Sustained Reduction in Surgical Site Infection after Abdominal Hysterectomy

Decreasing post hysterectomy surgical site infections with the implementation of a hysterectomy-specific bundle

BACKGROUND

Surgical site infections (SSI) are a common complication of hysterectomy. Surgical bundles have been shown to reduce SSIs. Here we describe a bundle that was used to combat an abnormal rise in SSI events that resulted in a greater than 75% reduction at our institution.

METHODS

A hysterectomy-specific bundle was developed based on the prior success of SSI prevention bundles. Development involved longitudinal education and training to ensure accuracy and compliance. All inpatient abdominal, laparoscopic, and vaginal hysterectomies performed at a tertiary referral center were included. The preintervention, intervention, and postintervention periods were each one year in length. SSI rates were peer-reviewed monthly and overall trends were tracked, including compliance with bundle guidelines.

RESULTS

Preintervention, an abnormal rise in SSI was identified at 3.76%. During the intervention, 309 inpatient hysterectomies were completed. In this period, 6 posthysterectomy SSI events occurred (3.76% vs 1.94%, P = .21). Four SSIs followed laparotomy and 2 followed laparoscopy. Compliance during the intervention period ranged from 79% to 89% with a mean of 85%. In the postintervention period, there were 6 SSI following 689 hysterectomies (3.76% vs 0.87%, P = .004). The majority of SSI occurred after abdominal hysterectomy.

CONCLUSIONS

Implementation of a hysterectomy-specific surgical bundle allowed for a significant reduction in post hysterectomy SSI during a yearlong intervention period and a sustained, further reduction in the postintervention period.

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

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database

BACKGROUND

Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database.

METHODS

IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period.

RESULTS

Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy.

CONCLUSIONS

Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.

Epidemiology of surgical site infection following abdominal surgeries at a reference hospital in North-West Cameroon

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Exploring the Relationship Between Nursing Specialty Certification and Surgical Site Infections

OBJECTIVE

The aim of this study is to explore the relationship between nursing specialty certification and surgical site infections (SSIs) for colon (COLO) and abdominal hysterectomy (HYST) surgical procedures.

BACKGROUND

SSI following COLO and HYST procedures is a preventable complication now included in the Centers for Medicare & Medicaid Services' Hospital Inpatient Quality Reporting Program.

METHODS

Data from 69 hospitals, 346 units, and 6585 RNs participating in the National Database of Nursing Quality Indicators and SSI data on 22 188 patient COLO and HYST procedures from the National Healthcare Safety Network were examined in multivariate logistic regression analysis.

RESULTS

Magnet® status was associated with lower SSI occurrence after adjusting for other variables. Higher American Society of Anesthesiologists scores, longer surgical procedure time, and wound class were associated with higher SSI occurrence.

CONCLUSIONS

Future theory-based research should examine the association of nursing specialty certification with patient outcomes and investigate the effect of Magnet status on SSI.

Surgical-site infection in gynecologic surgery: pathophysiology and prevention

Surgical-site infections (SSIs) represent a well-known cause of patient morbidity as well as added health care costs. In gynecologic surgery, particularly hysterectomy, SSIs are often the result of a number of risk factors that may or may not be modifiable. As both the Centers for Medicaid and Medicare Services and the Joint Commission on the Accreditation of Healthcare Organizations have identified SSIs as a patient safety priority, gynecologic surgeons continue to seek out the most effective interventions for SSI prevention. This review studies the epidemiology and pathophysiology of SSIs in gynecologic surgery and evaluates the current literature regarding possible interventions for SSI prevention, both as individual measures and as bundles. Data from the obstetrical and general surgery literature will be reviewed when gynecological data are either unclear or unavailable. Practitioners and hospitals may use this information as they develop strategies for SSI prevention in their own practice.

Infection Risk in Sterile Operative Procedures

BACKGROUND

The main objective of hospital hygiene and infection prevention is to protect patients from preventable nosocomial infections. It was recently stated that the proper goal should be for zero infection rates in sterile surgical procedures. In this article, we attempt to determine whether this demand is supported by the available literature.

METHODS

We systematically searched the Medline and EMBASE databases for studies published in the last 10 years on the efficacy of infection control measures and carried out a meta-analysis according to the PRISMA tool. We used the following search terms: "aseptic surgery," "intervention," "surgical site infection," "nosocomial infection," "intervention," and "prevention."

RESULTS

2277 articles were retrieved, of which 204 were acquired in full text and analyzed. The quantitative analysis included 7 prospective cohort studies on the reduction of nosocomial infection rates after aseptic surgery. The measures used included training sessions, antibiotic prophylaxis, and operative-site disinfection and cleaning techniques. These interventions succeeded in reducing postoperative wound infections (relative risk (RR] 0.99 [0.98; 1.00]). Subgroup analyses on antibiotic prophylaxis (RR 0.99 [0.98; 1.01]) and noncontrolled trials (RR 0.97 [0.92; 1.02]) revealed small, insignificant effects.

CONCLUSION

A multimodal approach with the participation of specialists from various disciplines can further reduce the rate of postoperative infection. A reduction to zero is not realistic and is not supported by available evidence.

Interaction of obesity and infections

There is evidence that certain infections may induce obesity. Obese persons may also have more severe infections and have compromised response to therapies. The objective of this study is to review the available literature identifying infections that potentially contribute to greater body mass index (BMI) and differential responses of overweight and obese persons to infections. A systematic literature review of human studies examining associations between infections and weight gain, differential susceptibility, severity, and response to prevention and treatment of infection according to BMI status (January 1980-July 2014) was conducted. Three hundred and forty-three studies were eligible for inclusion. Evidence indicated that viral infection by human adenovirus Ad36 and antibiotic eradication of Helicobacter pylori were followed by weight gain. People who were overweight or obese had higher susceptibility to developing post-surgical infections, H1N1 influenza and periodontal disease. More severe infections tended to be present in people with a larger BMI. People with a higher BMI had a reduced response to vaccinations and antimicrobial drugs. Higher doses of antibiotics were more effective in obese patients. Infections may influence BMI, and BMI status may influence response to certain infections, as well as to preventive and treatment measures. These observations have potential clinical implications.

Amikacin prophylaxis and risk factors for surgical site infection after kidney transplantation

BACKGROUND

Antibiotic prophylaxis plays a major role in preventing surgical site infections (SSIs). This study aimed to evaluate antibiotic prophylaxis in kidney transplantation and identify risk factors for SSIs.

METHODS

We evaluated all kidney transplantation recipients from January 2009 and December 2012. We excluded patients who died within the first 72 hr after transplantation, were undergoing simultaneous transplantation of another organ, or were below 12 years of age. The main outcome measure was SSI during the first 60 days after transplantation.

RESULTS

A total of 819 kidney transplants recipients were evaluated, 65% of whom received a deceased-donor kidney. The antibiotics used as prophylaxis included cephalosporin, in 576 (70%) cases, and amikacin, in 233 (28%). We identified SSIs in 106 cases (13%), the causative agent being identified in 72 (68%). Among the isolated bacteria, infections caused by extended-spectrum β-lactamase-producing Enterobacteriaceae predominated. Multivariate analysis revealed that the risk factors for post-kidney transplantation SSIs were deceased donor, thin ureters at kidney transplantation, antithymocyte globulin induction therapy, blood transfusion at the transplantation procedure, high body mass index, and diabetes mellitus. The only factor associated with a reduction in the incidence of SSIs was amikacin use as antibiotic prophylaxis. Factors associated with reduced graft survival were: intraoperative blood transfusions, reoperation, human leukocyte antigen mismatch, use of nonstandard immunosuppression therapy, deceased donor, post-kidney transplantation SSIs, and delayed graft function.

CONCLUSION

Amikacin prophylaxis is a useful strategy for preventing SSIs.