomes remains underexplored.

Objective

To investigate the association between food insecurity and postoperative clinical outcomes in adult surgical trauma patients.

Design, Setting, and Participants

This prospective longitudinal cohort study was conducted from October 2021 to June 2023 and surveyed patients at admission and at 1 and 3 months postoperatively. This multicenter study was conducted across 3 public and private tertiary care centers in India. Adult patients who underwent inpatient operative intervention for traumatic injury were included through consecutive sampling.

Exposures

Food insecurity, which was identified using the validated Hunger Vital Sign tool. This was determined at admission as preoperative food insecurity. Also assessed was a subset of participants who were food secure at admission but then became food insecure during the follow-up period.

Main Outcomes and Measures

Postoperative complications and length of stay. These outcomes were tracked during hospitalization and also at 1 month and 3 months after discharge to compare between time points.

Results

A total of 848 patients (median [IQR] age, 32 [24-45] years; 692 male [82%]) were included in this analysis. Of the total cohort, 174 participants (21%) reported experiencing food insecurity in the year before admission. Patients with food insecurity had significantly higher rates of postoperative complications compared with those without food insecurity (41.4% [72 of 174] vs 12.5% [84 of 671]; odds ratio [OR], 3.68; 95% CI, 2.24-6.05). Additionally, patients with food insecurity had a longer median (IQR) length of stay (13 [6-28] days vs 5 [3-9] days; incidence rate ratio, 1.51; 95% CI, 1.31-1.74). Furthermore, new-onset food insecurity at 1 month postoperatively was associated with an increased risk of new complications at 3 months postoperatively (OR, 5.06; 95% CI, 2.21-11.13).

Conclusions and Relevance

Results demonstrate that food insecurity was significantly associated with increased postoperative complications and longer hospital stays in surgical trauma patients. Routine screening for food insecurity and targeted interventions like medically tailored meals, food prescription programs, and philanthropic food resources may mitigate the detrimental impact of food insecurity on surgical outcomes.

Time of developing surgical site infections and its association with patient and procedure characteristics

BACKGROUND

Understanding the timeframe and risk of developing surgical site infection (SSI) is essential for effective prevention and management strategies. The objective was to examine the post-operative duration before developing SSI and to characterize their patient and procedure characteristics.

METHODS

Prospective SSI surveillance was conducted on 15 operative procedures between 2014 and 2023 in a tertiary-care hospital system. The duration before developing SSI was divided into two groups; early-onset (

RESULTS

A total 322 SSI events were included. Approximately 76.7 % of them were superficial, 13.0 % deep, and 10.2 % organ. The majority were detected after discharge (66.6 %) and were laboratory-confirmed (64.6 %). The majority of procedures with SSI were inpatient procedures (96.9 %) and had risk index category of one (70.2 %). The median and mode (most frequent) duration before developing SSI were 15 and 10 days, respectively. Approximately 92.5 % and 98.8 % of SSI were detected within first 30 or 60 days, respectively. After adjusting for all variables that were associated with the duration before developing SSI in univariate analysis, early-onset SSI was significantly associated with female gender (odds ratio [OR] = 2.29, 95 % confidence 1.18-4.45, p = 0.015) and detection before hospital discharge (OR = 8.06, 95 % confidence 3.83-16.93, p < 0.001) but not coronary artery bypass graft (OR = 0.27, 95 % confidence 0.15-0.51, p < 0.001).

CONCLUSIONS

As most of SSI are detected after discharge, the findings underscore the importance of post-discharge surveillance that can be considered as a quality indicator for surveillance. Reducing the SSI follow-up durations from 90 days to 60 days, wouldn't make much difference.

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Key Words

• Early-onset
• Follow-up duration
• Saudi Arabia
• Surgical site infection
• Surveillance

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MESH Headings

• Humans
• Surgical Wound Infection/epidemiology
• Female
• Male
• Middle Aged
• Aged
• Prospective Studies
• Tertiary Care Centers
• Time Factors
• Risk Factors
• Adult
• Aged, 80 and over

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Affiliation(s)

Saad A Almohrij King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdulaziz Medical City (KAMC), Ministry of National Guard Health Affairs (MNGHA), Riyadh, Saudi Arabia.

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Effectiveness of advanced dressings in preventing surgical site infections compared to that of standard dressings in gastrointestinal surgery: A systematic review and meta-analysis for guideline revision by the Japanese Society for Surgical Infection

Introduction

This is a systematic review and meta-analysis of the efficacy of wound coverage using advanced dressings specifically for the prevention of surgical site infections (SSI) in gastrointestinal surgery, as part of the update of the SSI prevention guidelines of the Japan Society for Surgical Infection (JSSI).

Methods

After searching CENTRAL, PubMed, and ICHUSHI-Web in July 2024, we included randomized controlled trials (RCTs) comparing advanced dressings and standard dressings for surgical wounds in gastrointestinal surgery (PROSPERO No. CRD42024569084). Three authors independently screened the RCTs. We assessed the risk of bias and certainty of the body of evidence for the extracted data. The primary outcome was superficial SSI, and the secondary outcomes were length of postoperative hospital stay, costs, and allergy. This study was partially supported by the JSSI.

Results

A total of seven RCTs and 927 patients were included. The use of advanced dressings significantly lowered the risk of SSI compared to that associated with standard dressings (risk ratio: 0.54, 95% confidence intervals: 0.34-0.88). The certainty of the evidence was rated as moderate. According to the subgroup analysis, advanced dressings reduced the risk of SSI in colorectal surgery. Advanced dressings did not reduce the length of postoperative hospital stay or costs compared to that of standard dressings. Allergies were reported in only one patient using silver-impregnated dressings.

Conclusion

The use of advanced dressings for primary wounds in gastrointestinal surgery was associated with a significantly lower risk of SSI than that associated with standard dressings.

Antibiotic prophylaxis for surgical-site infections and adherence to evidence-based guidelines

BACKGROUND

Antimicrobial prophylaxis is an established practice for reducing surgical-site infections; however, its misuse promotes alternative challenges including antimicrobial resistance. The objective of this study was to determine factors associated with adherence to surgical antibiotic prophylaxis guidelines.

METHODS

Adults aged 18 and older who underwent 1 of 5 selected procedures between 2004 and 2022 were included. The proportion of appropriate antibiotic prophylaxis was determined for each procedure type. A logistic regression model was built to identify factors impacting appropriate prophylaxis practices.

RESULTS

Among our cohort of 9,543 patients, 4,883 were women (51.2%); mean age was 60.1 years. Most patients were White (8,407; 88.1%). Cardiothoracic, neurosurgical, gastrointestinal, and plastic surgery procedures were individually associated with decreased odds of appropriate antibiotic prophylaxis use compared with orthopedic procedures (P < .05). Patients undergoing a cardiothoracic procedure were less likely to receive the correct antibiotic (59.0%). Patients undergoing a gastrointestinal procedure were less likely to receive prophylaxis with the appropriate start time (72.6%) or duration (5.4%). Appropriate antibiotic prophylaxis was more likely in patients who were male (odds ratio, 1.14; 95% confidence interval, 1.10-1.18) and White (odds ratio, 1.17; 95% confidence interval, 1.11-1.22). Appropriate prophylaxis was significantly greater in procedures after 2010 (representing the establishment of an antimicrobial stewardship program) compared with procedures before 2010 (odds ratio, 2.05; confidence interval, 1.95-2.16).

CONCLUSION

Appropriate antibiotic prophylaxis practices demonstrated significant variation according to specialty type, patient characteristics, and the implementation of an antimicrobial stewardship program. These findings suggest the beneficial role of stewardship programs and gaps where interventions can be targeted, particularly antibiotic selection and discontinuation timing.

The Crani Bundle: Chlorhexidine Gluconate Bathing, Patient Hand Hygiene, and Surgical Site Dressing Care in Preventing Surgical Site Infections

BACKGROUND

Surgical site infections (SSIs) are preventable complications. The Joint Commission (TJC) National Patient Safety Goal® (NPSG) 7 focuses on decreasing health care-associated infections (HAIs), such as SSIs.

LOCAL PROBLEM

The neurosurgery service line encountered 4 SSIs from craniotomy procedures over a 27-month period with 2 occurring in 1 month requiring immediate attention.

METHODS

A pre- (January 2018 to March 2020)/post-implementation (April 2020 to July 2022) design, using rapid Plan-Do-Study-Act cycles, guided this evidenced-based practice quality improvement project.

INTERVENTIONS

The Crani Bundle, a nurse-led SSI prevention initiative focusing on patient hand hygiene and postoperative chlorhexidine gluconate bathing, was developed and implemented to reduce SSI after craniotomy (SSI-CRAN).

RESULTS

Implementation of the Crani Bundle decreased SSI-CRAN from 3.38% (n = 4/118) to 0.0% (n = 0/87).

CONCLUSIONS

The Crani Bundle was effective in reducing SSI-CRAN, meeting TJC NPSG® of preventing HAIs and improving patient safety.

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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

Preventing Orthopedic Infections

The prevention of orthopedic infections is of critical importance to improve patient outcomes and reduce health care costs. Preventative strategies can be employed preoperatively, including mitigation of medical risk factors, methicillin-resistant Staphylococcus aureus decolonization, appropriate skin preparation, and optimizing perioperative antimicrobial prophylaxis; intraoperatively, including utilizing irrigation, topical antibiotics, infection control measures, and timely debridement/optimal surgical techniques; and postoperatively, including consideration of antibiotic duration after primary arthroplasty and reimplantation. This article provides an evidence-based discussion of these strategies while also highlighting areas where ongoing research may be beneficial.

Empowering patients through a perioperative prevention bundle to reduce surgical site infections in colorectal surgery

BACKGROUND

Surgical site infections (SSIs) are common in colorectal surgery, with rates ranging from 5.4% to 30%. This study evaluated the impact of a perioperative prevention bundle on SSI incidence.

METHODS

A prospective cohort study with a before-after analysis was conducted from April 2022 to April 2023. The intervention included patient education, preoperative and postoperative chlorhexidine bathing, and mandatory glove change before fascial closure.

RESULTS

The implementation of the perioperative prevention bundle resulted in a significant reduction in the overall SSI rate, from 18.5% to 3.8% (P = .016). Superficial SSIs were decreased from 11.1% to 0% (P = .012), while reductions in deep and organ-space SSIs were not statistically significant. Additionally, rehospitalization rates within 30 days dropped from 14.0% to 2.0% (P = .029). The intervention achieved full compliance among patients and staff.

DISCUSSION

The individualized approach likely contributed to high compliance, potentially enabling patients to take a more active role in their care. Further research is needed to address the challenges associated with deep and organ-space infections.

CONCLUSIONS

The implementation of a perioperative prevention bundle, emphasizing patient education and engagement, effectively reduced the incidence of SSIs and rehospitalization rates following colorectal surgery.

[Perioperative antibiotic prophylaxis in obesity]

BACKGROUND

In terms of perioperative infections, arthroplasty for obese patients represents a high-risk procedure. Correct antibiotic prophylaxis is a central pillar of infection prophylaxis. Studies showed increased infection rates if an antibiotic other than cefazolin was administered for prophylaxis. In patients with anamnestic penicillin allergy, an existing allergy is extremely rare, and the presence of cross-allergies to cephalosporins is similarly rare. Consequently, every effort should be made to administer a first- or second generation cephalosporin such as cefazolin.

DOSAGE

Whether the dosage of antibiotic prophylaxis should be adjusted to the body weight remains unclear due to the limited data available: case series showed increased infection rates when cefazolin was underdosed and recommended increasing the dose to 3 g if the body weight exceeds 120 kg. However, no studies with a higher level of evidence exist. Published studies on the effective antibiotic levels in the tissue remain contradictory with regard to possible weight-dependent dose adjustments. Similarly, there is insufficient data on whether local intraoperative antibiotic prophylaxis may be useful in obese patients. By contrast, there is no evidence for a positive benefit of double prophylaxis with two different antibiotics or prolonged postoperative antibiotic prophylaxis in obesity.

CONCLUSION

In summary, the data on antibiotic prophylaxis is generally insufficient, especially when focussing on possible dose adjustments in obesity. The well-timed administration of a cephalosporin such as cefazolin represents the golden standard in orthopedics and trauma surgery. A possible dose adjustment to 3 g for a body weight over 120 kg appears reasonable considering the low costs and the broad therapeutic window and is therefore recommended in the current AWMF S3 guideline.

Exploring social vulnerability in National Health Safety Network surgical site infections

OBJECTIVE

To assess the association between social vulnerability index (SVI) and surgical site infections (SSIs) using National Healthcare Safety Network (NHSN) criteria.

DESIGN

Retrospective cohort study between August 1, 2022, and August 31, 2023.

SETTING

In total, 20 acute care hospitals in the Southeast United States.

PATIENTS

Totally, 23,768 total hip arthroplasty, total knee arthroplasty, abdominal hysterectomy, colon, and spinal fusion surgeries in 22,239 patients were included. Procedures with infection present at the time of surgery or incomplete geographic tracking data were excluded.

METHODS

Patient addresses as noted in the electronic health record were geocoded to determine census tract of residence and determine SVI. Demographic and clinical data were linked with SVI scores. SSIs were identified according to NHSN criteria. SVI was categorized into quartiles, and logistic regression was used to evaluate the association between SVI quartile (overall and for each SVI theme) and SSI risk. Subgroup analyses by procedure type and race were performed. Multivariable models of the association between overall SVI and SSI were adjusted for demographic and clinical factors.

RESULTS

Patients in the top SVI quartiles had significantly higher odds of developing SSIs after adjusting for other clinical and demographic factors. Increased risk was found for socioeconomic status and household characteristics themes, but not for the racial/ethnic minority theme. Association between SVI and SSI risk varied by type of surgery.

CONCLUSIONS

Living in an area with a higher SVI is associated with increased SSI risk. Targeted interventions are needed to mitigate these disparities and improve outcomes.

Society of Family Planning clinical recommendation: Prevention of infection after abortion and pregnancy loss

This Clinical Recommendation serves as a revision to the Society of Family Planning's 2010 Prevention of infection after induced abortion guidance. It examines infection risk, identifiable risk factors, and prophylactic measures for the prevention of infection associated with procedural and medication management of abortion and pregnancy loss to make evidence-based recommendations for the clinical care of patients. The following are the Society of Family Planning's recommendations: We recommend clinicians test and treat patients for gonorrhea and chlamydia at the time of abortion if there is (1) high clinical suspicion, (2) a positive diagnosis, or (3) the pregnant individual is under 25 years old and due for routine screening according to Centers for Disease Control and Prevention's guidelines; clinicians should not delay abortion while awaiting diagnosis or treatment (GRADE 1C). We recommend against screening for bacterial vaginosis before abortion (GRADE 1C). Since the rate of infection is low for nonprocedural abortion and the number needed to treat is high, coupled with inherent risks associated with antibiotic use, we recommend against the use of universal antibiotic prophylaxis in the setting of medication abortion, medication management of early pregnancy loss, or self-managed abortion (GRADE 1C). We recommend universal antibiotic prophylaxis for patients undergoing procedural abortion across all gestational durations (GRADE 1A). For procedural management of pregnancy loss, we recommend antibiotic prophylaxis (GRADE 1A). We recommend clinicians initiate antibiotic prophylaxis for procedural abortion and procedural management of pregnancy loss before instrumentation to maximize efficacy (GRADE 1B). Antibiotics should be given with adequate time for absorption, but data on the optimal timing for prophylaxis are lacking. In the setting of osmotic cervical dilator use, there is insufficient evidence to recommend for or against routine antibiotic prophylaxis before osmotic cervical dilator placement. We recommend discontinuing antibiotic prophylaxis after the procedure is completed (GRADE 1B). We recommend a single dose of doxycycline 200 mg orally or azithromycin 500 mg orally before a procedural abortion or procedural management of pregnancy loss (GRADE 1B). Metronidazole is a second-line option as it has evidence to suggest a prophylactic effect despite being less effective than doxycycline or azithromycin against aerobic bacteria. We recommend against the use of fluoroquinolones for prophylaxis in the setting of procedural abortion or procedural management of pregnancy loss due to the increased risk of side effects and complications (GRADE 1B). There is insufficient evidence to recommend for or against vaginal preparation with a local antiseptic solution or to recommend a specific vaginal preparation regimen before procedural abortion or procedural management of pregnancy loss.

Closed Incisional Negative Pressure Wound Therapy is Cost-Effective at Reducing Superficial Surgical Site Infections

Background: Surgical site infections (SSIs) have a significant health economic burden, accounting for more than US $3.3 billion in costs, and lead to increased microbial resistance, prolonged hospital stays, elevated 30-day mortality rates, greater incidences of reoperation, and decreased quality of life. Recently, evidence has emerged suggesting that prophylactic closed incision negative pressure wound therapy (ciNPWT) may substantially reduce the risk of post-operative wound complications, specifically SSIs. This study aimed to evaluate whether ciNPWT is cost-effective compared with routine incision care for the prevention of superficial SSIs. Hypothesis: We hypothesized that ciNPWT is cost-effective compared with routine incision care for the prevention of superficial SSIs. Methods: A cost-effectiveness decision analytic model was created comparing the use and non-use of ciNPWT. Superficial SSI probabilities, cost of care for patients with and without post-operative infection, and quality of life Short Form (SF)-36 survey data were obtained from a literature review. Cost of ciNPWT was obtained from health administrative data. A decision tree was constructed using TreeAge Software Pro Version 2020 (TreeAge Software, Inc., Williamstown, MA). Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness and reliability of the model. Results: One-way sensitivity analysis with a willingness-to-pay threshold of $5,000 demonstrated that above a baseline infection rate of approximately 6.4%, ciNPWT is cost-effective at reducing superficial SSI. Probabilistic sensitivity analysis indicated that even with uncertainty present in the parameters analyzed, the majority of simulations (95.4%) favored ciNPWT as the more effective tactic. Conclusions: Despite the added device cost, ciNPWT is cost-effective for superficial SSI prevention across a variety of surgical infection risk profiles.

High incidence of multidrug-resistant organisms and modifiable risk factors associated with surgical site infections: a cohort study in a tertiary medical center in Kuala Lumpur, Malaysia from 2020 to 2023

BACKGROUND

Surgical site infections (SSIs) are a persistent challenge in healthcare, contributing significantly to patient morbidity, mortality, and healthcare costs. Despite advancements in preventive measures, SSIs remain prevalent, especially in countries like Malaysia where rates are higher than in high-income nations.

METHODS

A prospective, cohort study was conducted at the University Malaya Medical Center (UMMC), Malaysia, from November 2020 to May 2023. Clinical and microbiological data were collected, and logistic regression were performed to identify risk factors associated with SSIs.

RESULTS

A total of 1,815 patients undergoing orthopedic, neurosurgical, and general surgical procedures were monitored for SSIs. The incidence rate of SSIs was 3.23 per 100 procedures (n = 71) with significant associations observed between SSI occurrence and prolonged surgical duration > 100 min, extended hospitalization > 5 days, trauma-to-surgery interval > 8 days, and presence of implants. Common pathogens isolated included Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Multidrug-resistant organisms (MDROs) were identified in 42.1% of the total isolates.

CONCLUSIONS

In this study, a high rate of MDRO and risk factors for SSI were identified. It emphasises the need for ongoing surveillance to guide infection prevention strategies and antimicrobial stewardship programs. Future research should prioritize evaluating the impact of targeted interventions tailored to identified risk factors to optimize surgical patient outcomes.

Clinical Outcomes Among Patients Undergoing Open Abdominal or Orthopedic Surgery with Wound Closure Incorporating Triclosan-Coated Barbed Sutures: A Multi-Institutional, Retrospective Database Study

Purpose

Determining the best suture for wound closure in high-tension areas by anatomical site and procedure type remains a challenge. This study assessed the cumulative incidence of clinical outcomes among patients undergoing procedures incorporating the STRATAFIX Symmetric PDS™ Plus Knotless Tissue Control Device (STRATAFIX Symmetric) for closure of high-tension areas, such as the abdominal fascia and hip and knee joint capsule, in the course of routine clinical practice.

Patients and Methods

Patients undergoing open abdominal or orthopedic surgery between October 1, 2016, and October 31, 2023, using size 0 or 1 STRATAFIX Symmetric were identified from the Premier Healthcare Database. The cumulative incidences of 30-day internal wound dehiscence and 30-day surgical site infection (SSI) were measured. To contextualize the results, a targeted literature search of articles published between October 2016 and April 2024 describing the use of STRATAFIX Symmetric for wound closure in the abdominal fascia or joint capsule was performed.

Results

A total of 8156 patients undergoing open abdominal surgery and 25,807 patients undergoing open orthopedic surgery met the study criteria. In the abdominal surgery cohort, the cumulative incidences of 30-day internal wound dehiscence and SSI were 0.65% (95% CI: 0.49%, 0.85%) and 3.54% (95% CI: 3.15%, 3.97%), respectively. The overall cumulative incidences of 30-day internal wound dehiscence and SSI in the orthopedic surgery cohort were 0.07% (95% CI: 0.04%, 0.11%) and 0.58% (95% CI: 0.49%, 0.68%), respectively. These findings were within the range of clinical outcomes reported in 12 articles identified during the targeted literature search.

Conclusion

The cumulative incidence of 30-day internal wound dehiscence and SSI among patients undergoing abdominal and orthopedic procedures incorporating STRATAFIX Symmetric for wound closure of high-tension areas was low and comparable to prior literature.

Surgical Site Infections, Risk Factors, and Outcomes After Liver Transplant

Importance

Surgical site infections (SSIs) are one of the most common health care-associated infections. Surgical site infections can have harmful effects in liver transplant (LT) recipients.

Objective

To assess the incidence of SSI after LT and identify risk factors associated with SSIs and whether SSIs are associated with death and graft loss.

Design, Setting, and Participants

A multicenter cohort study encompassing data on LT performed at all Swiss transplant centers between May 1, 2008, and September 30, 2020, was conducted. Data analyses were performed in 2023.

Exposure

Liver transplant.

Main Outcomes and Measures

Frequency of SSIs within 90 days after transplant, risk factors associated with SSIs, and association of SSIs with 1-year death or graft loss. Surgical site infections were defined according to Centers for Disease Control and Prevention criteria with SSIs occurring within 90 days after LT. For association with posttransplant outcomes, 1-year follow-up data were analyzed.

Results

Among 1333 LT recipients in the Swiss Transplant Cohort Study, 1158 adults were included in analyses. Median age was 57.2 (IQR, 49.3-62.8) years and 792 were men (68.4%). Seventy patients (6.0%) had an SSI. Most SSIs were deep incisional (9 [12.8%]) or organ-space infections (54 [77.1%]). In most SSIs (56 [80.0%]), bacteria were detected, most frequently Enterococcus spp (36 of 75 [48.0%]) and Escherichia coli (12 of 75 [16.0%]). In multivariable analysis, prior liver transplant (odds ratio [OR] 4.01; 95% CI, 1.44-11.18; P = .008) and living liver donation (OR, 4.08; 95% CI, 1.37-12.16; P = .01) were independent risk factors associated with SSIs. Surgical site infections were independently associated with graft loss and/or death (hazard ratio [HR], 3.24; 95% CI, 1.82-5.79; P < .001); this association was observed in separate analyses on graft loss (HR, 2.97; 95% CI, 1.32-6.68; P = .02) and death (HR, 3.25; 95% CI, 1.44-7.35; P = .01).

Conclusions and Relevance

The findings of this study suggest that prior liver transplant and living liver donation are independent risk factors associated with SSIs and that SSIs are independently associated with graft loss and/or death, highlighting the relevance of this health care-associated infection.

Intraoperative redosing of antibiotics for prevention of surgical site infections: A systematic review and meta-analysis

BACKGROUND

Appropriate antibiotic prophylaxis is essential for preventing surgical site infections (SSI); however, the clinical benefit of intraoperative redosing remains unclear and controversial owing to insufficient reliable evidence. Therefore, we performed a systematic review and meta-analysis to assess the effectiveness of prophylactic antibiotic redosing in lengthy surgical procedures.

METHODS

We systematically searched the PubMed, Cochrane Library, Web of Science, and Ichushi-Web databases for articles published until 31 December, 2023. We compared the incidence of SSI between patients receiving and not receiving intraoperative redosing of antibiotics in surgeries lasting ≥3 h. Subgroup analyses were conducted across study characteristics. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel random effects model. The risk of bias was assessed using the ROBINS-I.

RESULTS

Overall, seven observational studies involving 4,671 patients were included. Intraoperative antibiotic redosing significantly reduced the risk of SSI compared with non-redosing (OR = 0.65, 95% CI = 0.45-0.94, p = 0.02). Subgroup analyses showed that intraoperative redosing decreased SSI risk in studies with a minimum 4-h operative time, no postoperative antibiotic continuation, and a moderate risk of bias. However, the statistical heterogeneity of the analyses was high among the studies.

CONCLUSIONS

Intraoperative redosing with prophylactic antibiotics during lengthy surgeries may be associated with a lower risk of SSI than non-redosing. Therefore, we recommend intraoperative redosing for surgeries lasting beyond 3-4 h to reduce the risk of infection. Further research is required to clarify the optimal redosing interval, which should be prioritized in future studies.

Chlorhexidine Gluconate Irrigation in the Prevention of Surgical Site Infection Following Cesarean Delivery

OBJECTIVE

To determine if the use of 0.05% chlorhexidine gluconate (CHG) irrigation solution during cesarean delivery (CD) can reduce the post-cesarean surgical site infection (SSI) rate when compared to standard practices without CHG irrigation.

MATERIALS AND METHODS

A single-center retrospective observational study was performed at a community hospital in Toledo, Ohio. Control and treatment periods were defined, and patients in the treatment group received irrigation with CHG solution during CD, while the control group did not. An electronic medical record review was conducted to note additional perioperative procedures that affect SSI rates. Patients were evaluated for infection at standard postoperative appointments using the CDC criteria, and the hospital system's department of infection prevention provided records of all documented SSIs in both groups. Characteristics of the deliveries and SSIs of each group were compared using the chi-square or Fisher's exact two-tailed tests.

RESULTS

Data were available for 351 deliveries after the implementation of the CHG protocol, and 432 deliveries were used as the control group. No significant difference in rates of infection was found between the two groups (p = 0.68). There were significantly more endometritis infections diagnosed in the treatment group compared to the control group (four (1.1%) versus zero; p = 0.04). Compared to the controls, the treatment group had fewer deliveries with the use of silver dressing, more deliveries with a negative pressure dressing, and more deliveries with a diagnosis of pregestational or gestational diabetes (p < 0.05). There were no other differences between the groups, including the use of abdominal and vaginal prep, BMI > 35, and perioperative antibiotics.

CONCLUSION

This single center retrospective observational study revealed no difference in post-cesarean SSI rates when performing intra-abdominal and subcutaneous irrigation with CHG solution. A significant increase in endometritis was observed with the use of CHG irrigation; however, further studies are required to determine the benefit or harm of antimicrobial irrigation in CDs.

Clinical outcomes and hospital-reported cost associated with surgical site infections and the co-occurrence of hospital-onset bacteremia and fungemia across US hospitals

OBJECTIVE

To evaluate the hospital-reported cost of care, clinical burden, and incidence of hospital-onset bacteremia and fungemia (HOB) for hospital admissions with surgical site infections (SSI).

METHODS

A cross-sectional study of 38 acute-care hospital admissions with a procedure under the National Healthcare Safety Network (NHSN) surveillance for SSI was conducted. SSI admissions were identified through NHSN reporting by the hospital. Clinical outcomes were estimated for SSI compared to no SSI controls using propensity matching and multivariable adjusted models that controlled for patient and hospital demographics; these endpoints were also compared for SSI admissions with and without HOB co-occurrence.

RESULTS

The rate of hospital-reported SSI was 0.15 per 100 admissions with a procedure under surveillance for SSI. Admissions with SSI compared to no SSI had significantly higher incremental hospital-reported cost of $30,689 and length of stay (LOS) was 11.6 days higher. The incidence of HOB was 6-fold higher in admissions with SSI compared to no SSI. For SSI admissions with HOB vs. no HOB, HOB added $28,049 to cost of care and 6.5 days to the LOS.

CONCLUSIONS

Hospital-reported SSIs were associated with higher clinical and economic burden. Patients with SSI and HOB had even more deleterious outcomes. These data may inform programs to augment infection prevention bundles targeting SSIs and downstream complications or comorbidities like HOB.

Interdisciplinary Strategies to Reduce Surgical Infectious Risk in the Operating Theater: Protocol for Scoping Review

BACKGROUND

Surgical site infections (SSIs) represent one of the most prevalent and significant complications associated with surgical procedures, often leading to prolonged hospitalization and delayed patient recovery. While recent international consensus guidelines have proposed evidence-based strategies to mitigate SSIs, they fall short in addressing the efficient and interdisciplinary implementation of these measures within the operating theater. Consequently, further research is required to identify and evaluate optimal interdisciplinary organizational approaches for the prevention of SSIs.

OBJECTIVE

This study aims to map the scope, diversity, and nature of research on interdisciplinary strategies aimed at reducing SSIs and to analyze the impact of interdisciplinary on the effectiveness of preventive interventions.

METHODS

Using the Joanna Briggs Institute (JBI) methodology for scoping reviews, a comprehensive search will be conducted across databases including Embase (encompassing MEDLINE and PubMed-not-MEDLINE), CINAHL, and the Cochrane Library, supplemented by manual searches of reference lists from included papers. This review targets studies published between 2016 and 2024, aligning with the World Health Organization's 2016 SSI prevention guidelines, which introduced significant advancements in practice and remain the global benchmark. Only studies published in English or French will be considered. Around 5 reviewers independently distributed the included papers for detailed reading and data extraction, while the lead author concurrently and independently reviewed all papers. Inclusion criteria follow the Participants, Concept, and Context (PCC) framework, specifying that the eligible population comprises surgical teams. The primary concept of interest is interdisciplinary strategies aimed at preventing infection risk. The context focuses on adult surgical procedures within the operating room during turnover periods. Studies using experimental, quasi-experimental, preexperimental, observational, case-control, or cross-sectional designs will be included.

RESULTS

From the 1679 papers initially identified, 45 were selected for detailed analysis by 5 reviewers, with the selection process completed by November 2024.

CONCLUSIONS

Emerging interdisciplinary strategies demonstrate significant potential in reducing the incidence of SSIs. This initiative forms part of a broader global project focused on codeveloping standardized protocols for preoperative preparation within the operating room to mitigate SSI risks. The findings of this scoping review will serve as the foundation for a subsequent qualitative survey and a pre-post quasi-experimental quantitative study to evaluate the integration and effectiveness of these strategies in clinical practice. The review protocol will be formally registered in the Open Science Framework (OSF) in 2024.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/67660.

Surgical Site Preparation Using Alcohol with Chlorhexidine Compared with Povidone Iodine with Chlorhexidine Results in Similar Rate of Infection After Primary Total Joint Arthroplasty

Background: Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. A skin antiseptic solution is used to reduce the bacterial count and prevent PJI. There is no consensus in the literature on the application of antiseptic solutions. This study aims to compare the rate of infection between patients who received alcohol wash with Chloraprep to those who received povidone iodine wash with Chloraprep. Methods: A total of 607 patients who underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a single institution between January 2009 and July 2023 were reviewed. Perioperative variables were collected. The infection rate was used as a primary outcome. An odds ratio was calculated to compare infection and complication rates between the groups. Results: For patients who underwent THA, no difference in the rate of complications (alcohol wash: n = 6, 4.5%; povidone wash: n = 5, 3.6%; OR: 0.796; 95% CI: 0.237-2.673) or infection (alcohol wash: n = 1, 0.7%; povidone wash: n = 2, 1.4%; OR: 1.942; 95% CI: 0.174-21.667) was found. No difference in the rate of complications (alcohol wash: n = 3, 1.9%; povidone wash: n = 2, 1.2%; OR: 0.635; 95% CI: 0.105-3.849) or infection (alcohol wash: n = 0; povidone wash: n = 1, 0.6%; OR: 0.994; 95% CI: 0.983-1.006) was found in patients who underwent TKA. Conclusions: Surgical site preparation using alcohol wash with chlorhexidine offers similar short-term benefits in preventing postoperative infection to a povidone iodine wash with chlorhexidine in primary total joint arthroplasty. The use of alcohol wash and chlorhexidine is effective, while reducing the preparation time.

Hypothermia: Pathophysiology and the propensity for infection

Hypothermia in combination with infection presents a complex challenge in clinical and battlefield medicine. Multifaceted physiological and immunological consequences of hypothermia drastically change the risk, progression, and treatment of a concomitant infection. Managing hypothermia and infection in extreme cold settings is particularly relevant in an era with increased risk of military operations in Polar climates. Here, we discuss the elevated instance of infection during accidental and therapeutic hypothermia and speculate how a compromised immune system may contribute. We focus on skin and soft tissue infections and sepsis, which are among the serious infectious complications of hypothermia and battlefield injuries. We also present the challenges associated with treating infections under hypothermic conditions. Finally, we advocate for a renewed focus on identifying causal relationships between hypothermia and infection risk and assessing established infection treatment regiments in hypothermic patients to enhance trauma management and survival outcomes in hypothermia-related injuries.

Implementation of Bundled Interventions to Reduce Surgical Site Infections in Pediatric Patients Undergoing Cardiothoracic Surgery: A Quality Improvement Project

Pediatric patients undergoing cardiothoracic surgery are at increased risk for health care-associated infections, especially surgical site infections (SSIs). Delayed sternal closures are associated with prolonged lengths of stay and contribute to infection risks and morbidities. At a single-site academic pediatric center, we created an SSI-prevention bundle targeting the preoperative, intraoperative, and postoperative care periods. Using standard criteria, we determined the epidemiology of SSIs and measured SSI rates per 100 procedures from 2017 through 2023 before and after bundle implementation. Infections were predominantly caused by skin commensal bacteria. Despite an initial decrease in SSI rates for routine procedures and procedures with delayed sternal closures, there was no significant difference in SSI rates per 100 procedures during the preimplementation and postimplementation periods. However, compliance with bundle elements was preserved throughout the postimplementation period, including during the COVID-19 pandemic, which suggests that the use of the bundle is sustainable at our facility.

Adherence to Perioperative Antimicrobial Prophylaxis in Children in the Settings of Neurosurgery, Otorhinolaryngology, and Orthopedics

Introduction: Data about compliance with perioperative antimicrobial prophylaxis (PAP) guidelines in the pediatric population are limited. This study aims to evaluate PAP adherence in pediatric surgical subspecialty departments. Methods: A prospective cohort study was conducted from September 2023 to October 2024 at "Aghia Sophia" Children's Hospital, Athens, Greece. Children <16 years old undergoing surgical procedures in the neurosurgery (NS), orthopedics (OP), and otolaryngology (ORL) departments were included. Data on demographics, surgical characteristics, and PAP practices (timing, agent, duration, and redosing) were collected and compliance with the international guidelines was evaluated. Results: A total of 301 children were included, with a median age (IQR) of 7 (8) years. PAP was received by 249/301 (82.7%) children (100% in the OP and NS, and 48% in the ORL). However, indications for PAP had 50.8% of children: 102/103 (99%) in the NS, 47/98 (47.9%) in the OP, and 4/48 (8.3%) in the ORL. Most children received broad-spectrum or combination of antimicrobials and/or antibiotics for longer duration. Appropriate PAP according to the guidelines was administered in 0% children in NS, 2% in OP, and 2.1% in ORL. Multivariable analysis in the ORL regarding the use of PAP revealed that shorter procedures (≤60 min; OR: 22.9, p = 0.003) and clean wounds (OR: 33.4, p < 0.001) were significantly associated with not using PAP. Conclusions: This study highlights gaps in the PAP guideline adherence in pediatric surgical departments, and the need for educational interventions to improve compliance and reduce antimicrobial use. Based on these findings, we plan to implement an educational intervention in order to optimize PAP practices in the pediatric population.

Incidence of surgical infection in cefazolin 3 g versus 2 g for colorectal surgery in obese patients

OBJECTIVE

To compare the incidence of surgical site infection (SSI) between cefazolin 3 g and 2 g surgical prophylaxis in patients weighing ≥120 kg that undergo elective colorectal surgery.

METHODS

A multicenter, retrospective cohort study was performed utilizing a validated database of elective colorectal surgeries in Michigan acute care hospitals. Adults weighing ≥120 kg who received cefazolin and metronidazole for surgical prophylaxis between 7/2012 and 6/2021 were included. The primary outcome was SSI, which was defined as an infection diagnosed within 30 days following the principal operative procedure. Multivariable logistic regression was used to identify variables associated with SSI; the exposure of interest was cefazolin 3 g surgical prophylaxis.

RESULTS

A total of 581 patients were included; of these, 367 (63.1%) received cefazolin 3 g, while 214 (36.8%) received 2 g. Patients who received cefazolin 3 g had less optimal antibiotic timing (324 [88.3%] vs 200 [93.5%]; P = .043) and a higher receipt of at least 1 of the prophylaxis antibiotics after incision (22 [6%] vs 5 [2.3%]; P = .043). There was no SSI difference between cefazolin 3 g and 2 g cohorts (23 [6.3%] vs 16 [7.5%], P = .574). When accounting for age, smoking status, and surgical duration, cefazolin 3 g was not associated with a reduction in SSI (adjOR, .64; 95%CI, .32-1.29).

CONCLUSIONS

Surgical prophylaxis with cefazolin 3 g, in combination with metronidazole, was not associated with decreased SSI compared to 2 g dosing in obese patients undergoing elective colorectal surgery.

Prevention and Management of Postoperative Infection After Anterior Cruciate Ligament Reconstruction: A Narrative Review

Background: Postoperative infection following anterior cruciate ligament reconstruction (ACLR) is a rare yet severe complication that can compromise patient outcomes, leading to prolonged recovery, graft failure, and knee dysfunction. Although infection rates are reported to be less than 2%, it remains essential to implement strategies to reduce infection risk and improve surgical outcomes. Methods: This review explores current evidence on the prevention of infections in ACLR, emphasizing the importance of timely antibiotic prophylaxis and vancomycin presoaking of grafts, which has been associated with a substantial reduction in infection rates. Results: Empirical antibiotic therapy should be started immediately after joint aspiration when infection is suspected. Treatment must prioritize culture-specific antibiotic regimens to optimize patient outcomes. Surgical intervention with arthroscopic debridement and irrigation needs to occur as soon as the diagnosis of infection is made. Often, this is performed with a focus on retaining the graft in order to preserve knee stability, if possible. Careful intraoperative management, along with the aid of infectious disease specialists, is paramount to help optimize outcomes following infection after ACLR. Conclusions: This review emphasizes the need for treatment protocols and highlights areas for future research to establish clear guidelines on infection after ACLR, especially with decisions of graft retention versus removal.

Transferability of the Surgical Attire Guideline Adherence Decision-Making Theory Beyond New England

The AORN surgical attire guideline promotes cleanliness in the perioperative environment to minimize patients' risks of developing surgical site infections. In 2020, the surgical attire guideline adherence decision-making model was published based on findings from a study involving New England intraoperative team members. To explore the model's transferability across the United States, we replicated the 2020 study with intraoperative personnel who did not live or work in New England. The study results included the same core category as the 2020 study (ie, critical thinking), and we confirmed that intraoperative team members across the United States weigh the influence of various factors when deciding to what extent they would adhere to the surgical attire guideline. The results showed transferability of the theoretical model to perioperative settings across the United States. This model can be used to enhance intraoperative team members' surgical attire guideline adherence decisions.

Impact of Antibiotic Choice at the Time of Sacral Neuromodulation Implantation on Rates of Surgical Site Infection

PURPOSE

To evaluate the efficacy of specific antibiotic regimens in preventing infection following sacral neuromodulation.

MATERIALS AND METHODS

This is a retrospective cohort study utilizing the Premier Healthcare Database. Patients who underwent sacral neuromodulation placement between January 2016 and March 2020. The patients were grouped by those who received dual antibiotic therapy per 2019 AUA guidelines (Gram positive + broad Gram negative coverage), first- or second-generation cephalosporins or any other regimen. Comparison between groups was performed using Kruskal-Wallis and χ2 tests for continuous and categorical variables, respectively. Inverse probability of treatment weighted (IPTW) analysis was used to estimate the average treatment effect of AUA guidelines regimens versus the use the first- or second-generation cephalosporins alone.

RESULTS

The sample included 14 179 patients, with 2211 patients receiving prophylaxis that followed the AUA guideline recommendations. There was no significant difference in surgical site infection rates within 3 months (p = 0.28) or within 12 months (p = 0.53) between the groups. On IPTW, the probability of an infection at 3 months was lower with the AUA guideline regimens compared to those who received first- or second-generation cephalosporins alone, but this difference was not statistically significant (OR = 0.73, 95% CI: [0.43, 1.24]).

CONCLUSIONS

In the absence of allergies to cephalosporins or penicillin, first- or second-generation cephalosporins alone may be a sufficient preoperative antibiotic regimen for prevention of infection at the time of sacral neuromodulation.

TRIAL REGISTRATION

Not applicable due to being a database study.

Spine surgical site infection outcome with preoperative application of a presaturated 10% povidone-iodine nasal decolonization product in a 32-bed surgical hospital

BACKGROUND

To pursue an irreducible minimum overall surgical site infection (SSI) rate, a 32-bed surgical hospital employed an outside consultant and performed sterile processing and surgery internal audits: No obvious improvements were identified. A 10-year review determined that 70% of SSI's were spine procedure patients. After a nasal decolonization product literature review, an intervention was implemented. The purpose of this study was to assess if the intervention impacted spine SSI rates.

METHODS

A 36-month implementation science study was conducted. The 18-month intervention was the immediate preoperative application of a manufactured presaturated 10% povidone-iodine nasal decolonization product in spine surgery patients, with monthly product application documentation surveillance feedback to the preoperative staff. Chi-square test was used to determine the difference in types of spine SSI surgery rates pre and post intervention.

RESULTS

Overall spine SSI decreased 35.7% (P = .04) with a 58.7% reduction in superficial incisional SSI (P = .02). The 16.1% decline in deep incisional SSI was not significant (P = .29).

CONCLUSIONS

Within this hospital, conducting 7,576 surgical spine procedures over 36 months, with the immediate preoperative application of a presaturated 10% povidone-iodine nasal decolonization product, the only intervention in SSI prevention protocol, produced a statistically significant decrease in spine patient SSI rate percent.

Global surgery is stronger when infection prevention and control is incorporated: a commentary and review of the surgical infection landscape

Incorporating infection prevention and control (IPC) is crucial for strengthening global surgery, particularly in low- and middle-income countries (LMICs). This review article highlights the critical role IPC plays in ensuring equitable and sustainable surgical care, aligning with the Sustainable Development Goals (SDG) 3 and 10, which aim to promote health and reduce inequalities. Surgical site infections (SSIs) and other healthcare-associated infections (HAIs) disproportionately affect LMICs, where IPC infrastructure is often underdeveloped. Without robust IPC measures, surgeries in these regions can result in higher morbidity, mortality, and healthcare costs, exacerbating disparities in healthcare access and outcomes. Despite global efforts, such as the World Health Organization (WHO) Guidelines on the Prevention of Surgical Site Infections, IPC integration in surgical practices remains inconsistent, particularly in resource-constrained settings. More widespread adoption and implementation are necessary. By embedding IPC within global surgery frameworks, health systems can improve surgical outcomes, reduce costs, and enhance the resilience of healthcare systems. Effective IPC reduces extended hospital stays, limits the spread of antimicrobial resistance, and increases trust in surgical services. Moreover, the cost savings from preventing SSIs are substantial, benefiting both healthcare systems and patients by reducing the need for prolonged care and antibiotic treatments. This review article calls for greater integration of IPC measures in global surgery initiatives to ensure that surgical interventions are both life-saving and equitable. Strengthening IPC is not optional but essential for achieving the broader goals of universal health coverage and improving public health outcomes globally.

European Society of Clinical Microbiology and Infectious Diseases/European Committee on infection control clinical guidelines on pre-operative decolonization and targeted prophylaxis in patients colonized by multidrug-resistant Gram-positive bacteria before surgery

SCOPE

The aim of these guidelines is to provide recommendations for decolonization and perioperative antibiotic prophylaxis (PAP) in multidrug-resistant Gram-positive bacteria (MDR-GPB) adult carriers before inpatient surgery.

METHODS

These European Society of Clinical Microbiology and Infectious Diseases/European Committee on Infection Control guidelines were developed following a systematic review of published studies targeting methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, methicillin-resistant coagulase-negative Staphylococci, and pan-drug-resistant-GPB. Critical outcomes were the occurrence of surgical site infections (SSIs) caused by the colonizing MDR-GPB and SSIs-attributable mortality. Important outcomes included the occurrence of SSIs caused by any pathogen, hospital-acquired infections, all-cause mortality, and adverse events associated with the interventions, including resistance development to the agents used and the incidence of Clostridioides difficile infections. The last search of all databases was performed on 1 November 2023. The level of evidence and the strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included.

RECOMMENDATIONS

The guideline panel reviewed the impact of decolonization, targeted PAP, and combined interventions (e.g. decolonization and targeted PAP) on the risk of SSIs and other outcomes in MDR-GPB carriers, according to the type of bacteria and type of surgery. We recommend screening for S. aureus before high-risk operations, such as cardiothoracic and orthopaedic surgery. Decolonization with intranasal mupirocin with or without a chlorhexidine bath is recommended in patients colonized with S. aureus before cardiothoracic and orthopaedic surgery and suggested in other surgeries. The addition of vancomycin to standard prophylaxis is suggested for MRSA carriers in cardiothoracic surgery, orthopaedic surgery, and neurosurgery. Combined interventions (e.g. decolonization and targeted prophylaxis) are suggested for MRSA carriers undergoing cardiothoracic and orthopaedic surgery. No recommendation could be made regarding screening, decolonization and targeted prophylaxis for vancomycin-resistant enterococci because of the lack of data. No evidence was retrieved for methicillin-resistant coagulase-negative Staphylococci and pan-drug-resistant-GPB. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship and infection control teams are warranted before implementing screening procedures or performing changes in PAP policy. Future research should focus on novel decolonizing techniques, on the monitoring of resistance to decolonizing agents and PAP regimens, and on standardized combined interventions in high-quality studies.

Periprosthetic Joint Infection: What's New?

Total joint arthroplasty (TJA) ranks among the most commonly performed orthopedic surgeries, with its annual incidence on the rise globally. Periprosthetic joint infection (PJI) remains a leading cause of arthroplasty failure. This review aims to summarize recent literature updates on the epidemiology, diagnosis, and management of PJI.

Building the Future of Infectious Diseases: A Call to Action for Quality Improvement Research and Measurement

Quality is central to value-based care, and measurement is essential for assessing performance and understanding improvement over time. Both value-based care and methods for quality measurement are evolving. Infectious diseases (ID) has been less engaged than other specialties in quality measure development, and ID providers must seize the opportunity to engage with quality measure development and research. Antimicrobial stewardship programs are an ideal starting point for ID-related quality measure development; antimicrobial stewardship program interventions and best practices are ID specific, measurable, and effective, yet they are grossly undercompensated. Herein, we provide a scheme for prioritizing research focused on development of ID-specific quality measures. Maturation of quality measurement research in ID, beginning with an initial focus on stewardship-related conditions and then expanding to non-stewardship topics, will allow ID to take control of its future in value-based care and promote the growth of ID through greater recognition of its value.

Mitigating infections in implantable urological continence devices: risks, challenges, solutions, and future innovations. A comprehensive literature review

PURPOSE OF REVIEW

Stress urinary incontinence is a growing issue in ageing men, often following treatment for prostate cancer or bladder outflow obstruction. While implantable urological devices offer relief, infections are a significant concern. These infections can lead to device removal, negating the benefits and impacting patient outcomes. This review explores the risks and factors contributing to these infections and existing strategies to minimize them. These strategies encompass a multifaceted approach that considers patient-specific issues, environmental issues, device design and surgical techniques. However, despite these interventions, there is still a pressing need for further advancements in device infection prevention.

RECENT FINDINGS

Faster diagnostics, such as Raman spectroscopy, could enable early detection of infections. Additionally, biocompatible adjuncts like ultrasound-responsive microbubbles hold promise for enhanced drug delivery and biofilm disruption, particularly important as antibiotic resistance rises worldwide.

SUMMARY

By combining advancements in diagnostics, device design, and patient-specific surgical techniques, we can create a future where implantable urological devices offer men a significant improvement in quality of life with minimal infection risk.

Predictive Value of Preoperative Peripheral Blood Inflammatory Markers for Surgical Site Infection in Laparoscopic Radical Gastrectomy for Gastric Cancer

Background: To investigate the predictive value of preoperative peripheral blood inflammatory markers for surgical site infection (SSI) in laparoscopic radical gastrectomy for gastric cancer. Methods: A retrospective analysis was conducted on patients undergoing laparoscopic radical gastrectomy for gastric cancer, categorized into SSI and non-SSI groups based on postoperative SSI occurrences. Patient demographics, surgical details, laboratory results, and SSI incidence data were extracted. Differences in indicators, including neutrophil-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), and platelet-lymphocyte ratio (PLR), were assessed between the two groups. Multivariate logistic regression was utilized to determine the independent association of each indicator with SSI. Receiver operating characteristics (ROC) curve analysis was utilized to evaluate the predictive value of parameters. Results: Of 169 patients, 36 (21.30%) experienced SSI postoperatively. The SSI group exhibited higher preoperative NLR and SII (p < 0.05). After adjusting for variables, preoperative NLR (OR = 1.691, 95% CI: 1.211-2.417, p = 0.003) and SII (OR = 1.001, 95% CI: 1.000-1.002, p = 0.006) were identified as independent risk factors for SSI. Both NLR (AUC = 0.758, 95% CI: 0.666-0.850) and SII (AUC = 0.753, 95% CI: 0.660-0.850) demonstrated favorable diagnostic performance for predicting postoperative SSI. Conclusion: Preoperative NLR and SII significantly associate with postoperative SSI in laparoscopic radical gastrectomy for gastric cancer, making them valuable indicators for early prediction of SSI.

Chlorhexidine Wound Irrigation for the Prevention of Early Surgical Site Infection in Orthopaedic Surgeries in Resource-Limited Settings: A Randomized Controlled Trial

Background and objectives Surgical site infections (SSIs) in orthopaedic surgeries continue to pose significant challenges, leading to increased morbidity and strain on healthcare resources especially in resource-limited countries. Intra-operative wound irrigation is a common practice globally, although evidence supporting this practice is lacking. We aimed to determine the preventative effective of chlorhexidine gluconate (CHG) for prevention of early SSIs in orthopaedic surgeries. Methods This is a prospective randomized controlled interventional clinical trial which was designed at National Hospital Abuja, Abuja, Nigeria. A total of 50 patients were enrolled and randomized into two groups: one receiving 0.05% CHG solution and the other receiving isotonic 0.9% saline for wound irrigation. The incidence of early SSIs (within 30 days) postoperatively was the primary outcome measured. Patients and outcome assessors were blinded to intervention allocation. Results The results showed no significant difference in the clinical profile of the patients in both groups. There was a similar rate of early SSIs between the CHG (4%) and isotonic saline (4%) groups. Conclusions There is no significant difference between CHG and isotonic 0.9% saline in preventing early SSIs in clean orthopaedic implant surgeries. These data will improve care and allow appropriate allocation of scarce resources in resource-limited settings.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for surgical-site infection prevention: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023

OBJECTIVES

Surgical-site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume health care resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs after cardiac surgery.

METHODS

Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set for SSI reduction. Orders derived from consistent class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the turnkey order set in bold type. Selected orders that were inconsistent class I or IIA, class IIB or otherwise supported by published evidence, were also included in italicized type.

RESULTS

Preventative care begins with the preoperative identification of both modifiable and nonmodifiable SSI risks by health care providers. Assessment tools can be used to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement.

CONCLUSIONS

Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This article provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.

Exeporfinium chloride (XF-73) nasal gel significantly reduces Staphylococcus aureus nasal carriage in cardiac surgery patients throughout surgery and the early recovery period: results from a randomized placebo-controlled Phase 2 study

Staphylococcus aureus nasal carriers were randomized (1:1) to XF-73 or placebo nasal gel, administered 5x over ∼24hrs pre-cardiac surgery. S. aureus burden rapidly decreased after 2 doses (-2.2log10 CFU/mL; placebo -0.01log10 CFU/mL) and was maintained to 6 days post-surgery. Among XF-73 patients, 46.5% received post-operative anti-staphylococcal antibiotics versus 70% in placebo (P = 0.045).

The burden of healthcare-associated infections in New Zealand public hospitals 2021

BACKGROUND

There are no contemporary data on the burden of healthcare-associated infections (HAIs) in New Zealand.

OBJECTIVES

To estimate the economic burden of HAIs in adults in New Zealand public hospitals by number and monetary value of bed days lost; number of deaths, number of life years lost, and the monetary value (in NZ dollars); Accident Compensation Commission (ACC) HAI treatment injury payments; and disability-adjusted life years (DALYs).

METHODS

The annual incidence rate was calculated from the observed prevalence of HAIs in New Zealand, and length of patient stays. Total HAIs for 2021 were estimated by multiplying adult admissions by incidence rates. The excess length of stay and mortality risk attributed to those with HAI was calculated using a multistate model. Payments for treatment injuries were obtained from the ACC. DALYs for HAIs were estimated from the literature.

RESULTS

The incidence rate of HAI was 4.74%, predicting 24,191 HAIs for 2021, resulting in 76,861 lost bed days, 699 deaths, with 9,371 years of life lost (YoLL). The annual economic burden was estimated to be $955m comprised of $121m for lost bed days, $792m for cost of YoLL, and $43m ACC claims. There were 24,165 DALY which is greater than many other measured injuries in New Zealand, eg motor vehicle traffic crashes with 20,328 DALY.

CONCLUSIONS

HAIs are a significant burden for patients, their families, and the public health system. Preventive guidelines for many HAIs exist and a strategic plan is needed to reduce HAIs in New Zealand.

Postoperative outcomes after receipt of ertapenem antimicrobial prophylaxis for colon surgery: a multicenter retrospective cohort study

OBJECTIVE

To evaluate postoperative outcomes among patients undergoing colon surgery who receive perioperative prophylaxis with ertapenem compared to other antibiotic regimens.

DESIGN AND SETTING

Multicenter retrospective cohort study among adults undergoing colon surgery in seven hospitals across three health systems from 1/1/2010 to 9/1/2015.

METHODS

Generalized linear mixed logistic regression models were applied to assess differential odds of select outcomes among patients who received perioperative prophylaxis with ertapenem compared to other regimens. Postoperative outcomes of interest included surgical site infection (SSI), Clostridioides difficile infection (CDI) and clinical culture positivity for carbapenem-resistant Enterobacteraciae (CRE). Inverse probability weights were applied to account for differing covariate distributions across ertapenem and non-ertapenem groups.

RESULTS

A total of 2,109 patients were included for analysis. The odds of postoperative SSI was 1.56 times higher among individuals who received ertapenem than among those receiving other perioperative antimicrobial prophylaxis regimens in our cohort (46 [3.5%] vs 20 [2.5%]; IPW-weighted OR 1.56, [95% CI, 1.08-2.26], P = .02). No statistically significant differences in odds of postoperative CDI (24 [1.8%] vs 16 [2.0%]; IPW-weighted OR 1.07 [95% CI, .68-1.68], P = .78) were observed between patients who received ertapenem prophylaxis compared to other regimens. Clinical CRE culture positivity was rare in both groups (.2%-.5%) and did not differ statistically.

CONCLUSIONS

Ertapenem use for perioperative prophylaxis was associated with increased odds of SSI among patients undergoing colon surgery in our study population, though no differences in CDI or clinical CRE culture positivity were identified. Further study and replication of these findings are needed.

International Nosocomial Infection Control Consortium (INICC) report of health care-associated infections, data summary of 25 countries for 2014 to 2023, Surgical Site Infections Module

BACKGROUND

Surgical site infection (SSI) rates are higher in low-resource countries (LRC) than in high-income counterparts.

METHODS

Prospective cohort study using the INICC Surveillance Online System, from 116 hospitals in 75 cities across 25 Latin-American, Asian, Eastern-European, and Middle-Eastern countries: Argentina, Bahrain, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Egypt, Honduras, India, Kosovo, Kuwait, Lebanon, Mexico, Mongolia, Pakistan, Papua New Guinea, Philippines, Poland, Romania, Saudi Arabia, Thailand, Turkey, Venezuela, Vietnam. CDC/NHSN definitions were applied. Surgical procedures (SPs) were categorized according to the International Classification of Diseases criteria.

RESULTS

From 2014 to 2023, we collected data on 1,251 SSIs associated with 56,617 SPs. SSI rates were significantly higher in SPs of INICC compared to CDC/NHSN data: hip prosthesis (3.68% vs 0.67%, relative risk [RR]=5.46, 95% confidence interval [CI]=3.71-8.03, P<.001), knee prosthesis (2.02% vs 0.58%, RR=3.49, 95% CI=1.87-6.49, P<.001), coronary artery bypass (4.16% vs 1.37%, RR=3.03, 95% CI=2.35-3.91, P<.001), peripheral vascular bypass (15.69% vs 2.93%, RR=5.35, 95% CI=2.30-12.48, P<.001), abdominal aortic aneurysm repair (8.51% vs 2.12%, RR=4.02, 95% CI=2.11-7.65, P<.001), spinal fusion (6.47% vs 0.70%, RR=9.27, 95% CI=6.21-13.84, P<.001), laminectomy (2.68% vs 0.72%, RR=3.75, 95% CI=2.36-5.95, P<.001), among others.

CONCLUSIONS

Elevated SSI rates in LRCs emphasize the need for effective interventions.

Intraoperative wound irrigation to prevent surgical site infection: A systematic review and meta-analysis

INTRODUCTION

The potential benefit of intraoperative wound irrigation (IOWI) in preventing surgical site infection (SSI) remains unclear. The use of antimicrobial agents (AMA) or antiseptic agents (ASA) is controversial worldwide.

METHODS

We performed a systematic review and meta-analysis of randomized clinical trials comparing AMA or ASA with saline solution in patients who underwent abdominal surgery. Sub-analyses were performed on the type of surgery, type of intervention agent, and wound classification.

RESULTS

Nineteen studies comprising 4915 patients undergoing abdominal surgery were included. SSI was observed in 207 out of 2504 patients in the intervention group (8.26 %) and 344 out of 2411 patients in the control group (14.27%). Overall, intraoperative wound irrigation (IOWI) with AMA or ASA was associated with a lower SSI (Odds ratio (OR) 0.62; 95% CI 0.47, 0.82; p < 0.01; I2 = 50%). Sub-analyses have shown a tendency for decreased SSI in patients from emergency surgery (OR 0.46; 95% CI 0.30, 0.70; p < 0.01; I2 = 23%), patients with contaminated wound (OR 0.48; 95% CI 0.31, 0.74; p < 0.01; I2 = 24%), and either the use of AMA or ASA (OR 0.53 vs. 0.65).

CONCLUSION

The overall use of AMA or ASA before skin closure was associated with decreased SSI. Lower rates of SSI were observed in the subgroup analysis. Furthermore, we must consider the critical heterogeneity of the studies.

A Randomized Controlled Trial of 2% Chlorhexidine Gluconate Skin Preparation Cloths for the Prevention of Surgical Site Infections in Adults Undergoing Spine Surgeries: Residual Reduction in Skin Bacterial Load for 4 Days

Background

Surgical site infections (SSI) result in increased morbidity and mortality, prolonged recovery, longer hospital length of stay for medication or possible additional surgeries, and escalated health care costs. The purpose of this randomized controlled trial was to compare SSI rates and overall skin flora burden between those using chlorhexidine (CHG) cloths versus soap and water preoperatively in the adult spine surgery population.

Methods

Subjects were randomized preoperatively to use 2% CHG cloths versus soap and water the night before and morning of surgery prior to the operation. A skin culture was obtained at enrollment prior to any cleansing, again at post-operation day 4 or hospital discharge (whichever came first), and finally at the surgeons' postoperative visits. A blinded advanced practice nurse served as the assessor for SSI.

Results

Those enrolled in the research arm had more growth on their screening skin culture than the control arm (P = .02). While there was no difference in rates of SSI between groups, the CHG group had lower skin flora burden at hospital discharge (P = .004), indicating residual protection.

Conclusion

Surgical incisions are most vulnerable to bacterial entry prior to 72 hours post-operation before completion of epithelialization, which establishes a barrier from microbes. The use of CHG, which has a residual impact for up to 4 days, could offer additional risk reduction for SSI development.

Preventing and Controlling Healthcare-Associated Infections: The First Principle of Every Antimicrobial Stewardship Program in Hospital Settings

Antimicrobial resistance (AMR) is one of the main public health global burdens of the 21st century, responsible for over a million deaths every year. Hospital programs aimed at improving antibiotic use, referred to as antimicrobial stewardship programs (ASPs), can both optimize the treatment of infections and minimize adverse antibiotics events including the development and spread of AMR. The challenge of AMR is closely linked to the development and spread of healthcare-associated infection (HAIs). In fact, the management of patients with HAIs frequently requires the administration of broader-spectrum antibiotic regimens due to the higher risk of acquiring multidrug-resistant organisms, which, in turn, promotes resistance. For this reason, even before using antibiotics correctly, it is necessary to prevent and control the spread of HAIs in our hospitals. In this narrative review, we present seven measures that healthcare workers, even if not directly involved in the tasks of infection prevention and control, must know, support, and embrace. We hope that this review may raise awareness among all healthcare professionals about the issues with the increasing rate of AMR and the ongoing efforts towards minimizing its rise.

Surgical site infection prevention bundle in gynecology oncology surgery: a key element in the implementation of an enhanced recovery after surgery (ERAS) program

Surgical site infection rates are among 5-35% in all gynecologic oncology procedures. Such infections lead to increased patient morbidity, reduction in quality of life, higher likelihood of readmissions, and reinterventions, which contribute directly to mortality and increase in health-related costs. Some of these are potentially preventable by applying evidence-based strategies in the peri-operative patient setting. The objective of this review is to provide recommendations for the individual components that most commonly comprise the surgical site infection prevention bundles that could be implemented in gynecologic oncology procedures. We searched articles from relevant publications with specific topics related to each surgical site infection intervention chosen to be reviewed. Studies on each topic were selected with an emphasis on meta-analyses, systematic reviews, randomized control studies, non-randomized controlled studies, reviews, clinical practice guidelines, and case series. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. This review intends to serve as the most up-to-date frame of evidence-based peri-operative care in our specialty and could serve as the first initiative to introduce an enhanced recovery after surgery (ERAS) program.

Randomized Controlled Trial: Does the Use of Occlusive Hydrocolloid Silver-Containing Wound Dressing after Sternotomy Reduce Surgical Site Infection after Cardiac Surgery?

(1) Background: To reduce the incidence of surgical site infections (SSIs) following median sternotomy in cardiac surgery, we compared an occlusive hydrocolloid silver-containing wound dressing (OHSCWD) with a standard wound dressing. (2) Methods: This study was designed as a single-center randomized controlled trial. The primary endpoint was the overall rate of incidence of any kind of SSI. Secondary endpoints were the number of dressing changes, the severity of SSIs, and whether there was a need for treatment. Wounds were monitored daily until the seventh and on the 30th postoperative day. (3) Results: Of the 423 patients included, 352 were analyzed. No differences in demographics, cardiovascular risk factors, intraoperative processes, and postoperative care were found between both groups. Additionally, the incidence or extent of SSI showed no significant differences between the two groups. (4) Conclusions: In summary, out of all pre-, intra-, and postoperative factors, the contribution of postoperative wound care to the development of SSIs appears to play a subordinate role. However, by offering equivalent wound protection and a reduced number of dressing changes, OHSCWD after median sternotomy in cardiac surgery patients could be a good alternative to standard dressings from the point of view of the patient, the staff, and the clinic.

Bilateral rectus muscle turning-over for complicated and eventrated abdominal wall hernias: results of a novel method

PURPOSE

We present a technique for covering large midline loss of abdominal wall using a novel method by autologous tissues.

METHODS

Twenty-two patients (body mass index = 35,6 ± 6,9 kg/m2) were involved in the prospective cohort study. Acute and elective cases were included. The gap area was 450.1 ± 54 cm2. The average width of the midline gap was 16,3 ± 3,2 cm. The rectus muscles were mobilized from its posterior sheath. Both muscles were turned by180º medially, so that the complete abdominal wall gap could be covered without considerable tension. Changes in intra-abdominal pressure, quality of life and hernia recurrency were determined.

RESULTS

There was no significant increase in the intra-abdominal pressure. Wound infection and seroma occurred in four cases. Bleeding occurred in one case. Pre- and post-operative quality of life index significantly improved (23 ± 13 vs. 47 ± 6; p = 0,0013). One recurrent hernia was registered. The procedure could be performed safely and yielded excellent results. The method was applied in acute cases. The intact anatomical structure of rectus muscles was essential.

CONCLUSIONS

The midline reconstruction with bilateral turned-over rectus muscles provided low tension abdominal wall status, and it did not require synthetic mesh implantation.