Incidence and predictors of surgical-site infections in Vietnam

The Burden of Surgical Site Infection at Hospital Universiti Sains Malaysia and Related Postoperative Outcomes: A Prospective Surveillance Study

Surgical site infections (SSIs) are the most common healthcare-associated infections that occur among surgical patients. Surgical site infections result in longer hospital stays, hospital readmissions, and higher death and morbidity rates. The current study was designed to highlight the importance of such surveillance studies in a Malaysian surgical population with a motive to evaluate and revise concurrent infection control and prevention policies by exploring the burden of surgical site infection and identifying its associated risk factors for future considerations. In this prospective observational cohort study, a total of 216 patients admitted to a surgical ward were identified and studied. Of these 216 patients, 142 elective procedures and 74 emergency procedures were included in the study, of which 13 patients (9.2%) undergoing elective procedures and 15 (20.3%) patients undergoing emergency procedures were SSI positive (OR: 2.5, p = 0.02). Among surgical site infections, 21 were superficial and 7 were deep incisional SSI. No case of organ/space SSI was identified. The time taken for SSIs to develop ranged from 2-17 days with a median of 6 days. Risk factors such as presence of comorbidities (p = 0.011), major co-existing medical diagnosis ≥2 (p = 0.02), and pre-existing infection (p = 0.027) were statistically significant. SSI-positive patients experienced an increase in the post-operative length of hospital stay. In the current population, it was seen that identifying patients who were at high risk of malnutrition via MUST and the NNIS risk index will help clinicians in identifying high risk patients and in managing their patients appropriately. Identifying patients who were at high risk of malnutrition will also improve postoperative outcomes considerably.

Review of antibiotic prescriptions as part of antimicrobial stewardship programmes: results from a pilot implementation at two provincial-level hospitals in Viet Nam

Objectives

To investigate the feasibility of retrospective prescription-based review and to describe the antibiotic prescribing patterns to provide information for an antimicrobial stewardship programme in Viet Nam.

Methods

This study was conducted in two provincial-level hospitals between February and April 2020. Reviews were done by a clinical team consisting of leaders/senior doctors of each ward to assess the optimal level (optimal/adequate/suboptimal/inadequate/not assessable) of antibiotic prescriptions. Mixed-effect logistic regression at prescription level was used to explore factors associated with optimal antibiotic use.

Results

The retrospective prescription-based review was accepted by study clinical wards with varied levels of participants. One hundred and eighty-three patients (326 prescriptions) in Hospital 1 and 200 patients (344 prescriptions) in Hospital 2 were included. One hundred and nineteen of the 326 (36.5%) antibiotic prescriptions in Hospital 1 and 51/344 (14.8%) antibiotic prescriptions in Hospital 2 were determined to be optimal by the review teams. The number of adequate antibiotic prescriptions were 179/326 (54.9%) and 178 (51.7%) in Hospital 1 and Hospital 2, respectively. The optimal level was lower for surgical prophylaxis antibiotics than for empirical therapy (OR = 0.06; 95% CI 0.01-0.45), higher in prescriptions in the ICU (OR = 12.00; 95% CI 3.52-40.92), higher in definitive antibiotic therapy (OR = 48.12; 95% CI 7.17-322.57) and higher in those with an indication recorded in medical records (OR = 3.46; 95% CI 1.13-10.62).

Conclusions

This study provides evidence on the feasibility of retrospective prescription-based review, with adaption to the local situation. High and varying levels of optimal antibiotic prescriptions in clinical wards in hospitals were observed in Viet Nam.

Analysis of the use of antibiotics profile and factors of surgical site infections study on digestive and oncology surgeries

OBJECTIVES

The incision method operation with a high risk of infection in a clean and clean-contaminated operation requires the use of prophylactic antibiotics to minimize the risk of infection. This study was designed to analyze the effectiveness of prophylactic antibiotics in patients with digestive and oncology surgeries.

METHODS

The statistical method used was chi-square to determine the risk factors for infection at surgical site infections (SSI) in patients with digestive and oncology surgeries. This study had received ethical approval from the Ethics Committee of Dr. H. Slamet Martodirdjo Hospital, Pamekasan.

RESULTS

There were 67 patients consisted of 48 digestive surgeries (71.6%) and 19 oncology surgeries (28.4%). The criteria of observation on day 30 showed that as 1 (1.5%) SSI patient experienced purulence, inflammation, and erythema around the surgical wound so an analysis of p>0.05 was carried out so that there was no association with the incidence of SSI during hospitalization, but other factors originating from the patient, such as a lack of personal hygiene at home and lack of nutritious food intake was measured in temperature, pulse, respiration, and white blood cells examination before surgery and 24 h after surgery, all within normal ranges. The qualitative analysis of prophylactic antibiotics using the Gyssen method showed that 31 (46.3%) rationales needed an improvement process.

CONCLUSIONS

The widely used prophylactic antibiotics, namely cefazolin and cefuroxime are recommended antibiotics used in incision surgery and rationale used.

The Association Between Incorrect Use of Antibiotic Prophylaxis and in-Hospital Surgical Site Infections - A Prospective Observational Study

Background

Surgical site infection (SSI) is the most prevalent in developing countries where 61–90% of cases develop in-hospital. The study aimed to assess the correctness of antibiotic prophylaxis (AP) use, the incidence of in-hospital SSI, and its determinants.

Patients and Methods

A 3-month hospital-based prospective observational study design was used on general surgery patients. The criteria for identification of SSI were performed based on the Center for Disease Control and Prevention’s (CDC’s) definition of SSI. The correctness of AP was performed based on the American Society of Health System Pharmacist 2013 guideline (ASHP). Multiple stepwise backward logistic regression analysis was used at p-value <0.05 to predict SSI.

Results

Of 269 adult patients, the type of admission was almost equal between emergency and elective surgery. The mean (± SD) age of the study participants was 41.95±17.764. Only 19.7% of the study participants used AP correctly. The incidence rate of in-hospital SSI was 16.7% (45/269), which corresponds to 45/4736 or 9.5/1000 person-days. Independent predictors for SSI were American Society of Anesthesiology (ASA) class III–IV (p-value <0.0001), patients with age-adjusted Charlson co-morbidity index (CCI) of ≥1 score (p value=0.008), and incorrect use of AP (p-value =0.025).

Conclusion

Incorrect antibiotic prophylaxis use contributed to an increased risk of SSI, which needs urgent attention in the present study area.

Surgical Site Infection Rates in Seven Cities in Vietnam: Findings of the International Nosocomial Infection Control Consortium

BACKGROUND

Surgical site infections (SSIs) are the most common healthcare-associated infections (HAI) in lower-income countries. This is the first study to report the results of surveillance on SSI stratified by surgical procedure in seven Vietnamese cities.

METHODS

This was a prospective, active SSI surveillance study conducted from November 2008-December 2010 in seven hospitals using the U.S. Centers for Disease Control and Prevention's National Healthcare Safety Network (CDC-NHSN) definitions and methods. Surgical procedures (SPs) were classified into 26 types according to the International Classification of Diseases Edition 9 criteria.

RESULTS

We recorded 241 SSIs, associated with 4,413 SPs (relative risk [RR] 5.5%; 95% confidence interval [95% CI] 4.8-6.2). The highest SSI rates were found for limb amputation (25%), colon surgery (33%), and small bowel surgery (21%). Compared with CDC-NHSN SSI report, our SSI rates were higher for the following SPs: Limb amputation (25% vs. 1.3%; RR 20.0; p = 0.001); appendix surgery (8.8% vs. 3.5%; RR 2.54; 95% CI 1.3-5.1; p = 0.001); gallbladder surgery (13.7% vs. 1.7%; RR 7.76; 95% CI 1.9-32.1; p = 0.001); colon surgery (18.2% vs. 4.0%; RR 4.56; 95% CI 2.0-10.2; p = 0.001); open reduction of fracture (15.8% vs. 3.4%; RR 4.70, 95% CI 1.5-15.2; p = 0.004); gastric surgery (7.3% vs. 1.7%; RR 4.26; 95% CI 2.2-8.4, p = 0.001); kidney surgery (8.9% vs. 0.9%; RR 10.2; 95% CI 3.8-27.4; p = 0.001); prostate surgery (5.1% vs. 0.9%; RR 5.71; 95% CI 1.9-17.4; p = 0.001); small bowel surgery (20.8% vs. 6.7%; RR 3.07; 95% CI 1.7-5.6; p = 0.001); thyroid or parathyroid surgery (2.4% vs. 0.3%; RR 9.27; 95% CI 1.0-89.1; p = 0.019); and vaginal hysterectomy (14.3% vs. 1.2%; RR 12.3; 95% CI 1.7-88.4; p = 0.001).

CONCLUSIONS

Our SSIs rates were significantly higher for 11 of the 26 types of SPs than for the CDC-NHSN. This study advances our knowledge of SSI epidemiology in Vietnam and will allow us to introduce targeted interventions.

An evaluation of treatment results of emergency versus elective surgery in colorectal cancer patients

OBJECTIVE

Colorectal cancer is still one of the most common causes of cancer related deaths in the world despite improvements in diagnosis and treatment modalities, and application of community-based screening methods. Symptoms of colorectal cancer are non-specific and usually manifest following local progression. A number of patients with advanced stage colorectal cancer present to emergency departments with obstruction as the first sign of disease without any previous symptoms. This presentation is an indication for emergency surgery that has a high rate of morbidity and mortality. In this study, we aimed to determine the factors associated with early diagnosis and survival by comparing postoperative results of colorectal cancer patients who underwent surgery under emergency or elective situation.

MATERIAL AND METHODS

Files of colorectal patients treated between 2009-2013 were retrospectively analyzed. Data on patient age, gender, operation type, intraoperative results, length of hospital stay, co-morbidities, postoperative complications and pathological results were evaluated and compared.

RESULTS

There was no statistical difference between groups in terms of age, gender, and pathology results (p>0.05). The difference between groups in terms of postoperative length of hospital stay, presence of co-morbid diseases, pathological stage, and postoperative complications was statistically significant (p<0.05). Length of hospital stay, advanced stage on admission, complications such as surgical site infection, evisceration, and anastomosis leakage rates were higher in patients in the emergency surgery group.

CONCLUSION

Risk groups should be determined in order to diagnose colorectal cancer patients at an early stage while they are still asymptomatic, and this information should be incorporated into effective screening programs. This approach will be beneficial to treatment outcomes, complication rates, length of hospital stay, and survival and treatment results.

Nosocomial Infections and Epidemiology of Antibiotic Resistance in Teaching Hospitals in South East of Iran

Aim:

Antibiotic resistance as one of the most serious health threats worldwide leading to a high rate of morbidity and mortality. The aim of present study was to examine the prevalence of nosocomial infections (NIs) and pattern of antibiotic resistance in teaching hospitals in Iran

Methods:

This cross-sectional descriptive study was conducted in a period of one year in three teaching hospitals and all patients with suspected NIs symptoms were chooses. Among these patients who showed antibiotic resistance were included in the study. The samples for clinical test in laboratory were obtained with using standard methods and aseptic technique by trained personnel. Antibiotic susceptibility testing was performed by Kirby-Bauer’s disk diffusion method on Muller-Hinton agar (Hi Media, Mumbai, India) in accordance with the standards of the Clinical Laboratory Standards Institute.

Results:

During one year study, 561 patients with nosocomial infections were recognized and among them 340 patients (60.6%) showed some level of antibiotic resistance. The most common cause of NIs in present study was Acinetobacter and the most type of infection was respiratory system infections (52.7%). The highest resistance rate was against Ciprofloxacin (61.8%) followed by Imipenem (50.3%).

Conclusion:

Rate of NIs and antibiotics resistance is high in Iranian hospital. So Iranian health ministry should provide guideline and suitable programs for prevention of NIs and antibiotic therapy in hospitals.

Patient safety and quality of care in developing countries in Southeast Asia: a systematic literature review

OBJECTIVE

To establish current knowledge of patient safety and quality of care in developing countries in Southeast Asia, current interventions and the knowledge gaps.

STUDY DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Key words, synonyms and subject headings were used to search seven electronic databases in addition to manual searching of relevant journals.

DATA SYNTHESIS

Titles and abstracts of publications between 1990 and 2014 were screened by two reviewers and checked by a third. Full text articles were screened against the eligibility criteria. Data on design, methods and key findings were extracted and synthesized.

RESULTS

Four inter-related safety and quality concerns were evident from 33 publications: (i) the risk of patient infection in healthcare delivery, (ii) medications errors/use, (iii) the quality and provision of maternal and perinatal care and (iv) the quality of healthcare provision overall.

CONCLUSIONS

Large-scale prevalence studies are needed to identify the full range of safety and quality problems in developing countries in Southeast Asia. Sharing lessons learnt from extensive quality and safety work conducted in industrialized nations may contribute to significant improvements. Yet the applicability of interventions utilized in developed countries to the political and social context in this region must be considered. Strategies to facilitate the collection of robust safety and quality data in the context of limited resources and the local context in each country are needed.

Simple multiplex PCR assays to detect common pathogens and associated genes encoding for acquired extended spectrum betalactamases (ESBL) or carbapenemases from surgical site specimens in Vietnam

Abstract

Surgical site infection (SSI) is common in Vietnamese post-operative patients. It contributes to increased morbidity, mortality, hospitalization time and health care expenditure. Bacterial culture is considered the gold standard procedure to identify SSI pathogens and antibiotic resistant properties; however, it can detect microbes that can readily grow and is time-consuming. We propose optimized multiplex PCR assays to diagnose the most relevant microbes and associated genes encoding for acquired extended spectrum betalactamases (ESBL) or carbapenemases from Vietnamese patients with SSI in a hospital setting in Hanoi.

Methods

Ninety-one patients (n = 91) were collected in order to identify microbial pathogens and associated genes encoding for acquired extended spectrum betalactamases (ESBL) or carbapenemases by both conventional bacterial culture and in-house multiplex PCR assays.

Result and conclusion

The novel in-house multiplex PCR assays are comparable to the bacterial culture approach in screening for common pathogens causing SSI and for relevant genotypes conferring betalactam/carbapenem resistance for bacteria. This is the first report of Turkey-specific ESBL gene (PER-1) and two Oxacilinase families (Oxa23 and Oxa 58) in Vietnam.

Prospective Surveillance for Surgical Site Infection in St. Petersburg, Russian Federation

Objective.

To assess the risk-adjusted incidence and predictors of surgical site infections (SSIs).

Design.

Prospective, multicenter, observational cohort study.

Setting.

Seven surgical departments at 3 urban academic hospitals in St. Petersburg, Russian Federation.

Patients.

All patients had surgery performed between January 15 and May 12, 2000. A total of 1,453 surgical procedures were followed up. Medical records were unavailable for less than 3% of all patients; patients were not excluded for any other reason. The mean patient age was 49.3 years, 61% were female, and 34% had an American Society of Anesthesiologists physical status classification (hereafter, “ASA classification”) of at least 3. Surgery for 45% of the patients was emergent.

Results.

In all, 138 patients (9.5%) developed SSI, for a rate that was approximately 3.5 times the risk-stratified rates in the United States. Male sex (odds ratio [OR], 1.54), ASA classifications of 3 (OR, 3.7) or 4 (OR, 5.0), longer duration of surgery (OR, 2.2), and wound classes of 3 (OR, 5.5) or 4 (OR, 14.3) were associated with increased SSI risk in multivariate analysis. Endoscopic surgery was associated with a lower risk of SSI (OR, 0.23). Antibiotic prophylaxis was used in 0%-33% of operations, and 69% of uninfected patients received antibiotics after the operation.

Conclusions.

The SSI rates are significantly higher than previously reported. Although this finding may be attributable to inadequate antibiotic prophylaxis, local infection control and surgical practices may also be contributors. Use of antibiotic prophylaxis should be encouraged and the effect of local practices further investigated. Active SSI surveillance should be expanded to other parts of the Russian Federation.

The incidence and distribution of surgical site infection in mainland China: a meta-analysis of 84 prospective observational studies

Surgical site infection (SSI) is one of the most common surgical complications in the world, particularly in developing countries. This study aimed to estimate the incidence and distribution of SSI in mainland China. Eighty-four prospective observational studies (82 surveillance studies, 1 nested case control study, and 1 cohort study) were selected for inclusion in this meta-analysis. The average incidence of SSI in mainland China was 4.5% (95% CI: 3.1–5.8) from 2001 to 2012 and has decreased significantly in recent years. The remote western regions had a higher incidence of 4.6% (95% CI: 4.0–5.3). The most common surgical procedure was abdominal surgery (8.3%, 95% CI: 6.5–10.0). SSI occurred frequently in the elderly (5.1%, 95% CI: 2.2–8.0), patients confined to hospital for over 2 weeks (5.7%, 95% CI: 0.9–10.0), superficial incision wounds (5.6%, 95% CI: 4.4–6.8), dirty wounds (8.7%, 95% CI: 6.9–10.6), operations lasting for over 2 hours (7.3%, 95% CI: 4.9–9.7), general anaesthesia operations (4.7%, 95% CI: 2.7–6.6), emergency surgeries (5.9%, 95% CI: 4.2–7.7), and non-intra-medication operations (7.4%, 95% CI: 1.0–13.7).

Antibiotic use and emerging resistance: how can resource-limited countries turn the tide?

Antibiotic resistance is a global crisis driven by appropriate and inappropriate antibiotic use to treat human illness and promote animal growth. The antimicrobial resistance epidemic continues to spread due to the triple threat of unfettered access, minimal product regulation and oversight of antibiotic prescription, and lack of clinical diagnostic tools to support antibiotic de-escalation in low-resource settings. In high-resource settings, evidence-based strategies have improved the appropriateness of antibiotic use, limiting the spread of drug-resistant organisms and reducing hospital-associated infections, strategies which may also be effective to stop the spread of resistance in resource-poor countries. Current research and surveillance efforts on antimicrobial resistance and hospital-associated infections in low-resource settings are extremely limited and largely focused on intensive care units. Many challenges exist to improving antibiotic use and infection control in resource-limited settings, and turning the tide requires intensifying research and surveillance, antimicrobial stewardship, and developing new bedside diagnostic tools for bacterial infections and antimicrobial susceptibility.

Incidence and modifiable risk factors of surveillance of surgical site infections in Egypt: a prospective study

BACKGROUND

Surgical site infections (SSIs) contribute significantly to patient morbidity and mortality and exhaust health care system resources. The main objectives of the study were to describe the incidence rates of SSIs among patients undergoing urologic or cardiothoracic surgeries, the associated risk factors, and the common causative etiologies found at Alexandria University Hospital in Egypt.

METHODS

A prospective active surveillance study for patients undergoing urologic and cardiothoracic surgeries was implemented from July 2009 to December 2010. Patients were inspected daily for developing SSIs and with a 30-day postoperative follow-up. Wound swabs were obtained from patients who had clinical signs suggestive of infection. Swabs were cultured for bacterial identification and tested for antimicrobial sensitivity. Standard Centers for Disease Control and Prevention National Health Safety Network case definitions were used.

RESULTS

SSIs occurred in 187 (17%) of patients with complete follow-up (n = 1,062), of which 106 (57%) occurred in-hospital and 81 (43%) occurred after discharge. Higher SSI rates were observed in cardiothoracic surgeries (23.3%), compared with urologic surgeries (9%) (P < .001). A stepwise logistic model identified an increased risk of SSI for those who underwent cardiothoracic surgeries (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.2-11.1), those aged >45 years (OR, 2.32; 95% CI, 1.35-4.01), increased duration of hospital stay before (OR, 1.03; 95% CI, 1.01-1.05) and after (OR, 1.07; 95% CI, 1.04-1.09) surgery, antibiotics ≤24 hours before surgery (OR, 2.54; 95% CI, 1.63-3.94), and dirty wounds (OR, 4.09; 95% CI, 1.60-10.43).

CONCLUSIONS

Measures to reduce the high rates of SSI need to be instituted through a multidisciplinary effort including infection control education and specific SSI prevention activities at Alexandria University Hospital.

Performance, revision, and extension of the National Nosocomial Infections Surveillance system's risk index in Brazilian hospitals

OBJECTIVE

To assess the benefit of using procedure-specific alternative cutoff points for National Nosocomial Infections Surveillance (NNIS) risk index variables and of extending surgical site infection (SSI) risk prediction models with a postdischarge surveillance indicator.

DESIGN

Open, retrospective, validation cohort study.

SETTING

Five private, nonuniversity Brazilian hospitals.

PATIENTS

Consecutive inpatients operated on between January 1993 and May 2006 (other operations of the genitourinary system [n = 20,723], integumentary system [n = 12,408], or musculoskeletal system [n = 15,714] and abdominal hysterectomy [n = 11,847]).

METHODS

For each procedure category, development and validation samples were defined nonrandomly. In the development samples, alternative SSI prognostic scores were constructed using logistic regression: (i) alternative NNIS scores used NNIS risk index covariates and cutoff points but locally derived SSI risk strata and rates, (ii) revised scores used procedure-specific alternative cutoff points, and (iii) extended scores expanded revised scores with a postdischarge surveillance indicator. Performances were compared in the validation samples using calibration, discrimination, and overall performance measures.

RESULTS

The NNIS risk index showed low discrimination, inadequate calibration, and predictions with high variability. The most consistent advantage of alternative NNIS scores was regarding calibration (prevalence and dispersion components). Revised scores performed slightly better than the NNIS risk index for most procedures and measures, mainly in calibration. Extended scores clearly performed better than the NNIS risk index, irrespective of the measure or operative procedure.

CONCLUSIONS

Locally derived SSI risk strata and rates improved the NNIS risk index's calibration. Alternative cutoff points further improved the specification of the intrinsic SSI risk component. Controlling for incomplete postdischarge SSI surveillance provided consistently more accurate SSI risk adjustment.

Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis

BACKGROUND

Health-care-associated infection is the most frequent result of unsafe patient care worldwide, but few data are available from the developing world. We aimed to assess the epidemiology of endemic health-care-associated infection in developing countries.

METHODS

We searched electronic databases and reference lists of relevant papers for articles published 1995-2008. Studies containing full or partial data from developing countries related to infection prevalence or incidence-including overall health-care-associated infection and major infection sites, and their microbiological cause-were selected. We classified studies as low-quality or high-quality according to predefined criteria. Data were pooled for analysis.

FINDINGS

Of 271 selected articles, 220 were included in the final analysis. Limited data were retrieved from some regions and many countries were not represented. 118 (54%) studies were low quality. In general, infection frequencies reported in high-quality studies were greater than those from low-quality studies. Prevalence of health-care-associated infection (pooled prevalence in high-quality studies, 15·5 per 100 patients [95% CI 12·6-18·9]) was much higher than proportions reported from Europe and the USA. Pooled overall health-care-associated infection density in adult intensive-care units was 47·9 per 1000 patient-days (95% CI 36·7-59·1), at least three times as high as densities reported from the USA. Surgical-site infection was the leading infection in hospitals (pooled cumulative incidence 5·6 per 100 surgical procedures), strikingly higher than proportions recorded in developed countries. Gram-negative bacilli represented the most common nosocomial isolates. Apart from meticillin resistance, noted in 158 of 290 (54%) Staphylococcus aureus isolates (in eight studies), very few articles reported antimicrobial resistance.

INTERPRETATION

The burden of health-care-associated infection in developing countries is high. Our findings indicate a need to improve surveillance and infection-control practices.

FUNDING

World Health Organization.

Fact-finding survey of nosocomial infection control in hospitals in Vietnam and application to training programs

Nosocomial infection control is crucial for improving the quality of medical care. It is also indispensable for implementing effective control measures for severe acute respiratory syndrome (SARS) and the possible occurrence of a human influenza pandemic. The present authors, in collaboration with Vietnamese hospital staff, performed a fact-finding survey of nosocomial infection control in hospitals in northern Vietnam and compared the results with those of a survey conducted 4 years previously. Remarkable improvement was recognized in this period, although there were considerable differences between the central hospitals in Hanoi and local hospitals. In the local hospitals, basic techniques and the systems for infection control were regarded as insufficient, and it is necessary to improve these techniques and systems under the guidance of hospitals in the central area. Based on the results of the survey, programs were prepared and training courses were organized in local hospitals. Evaluation conducted after the training courses showed a high degree of satisfaction among the trainees. The results of the survey and the training courses conducted during the study period are expected to contribute to the improvement of nosocomial infection control in remote areas of Vietnam

[Etiology of surgical site infections at the orthopaedic trauma units]

OBJECTIVES

The aim of the study was to analyze the epidemiological and microbiological analysis of surgical site infections in the orthopedic wards.

MATERIALS AND METHODS

A 6-month prospective cohort study was conducted at the major teaching hospital in Belgrade. Patient's basic demographic data and data about surgical site infections were collected. Bacteria cultured from the surgical site were also analyzed.

RESULTS

A total of 277 patients operated in the Institute of Orthopedics and trauma surgery, Clinical Center of Serbia. Sixty-three cases of SSI were detected, and the overall incidence rate was 22.7% (95% IP = 17.8-27.6). Fifty-three (84.1%) SSIs had microbiological confirmation and overall 82 bacterial strains were isolated. The most frequent isolated bacteria were Staphylococcus aureus, Acinetobacter sp, Klebsiella pp, Pseudomonas sp and Enterococcus sp. Nineteen (79.2%) strains of Staphylococcus aureus isolated from infected surgical sites were meticillin- resistant.

CONCLUSION

This study suggests that it is necessary to maintain continuous surveillance of surgical site infections. It is important to emphasize the need for implementation the measures of contact isolation in order to prevent the nosocomial transmission of resistant bacteria.

A prospective study of surgical site infections in a teaching hospital in Goa

INTRODUCTION

Surgical Site Infections contribute significantly to increased health care costs in terms of prolonged hospital stay and lost work days. The problem was largely unexplored in an apex medical institute in Goa.

AIMS AND OBJECTIVES

To estimate the incidence, and study the bacteriology and the factors associated with SSI in the study setting.

SETTINGS AND DESIGN

Prospective study in the surgical wards of an apex medical teaching hospital in Goa.

MATERIALS AND METHODS

Clinico-bacterilogical follow-up of 114 post-operative cases to the development of SSI, as per the CDC criteria (1991). Incidence was expressed as the infection rate per 100 operations. Antibiotic sensitivity testing was done using the disc diffusion method.

STATISTICAL ANALYSIS

Association was tested by applying the Student t-test and the Chi-square test of significance, and the strength of association expressed as the Odd's Ratio.

RESULTS

The overall SSI rate was estimated to be 30.7%; 5.4% for clean, 35.5% for clean-contaminated, and 77.8% for contaminated operations. Seventy-nine per cent of the isolates were gram-negative and almost 64% demonstrated polyantimicrobial resistance.

CONCLUSIONS

The study emphasizes the need for the evidence-based infection control and antibiotic prescription policies in the hospital.

Surgical site infection rate and associated risk factors in elective general surgery at a public sector medical university in Pakistan

This prospective study aimed to determine the surgical site infection (SSI) rate and associated risk factors was carried in a general surgical ward at Liaquat University Hospital Jamshoro. A total of 460 patients requiring elective general surgery from July 2005 to June 2006 were included in this study. All four surgical wound categories were included. Primary closure was employed in all cases. Patients were followed up to 30th day postoperatively. All cases were evaluated for postoperative fever, redness, swelling of wound margins and collection of pus. Cultures were taken from all the cases with any of the above finding. Mean +/- SD age of the patients was 38.8 +/- 17.4 years with male to female ratio of 1.5:1. The overall rate of surgical site infection was 13.0%. The rate of wound infection was 5.3% in clean operations, 12.4% in clean-contaminated, 36.3% in contaminated and 40% in dirt-infected cases. Age, use of surgical drain, duration of operation and wound class were significant risk factors for increased surgical site infection (P < 0.05). Postoperative hospital stay was double in cases who had surgical site infection. Sex, haemoglobin level and diabetes were not statistically significant risk factors (P > 0.05). In conclusion, surgical site infection causes considerable morbidity and economic burden. The routine reporting of SSI rates stratified by potential risk factors associated with increased risk of infection is highly recommended.

Infection, host resistance, and antimicrobial management of the surgical patient

Chemotherapeutic management of the microbial milieu that impacts patients undergoing surgery is profoundly important in surgery involving the head and neck region. This region is a repository for a diverse population of microbes, which stand ready to invade the underlying structures once the barriers have been breached. This article evaluates human resistance to these microorganisms and reviews conditions that may increase susceptibility in patients undergoing surgery.

[Incidence of surgical site infections in the departments of orthopedics and traumatology]

BACKGROUND/AIM

Besides infections of urinary tract and pneumonias, as well as blood infections, surgical site infections (SSI) represent one of the most common localization of hospital infections. The aim of this study was to determine the incidence of SSI in the departments of orthopedics and traumatology as well as the SSI incidence in relation to the ASA score, surgical site contamination class and NNIS index.

METHODS

A prospective cohort study followed daily all the surgical patients hospitalized over 48 hours in the Institute for Orthopedic Surgery and Traumatology, Clinical Center of Serbia, as well as 30 days after the discharge, during the period betwen February 1 to July 31, 2002. The patients were examined and their diagnoses made according to the definition of hospital infections, i.e. upon clinical and/or laboratory analyses, using concurrently the ASA score, surgical site contamination class and NNIS index.

RESULTS

Out of 227 surgical patients, 60 were diagnosed with SSI during their hospitalization, while 3 of the patients developed SSI after the discharge. The incidence of SSI was 22.7% (95% CI = 17.8-27.6). In the patients with good health condition, i.e. ASA < or = 2, the incidence of SSI was 18.3% (43/235) and in those with ASA > 2, it was 47.6% (20/42) (chi2 = 17.4; p < 0.001). The incidence of SSI was 13.5% (25/185) in the clean wounds, 11.6% (5/43) in purely contaminated, while it was much higher in the contaminated 65.5%; (19/29) and soiled 70.0%; (14/20) wounds (chi2 = 67.6; p < 0.001). The incidence of SSI in relation to NNIS was 8.1% (13/161) in the patients with score 0, then 36.4% (32/88) in the patients with score 1, and 64.3% (18/28) in the patients with the scores 2 and 3 (chi2 = 57.3; p < 0.001). The patients with SSI stayed in the departments of orthopedics and traumatology approximately 1.8 times longer than the patients without SSI (t = 5.3; DF = 275; p < 0.0019.

CONCLUSION

It is important to emphasize the need for constant epidemiological surveillance of SSI and the implementation of preventive measures in Serbia.

Risk factors for wound infection after minor surgery in general practice

OBJECTIVE

To determine the incidence of and risk factors for surgical site infections in general practice.

DESIGN

Prospective, observational study of patients presenting for minor excisions.

SETTING

Primary care in a regional centre, Queensland, October 2004 to May 2005.

PARTICIPANTS

857 patients were assessed for infection.

RESULTS

The overall incidence of infection was 8.6% (95% CI, 3.5%-13.8%). Excisions from lower legs and feet (P = 0.009) or thighs (P = 0.005), excisions of basal cell carcinoma (P = 0.006) or squamous cell carcinoma (P = 0.002), and diabetes (P < 0.001) were independent risk factors for wound infection.

CONCLUSION

Our results indicate the high-risk groups for surgery in a general practice setting, such as people with diabetes and those undergoing excision of a non-melanocytic skin cancer or excision from a lower limb. Recognition of these groups could encourage more judicial use of prophylactic antibiotics and use of other interventions aimed at reducing infection rates.

Investigation of risk factors for surgical wound infection among teaching hospitals in Tehran

This prospective study was carried out to investigate the risk factors and incidence of surgical site infection (SSI) among patients in surgical wards of five hospitals affiliated to Iran University of Medical Sciences. Data was collected in a register card filled by specially trained staff. Nine-hundred and eighteen patients admitted in surgical wards were followed 30 days postoperatively for SSI during 1 April 2003 to 30 September 2003. A total of 77 patients were identified among 918 cases included in the study, with a resulting overall SSI rate of 8.4%. The risk of SSI was increased by age older than 60 years (OR = 3.9; P < 0.0001), diabetes mellitus (OR = 4.9; P < 0.0001), smoking (OR = 3.1; P < 0.0001), obesity (OR = 4.1; P < 0.0001) and wound drain (OR = 2.2; P < 0.0001). There were significant statistical difference in duration of anaesthesia (131.6 vs. 177 min, P < 0.001) and duration of surgery (99 vs. 140.5) between patients without SSI and patients with SSI. In conclusion, identification of the risk factors for SSI will help physicians to improve patient care and may decrease mortality and morbidity and hospital care costs of surgery patients.

Incidence of and risk factors for surgical-site infections in a Peruvian hospital

OBJECTIVE

To determine the incidence of and risk factors for surgical-site infections (SSIs) after abdominal surgery.

DESIGN

A cohort study was conducted from January to June 1998. CDC criteria for SSI and the NNIS System risk index were used.

SETTING

A tertiary-care hospital in Peru.

PATIENTS

Adult patients undergoing abdominal surgery who consented were enrolled and observed until 30 days after surgery. Patients who had undergone surgery at another hospital or who died or were transferred to another hospital within 24 hours after surgery were excluded.

RESULTS

Four hundred sixty-eight patients were enrolled. Their mean age was 37.2 years. One hundred twenty-five patients developed SSIs, 18% of which were identified after discharge. The overall incidence rate (IR) was 26.7%. The IR was 13.9% for clean, 15.9% for clean-contaminated, 13.5% for contaminated, and 47.2% for dirty interventions. The IR was 3.6% for NNIS System risk index 0 and 60% for index 3. Risk factors for SSI on logistic regression analysis were dirty or infected wound (RR, 3.8; CI95, 1.7-8.4), drain use longer than 9 days (RR, 6.0; CI95, 2.5-12.5), and length of surgery greater than the 75th percentile (RR, 2.1; CI95, 1.0-4.4). Patients with SSI had a longer hospital stay than did non-infected patients (14.0 vs 6.1 days; p < .001).

CONCLUSIONS

SSI is a major problem in this hospital, which has a higher IR (especially for clean interventions) than those of developed countries. In developing countries, prevention of SSI should include active surveillance and interventions targeting modifiable risk factors.

Incidence of surgical site infections and accompanying risk factors in Vietnamese orthopaedic patients

A cohort study of surgical site infections (SSIs) was conducted in 582 orthopaedic surgical patients at Cho Ray Hospital, a reference hospital in Ho Chi Minh City, Vietnam, in order to determine the incidence and analyse risk factors for SSIs in this population. The SSI incidence rate was 12.5% (73 of 582); 3.6% incisional SSIs, 6.8% deep incisional SSIs and 2.1% organ/space SSIs. The incidence increased from 2% in clean wounds to 44.6% in dirty wounds, or 1.3% in patients with a National Nosocomial Infections Surveillance (NNIS) risk index of 0 to 75% in patients with an NNIS risk ratio of 3. In multi-variate analysis, having a dirty wound [odds ratio (OR) 8.7; 95% confidence intervals (CI) 4.6--16.4], American Society of Anesthesiologists' score >2 (OR 3.9; 95%CI 1.8-8.8), procedures with external fixation (OR 2.9; 95%CI 1.4-5.9), emergency surgery with motor-vehicle-related trauma (OR 2.1; 95%CI 1.2-3.9), or duration of procedure >2h (OR 2.1; 95%CI 1.1-4.2) were independent risk factors for SSI. Lack of appropriate prophylaxis was of borderline significance (OR 3.2; 95%CI 0.9-11.1, P=0.06). Among 76 patients with SSIs, 22 patients were discovered during postdischarge follow-up. These late SSIs had age as an additional risk factor (OR 2.8; 95%CI 1.1-7.2). Our data show that SSIs were frequent and differed widely by wound class. The NNIS risk index was predictive of SSI for this population. With a high number of motor vehicle accidents in Vietnam, the majority of orthopaedic operations are trauma related. Emergency surgery for injuries sustained in these accidents, and procedures with external fixation were especially prone to infections.

Contribution of technical guidance on nosocomial infection control to the containment of Severe Acute Respiratory Syndrome in Vietnam

When Severe Acute Respiratory Syndrome (SARS) spread in Vietnam in March 2003, Bach Mai Hospital (BMH) contributed greatly to putting SARS under control by conducting strict nosocomial infection control. At BMH, technical guidance on nosocomial infection control had been implemented by Japanese experts since 2000. In addition, after the SARS outbreak, the Japan Disaster Relief Team was dispatched to assist in SARS control at BMH. SARS control in Vietnam was reviewed in reference to this technical guidance to investigate effective control measures. Major subjects of the technical guidance included the establishment of a control system, development of manuals and teaching materials, training of medical staff, and supplying protective attire. BMH provided medical care for 35 SARS cases; however, no nosocomial infection cases occurred leading to SARS containment. A swift reaction, effective nosocomial infection control, proper advice by the Ministry of Health and other elements are considered important factors in the success of SARS containment at BMH. In addition, the fruit of technical cooperation conducted under the project is regarded, to no small extent, as having formed the basis for this. Nosocomial infection control is a crucial factor in achieving high-quality medical care, as well as SARS control at the hospital level.

The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery

A retrospective chart review of 555 patients who received elective foot and ankle surgeries between 1995 and 2001 at 1 outpatient podiatric hospital clinic was performed to evaluate the efficacy of preoperative intravenous antibiotic use. Only those patients who were having elective foot or ankle surgery for the first time, were being followed up at the hospital's outpatient clinic, and had a nontraumatic cause for their surgery were included in this study. A wound was considered infected when purulent material from the wound sites was noted and an organism(s) was cultured. A wound complication was defined as a superficial dehiscence, edema, erythema, or stitch abscess. Three hundred six (55.1%) patients received a preoperative antibiotic and 249 (44.9%) patients did not. Of the 306 patients who received a preoperative antibiotic, 9 (1.6%) acquired a postoperative wound infection, whereas 8 (1.4%) of the 249 patients who did not receive preoperative antibiotics acquired a postoperative infection. A logistic regression model and chi square tests of association were used to determine if preoperative antibiotic use, age, gender, type of surgical procedure, operative time, tourniquet use, past medical history, and internal fixation were predictive of or associated with postoperative wound infection or complication. None of the study factors was predictive of postoperative wound infection or complication (P >.01). Preoperative antibiotic use was associated with surgical category and internal fixation use (P <.001) but not postoperative wound infection or complication (P >.01). The results suggest that prophylactic intravenous antibiotic use in routine elective foot and ankle surgery is not warranted.

Surgical site infections in patients undergoing major operations in a university hospital: using standardized infection ratio as a benchmarking tool

BACKGROUND

Because patterns of infection acquired in patients undergoing operation are ever changing, it is an essential part of nosocomial infection surveillance programs to periodically document the epidemiologic features of infection in these patients. This study was conducted with the primary intention of describing the incidence and risk factors of the surgical site infection (SSI).

METHODS

We performed a prospective study in patients undergoing certain major operations at a 750-bed university hospital in Thailand. The National Nosocomial Infection Surveillance (NNIS) system method and criteria were used for identifying and diagnosing infection. The infection rates were benchmarked with the NNIS report by means of indirect standardization and reported in terms of standardized infection ratio. Risk factors for SSI were evaluated using the multiple logistic regression model.

RESULTS

From September 1998 to March 2000, the study included 4193 patients with 4437 major operations. The study identified 192 SSIs, 76 urinary catheter-related urinary tract infections, 26 central line-related bloodstream infections, and 39 instances of ventilator-associated pneumonia (VAP), yielding an infection rate of 4.3 SSIs/100 operations, 11.0 catheter-related urinary tract infections/1000 urinary catheter-days, 6.1 central line-related bloodstream infections/1000 central line-days, and 11.0 VAPs/1000 ventilator-days. When compared with data from NNIS, the standardized infection ratio of SSI, catheter-related urinary tract infection, central line-related bloodstream infection, and VAP were 2.3, 2.1, 1.1, and 0.8, respectively. The factors that significantly associated with SSI were duration of operation in minutes, American Society of Anesthesiologists (ASA) class, and degree of wound contamination.

CONCLUSION

All of the infection rates identified, except VAP, were higher than the average NNIS rates. The risk factors for SSI were prolonged duration of operation, poor physical status according to ASA classification, and higher degree of wound contamination.