Use of Feedback Data to Reduce Surgical Site Infections and Optimize Antibiotic Use in Surgery: A Systematic Scoping Review

Cultural differences in attitudes towards surgical site infections among French anesthetists and surgeons in digestive surgery in 2022

BACKGROUND

Although it generates a significant burden, little attention has been paid to preventing Surgical Site Infection (SSI) in digestive surgery.

OBJECTIVE

This study explored the factors underpinning anesthetists' and surgeons' attitudes toward SSI prevention in digestive surgery, focusing on their perceptions of SSI, preventive measures, guidelines, and cooperation across both specialties.

METHODS

Qualitative semi-structured interviews were conducted with 15 surgeons and 19 anesthetists working in digestive surgery. Participants were approached through established mailing lists and snowball sampling. Interviews were recorded and transcribed verbatim. Transcripts were coded and analyzed thematically using a constant comparative approach.

RESULTS

SSI in digestive surgery was perceived as an inevitable consequence and ranked down in the priorities of surgeons. A paradox existed between the low consideration of superficial infections that are easily manageable through antibiotics and the strong awareness of the antibiotic resistance threat. Global trust appeared regarding the guidelines, but a knowledge gap of the guidelines was observed among surgeons in comparison with anesthetists. SSI ownership was perceived as collective, but the responsibility belonged to the surgeon alone. Surgeons focused on actions and short-term tasks within a culture of individualism, whereas anesthetists worked collectively with systemic approaches. Overall, the cooperation between both specialties was positive, but tightly reliant on teamwork, workload, and organization in the operating theatre.

CONCLUSIONS

The cultural differences between surgeons and anesthetists should be recognized as a key overarching factor in defining their respective roles in the prevention of SSI and in establishing accountability in digestive surgery - including aspects such as adherence to guidelines, and the implementation of preventive measures.

Cost Analysis of Postoperative Medications in a Tertiary Care Hospital in Northeast India

BACKGROUND

Postoperative medications play a crucial role in managing physiological changes and preventing complications after surgery. However, the cost of these medications can be a significant burden for patients, particularly in low-income settings. This study aimed to estimate the cost of postoperative medications in a tertiary care hospital and simulate the financial burden on patients undergoing elective surgery.

METHODS

A prospective, hospital-based observational study was conducted at a tertiary care hospital in India. Data were collected from 109 patients undergoing elective surgery, and the cost of medications was calculated using real-world data. A gamma distribution was used to simulate 100000 data points, and the mean, median, and interquartile range of medication costs were estimated.

RESULTS

The mean medication cost was ₹9332 (around $111 USD), with a median cost of ₹4989 (around $60 USD). The interquartile range was ₹11103, indicating substantial variability in patient costs. The simulation results showed that patients would need to work for an average of 51 days to cover the mean cost of medications, with up to 104 days required for 2.5% of patients.

CONCLUSION

The financial burden of postoperative medications is significant. The findings highlight the need for flexibility in government schemes like Ayushman Bharat to accommodate the variability in costs. Policymakers should consider revising the sanctioned amounts per treatment module to keep pace with inflation and changes in medical practice.

Incidence, bacteriological profile and predictors of surgical site infections following limb amputation at Bugando medical centre and Sekou toure referral regional hospital, Mwanza, Tanzania

BACKGROUND

Surgical site infections (SSIs) after limb amputations have been associated with increased patient morbidity, mortality and costs. This study aimed to determine the incidence, bacteriological profile and predictors of SSIs following limb amputation at Bugando Medical Centre (BMC) and Sekou Toure Regional Referral Hospital (SRRH).

METHODS

The longitudinal study was conducted among patients undergoing limb amputations between March and July 2024 at BMC and SRRH. Pre-tested structured questionnaires were used to collect sociodemographic and clinical data. Clinical diagnosis of SSI was done using CDC criteria followed by collection of wound or pus swab for culture and susceptibility testing. Univariate and multivariate logistic regression modelling was done using STATA version 15.0 to assess associations between clinical variables and odds of SSI.

RESULTS

A total of 120 patients with a median (IQR) age of 58 [43.5-66.5] years were enrolled. The indications for limb amputations included diabetic foot ulcers (50.8%,61/120), trauma (8.3%,10/120), malignancy (8.3%,10/120), gangrene (9.2%,11/120), peripheral vascular disease (16.7%,20/120) and congenital malformations (6.7%,8/120). The incidence of SSIs was (30%,36/120), with Escherichia coli (36.7%; 11/30) and Staphylococcus aureus (23%; 7/30) being the most frequently isolated pathogens. More than half of the Gram-negative isolates were resistant to third and fourth generations cephalosporins which were commonly used as prophylactic antibiotics in the study settings. Age above 65 years (OR = 0.21, 95% CI: 0.05-0.95, p = 0.043), smoking (OR = 14.3, 95% CI: 1.33-10.00, p = 0.027), ASA Class III (OR = 13.33, 95% CI: 2.82-63.14, p = 0.001), longer surgery duration (≥ 2 h) (OR = 4.09, 95% CI: 1.30-12.89, p = 0.016) and blood transfusion (OR = 2.4, 95% CI: 0.7-8.00, p = 0.02) were independently associated with SSIs.

CONCLUSION

About one third of the patients developed SSIs following limb amputation. Odds of SSIs were increased in patients with low age, smoking, high ASA score, prolonged surgery and who received blood transfusion. This highlighted the need to update the management protocol of limb amputation in relation to antibiotics prophylaxis among patients with increased risk of SSIs based on the local antimicrobial surveillance prevalence data.

Synthesizing evidence to guide the design and implementation of effective strategies for discontinuing postoperative antibiotic prophylaxis in surgical settings: an umbrella review post-WHO 2018 recommendations

BACKGROUND

Postoperative antibiotic prophylaxis (PAP) involves using antibiotics after surgery to prevent surgical site infections (SSIs). However, studies have shown that PAP offers no additional benefits compared to discontinuation after surgical incision closure, prompting its de-implementation to prevent unnecessary antibiotic use that may contribute to antibiotic resistance. We conducted this review to synthesize evidence for guiding the design and implementation of effective strategies for discontinuing PAP practice and optimizing antibiotic use in surgical settings.

METHODS

This umbrella review searched for articles from PubMed/MEDLINE and Scopus, focusing on reviews conducted on human subjects on PAP to prevent SSIs, published in English language from 2019 to 5th July 2024. This review followed guidelines from PRISMA-P and PRIOR. The risk of bias (methodological quality) was assessed using AMSTAR-2. The pooled risk ratio (RR) was estimated using a fixed-effects model (Mantel-Haenszel method), while I2 was used to assess the heterogeneity between reviews. This review was registered with PROSPERO (CRD42024566124).

RESULTS

In our umbrella review, we screened 1156 articles, with 28 review articles found eligible for final analysis, involving over 457 primary studies. About 80,483 patients were involved in 9 meta-analysis reviews, which were used to estimate the pooled RR. We found no significant benefits to patients from continuing PAP beyond 24-h post-surgery compared to immediate discontinuation, RR: 1.07 (95% CI: 0.97-1.17, I2: 25%, p-value: 0.22). Strategies such as regularly assessing and refining guidelines to fit specific surgical settings and patients' characteristics, multidisciplinary collaboration, availability of resources needed for best practices, education and training healthcare workers on SSI prevention and antibiotic stewardship, and patient education in SSI prevention and proper antibiotic use were recommended to improve best practices in surgical settings.

CONCLUSIONS

Prolonging antibiotic prophylaxis beyond 24-h post-surgery did not show significant protective benefits against SSIs. Our findings support the 2018 WHO recommendation for the immediate discontinuation of PAP following surgical incision closure in clean and clean-contaminated procedures. Further de-implementation research studies are needed to guide the effective discontinuation of PAP practice.

Evaluating and Improving Surgical Site Infection Prevention: Outcomes of a Two-Cycle Audit and Targeted Interventions in a Low-Resource Setting

Background Surgical site infections (SSIs) are among the most common healthcare-associated infections (HAIs), leading to significant morbidity, mortality, and increased healthcare costs. Despite the existence of international guidelines, adherence to best practices remains inconsistent, particularly in low- and middle-income countries (LMICs).  Objective The objectives of this study are to evaluate compliance with SSI prevention guidelines among medical professionals at Kasr El Ainy Teaching Hospital in Cairo, Egypt, identify gaps in practice and knowledge, and implement targeted interventions to improve outcomes.  Methods A prospective two-cycle audit was conducted over a period of eight months involving 225 elective surgical patients and 229 healthcare providers. Questionnaires were distributed to foundation year (FY) doctors and surgical residents to assess their knowledge and practices related to SSI prevention across the preoperative, intraoperative, and postoperative phases. Patients were followed up to monitor the incidence of SSIs. Interventions implemented included educational sessions, dissemination of posters, and hands-on training to enhance adherence to best practices. Results The initial audit revealed an SSI rate of 12.6% and significant gaps in guidelines knowledge, including improper preoperative hair removal methods and prolonged postoperative antibiotic use (85.7%). Post-intervention, SSI rates decreased to 6.6%, with the questionnaire results showing marked improvements in understanding of key components in SSI prevention: 100% became aware of appropriate intraoperative surgical antibiotic prophylaxis (SAP) (compared to 72.3%), a significant increase (p < 0.05) in the use of clippers (rather than razors) for hair removal (72.1% vs. 33.7%) and intraoperative (rather than preoperative) hair removal (91.8% vs. 10%) (p < 0.05), as well as the need for intraoperative warming practices (87.7% vs. 47.7%) (p < 0.05). Knowledge and adherence to aseptic techniques improved across all staff groups, with awareness increasing from 36.3% to 81.9% among junior doctors, representing a significant improvement (p < 0.05). Conclusion Targeted interventions, including education and practice standardization, significantly reduced SSI rates and improved compliance with prevention guidelines. These findings highlight the value of structured audits and educational programs in enhancing surgical outcomes and reducing the burden of SSI, particularly in resource-limited settings.

Development of machine learning models for the surveillance of colon surgical site infections

BACKGROUND

Conventional surgical site infection (SSI) surveillance is labour-intensive. We aimed to develop machine learning (ML) models for the surveillance of SSIs for colon surgery and to assess whether the ML could improve surveillance process efficiency.

METHODS

This study included cases who underwent colon surgery at a tertiary center between 2013 and 2014. Logistic regression and four ML algorithms including random forest (RF), gradient boosting (GB), and neural networks (NNs) with or without recursive feature elimination (RFE) were first trained on the entire cohort, and then re-trained on cases selected based on a previous rule-based algorithm. We assessed model performance based on the area under the curve (AUC), sensitivity, and positive predictive value (PPV). The estimated proportion of reduction in workload for chart review based on the ML models was evaluated and compared with the conventional method.

RESULTS

At a sensitivity of 95%, the NN with RFE using 29 variables had the best performance with an AUC of 0.963 and PPV of 21.1%. When combining both the rule-based algorithm and ML algorithms, the NN with RFE using 19 variables had a higher PPV (28.9%) than with the ML algorithm alone, which could decrease the number of cases requiring chart review by 83.9% compared with the conventional method.

CONCLUSION

We demonstrated that ML can improve the efficiency of SSI surveillance for colon surgery by decreasing the burden of chart review while providing high sensitivity. In particular, the hybrid approach of ML with a rule-based algorithm showed the best performance in terms of PPV.

Ten-year trends of antibiotic prescribing in surgery departments of two private sector hospitals in Central India: a prospective observational study

BACKGROUND

Inappropriate antibiotic use contributes to the global rise of antibiotic resistance, prominently in low- and middle-income countries, including India. Despite the considerable risk of surgical site infections, there is a lack of antibiotic prescribing guidelines and long-term studies about antibiotic prescribing in surgery departments in India. Therefore, this study aimed to analyse 10 years' antibiotic prescribing trends at surgery departments in two tertiary-care hospitals in Central India.

METHODS

Data was prospectively collected from 2008 to 2017 for surgery inpatients in the teaching (TH-15,016) and the non-teaching hospital (NTH-14,499). Antibiotics were classified based on the World Health Organization (WHO) Access Watch Reserve system and analysed against the diagnoses and adherence to the National List of Essential Medicines India (NLEMI) and the WHO Model List of Essential Medicines (WHOMLEM). Total antibiotic use was calculated by DDD/1000 patient days. Time trends of antibiotic prescribing were analysed by polynomial and linear regressions.

RESULTS

The most common indications for surgery were inguinal hernia (TH-12%) and calculus of the kidney and ureter (NTH-13%). The most prescribed antibiotics were fluoroquinolones (TH-20%) and 3rd generation cephalosporins (NTH-41%), and as antibiotic prophylaxis, norfloxacin (TH-19%) and ceftriaxone (NTH-24%). Access antibiotics were mostly prescribed (57%) in the TH and Watch antibiotics (66%) in the NTH. Culture and susceptibility tests were seldom done (TH-2%; NTH-1%). Adherence to the NLEMI (TH-80%; NTH-69%) was higher than adherence to the WHOMLEM (TH-77%; NTH-66%). Mean DDD/1000 patient days was two times higher in the NTH than in the TH (185 vs 90). Overall antibiotic prescribing significantly increased in the TH (β1 =13.7) until 2012, and in the NTH (β2 =0.96) until 2014, and after that decreased (TH, β2= -0.01; NTH, β3= -0.0005). The proportion of Watch antibiotic use significantly increased in both hospitals (TH, β=0.16; NTH, β=0.96).

CONCLUSION

Total antibiotic use decreased in the last three (NTH) and five years (TH), whereas consumption of Watch antibiotics increased over 10 years in both hospitals. The choice of perioperative antibiotic prophylaxis was often inappropriate and antibiotic prescribing was mostly empirical. The results of this study confirmed the need for antibiotic prescribing guidelines and implementation of antimicrobial stewardship programs.

Optimizing the Relationship Between Perioperative Personnel and Infection Preventionists to Reduce Surgical Site Infections

Prevention of surgical site infections (SSIs) is a critical aspect of ensuring positive patient outcomes. One of the challenges of SSI prevention is the communication barrier between perioperative staff members and infection preventionists (IPs), which may lead to frontline staff members who are primarily responsible for infection prevention being unaware of pertinent hospital SSI data. To overcome this challenge, IPs and perioperative staff members should develop a partnership that facilitates the sharing of feedback on SSI case review data and effective key performance indicators. A partnership also can help engage perioperative staff members in quality improvement efforts and increase collaboration with IPs. Perioperative leaders should identify effective methods to improve data transparency, SSI case reviews, audit and feedback programs, and education for perioperative team members. A strong perioperative-IP partnership and increased sharing of data in accessible formats may improve engagement and interest in SSI prevention.

Laminar airflow ventilation systems in orthopaedic operating room do not prevent surgical site infections: a systematic review and meta-analysis

BACKGROUND

Laminar airflow (LAF) technologies minimize infectious microorganisms to enhance air quality and surgical site infections (SSIs). LAF lowers SSIs in some clinical studies but not others. This study analyzes laminar airflow ventilation's capacity to reduce orthopaedic surgery-related SSIs.

METHODS

The PRISMA-compliant keywords were utilized to conduct a search for pertinent articles in various databases including PubMed, MEDLINE, CENTRAL, Web of Sciences, and the Cochrane databases. Observational studies, including retrospective, prospective, and cohort designs, satisfy the PICOS criteria for research methodology. The assessment of quality was conducted utilizing the Robvis software, while the meta-analysis was performed using the RevMan application. The study's results were assessed based on effect sizes of odds ratio (OR) and risk ratio (RR).

RESULTS

From 2000 to 2022, 10 randomized controlled clinical trials with 10,06,587 orthopaedic surgery patients met the inclusion criteria. The primary outcomes were: (1) Risk of SSI, (2) Bacterial count in sampled air and (3) Reduction in SSIs. The overall pooled OR of all included studies was 1.70 (95% CI 1.10-2.64), and the overall pooled RR was 1.27 (95% CI 1.02-1.59) with p < 0.05. LAF is ineffective at preventing SSIs in orthopaedic procedures due to its high-risk ratio and odds ratio.

CONCLUSIONS

The present meta-analysis has determined that the implementation of LAF systems does not result in a significant reduction in the incidence of surgical site infections (SSIs), bacterial count in the air, or SSIs occurrence in orthopaedic operating rooms. Consequently, the installation of said equipment in operating rooms has been found to be both expensive and inefficient.

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.

Antibiotic Utilization Patterns for Different Wound Types among Surgical Patients: Findings and Implications

Antimicrobial prophylaxis is effective in reducing the rate of surgical site infections (SSIs) post-operatively. However, there are concerns with the extent of prophylaxis post-operatively, especially in low- and middle-income countries (LMICs). This increases antimicrobial resistance (AMR), which is a key issue in Pakistan. Consequently, we conducted an observational cross-sectional study on 583 patients undergoing surgery at a leading teaching hospital in Pakistan with respect to the choice, time and duration of antimicrobials to prevent SSIs. The identified variables included post-operative prophylactic antimicrobials given to all patients for all surgical procedures. In addition, cephalosporins were frequently used for all surgical procedures, and among these, the use of third-generation cephalosporins was common. The duration of post-operative prophylaxis was 3-4 days, appreciably longer than the suggestions of the guidelines, with most patients prescribed antimicrobials until discharge. The inappropriate choice of antimicrobials combined with prolonged post-operative antibiotic administration need to be addressed. This includes appropriate interventions, such as antimicrobial stewardship programs, which have been successful in other LMICs to improve antibiotic utilization associated with SSIs and to reduce AMR.

An evaluation of the implementation of interventions to reduce postoperative infections and optimise antibiotic use across the surgical pathway in India: a mixed-methods exploratory study protocol

INTRODUCTION

Postoperative infections represent a significant burden of disease, demanding antibiotic prescriptions, and are contributing to antimicrobial resistance. The burden of infection as a surgical complication is greater in low- and middle-income countries (LMICs). We report the protocol of a pilot study for the co-design, implementation and evaluation of two infection prevention and control (IPC) and antimicrobial stewardship (AMS) interventions across the surgical pathway in a teaching hospital in India.

METHODS AND ANALYSIS

The two interventions developed following in-depth qualitative enquiry are (i) surveillance and feedback of postoperative infections to optimise the use of antibiotics in two surgical departments (gastrointestinal and cardiovascular and thoracic surgery) and (ii) raising awareness amongst patients, carers and members of public about IPC and AMS. We will conduct a prospective study, formatively evaluating the implementation process of delivering the two co-designed interventions using implementation science frameworks. The study will systematically assess the context of intervention delivery, so that implementation support for the interventions may be adapted to the needs of stakeholders throughout the study. Analysis of implementation logs and interviews with stakeholders upon completion of the implementation period, will offer insights into the perceived acceptability, appropriateness, feasibility and sustainability of the interventions and their implementation support. Implementation costs will be captured descriptively. Feasibility of clinical data collection to investigate effectiveness of interventions will also be assessed for a future larger study. Thematic framework analysis and descriptive statistics will be used to report the qualitative and quantitative data, respectively.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The paired interventions have been co-designed from their inception with involvement of stakeholders at different stages in the surgical pathway. • Simultaneous evaluation of implementation and clinical outcomes will inform the development of a future larger study to enable/assess the scalability of interventions • The study offers a novel combination of implementation theory-informed, stakeholder-driven and clinically relevant evaluation, carried out in the context of a middle-income country hospital. • The project may not be applicable to every low-resource setting and surgical context due to differences in healthcare systems and cultures. However, the application of implementation science concepts may facilitate transferability and adaptation to other settings.

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications

Background

Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.

Methods

A retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.

Results

Of the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).

Conclusions

SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

Scaling up of safety and quality improvement interventions in perioperative care: a systematic scoping review of implementation strategies and effectiveness

BACKGROUND

Globally, 5 billion people lack access to safe surgical care with more deaths due to lack of quality care rather than lack of access. While many proven quality improvement (QI) interventions exist in high-income countries, implementing them in low/middle-income countries (LMICs) faces further challenges. Currently, theory-driven, systematically articulated knowledge of the factors that support successful scale-up of QI in perioperative care in these settings is lacking. We aimed to identify all perioperative safety and QI interventions applied at scale in LMICs and evaluate their implementation mechanisms using implementation theory.

METHODS

Systematic scoping review of perioperative QI interventions in LMICs from 1960 to 2020. Studies were identified through Medline, EMBASE and Google Scholar. Data were extracted in two phases: (1) abstract review to identify the range of QI interventions; (2) studies describing scale-up (three or more sites), had full texts retrieved and analysed for; implementation strategies and scale-up frameworks used; and implementation outcomes reported.

RESULTS

We screened 45 128 articles, identifying 137 studies describing perioperative QI interventions across 47 countries. Only 31 of 137 (23%) articles reported scale-up with the most common intervention being the WHO Surgical Safety Checklist. The most common implementation strategies were training and educating stakeholders, developing stakeholder relationships, and using evaluative and iterative strategies. Reporting of implementation mechanisms was generally poor; and although the components of scale-up frameworks were reported, relevant frameworks were rarely referenced.

CONCLUSION

Many studies report implementation of QI interventions, but few report successful scale-up from single to multiple-site implementation. Greater use of implementation science methodology may help determine what works, where and why, thereby aiding more widespread scale-up and dissemination of perioperative QI interventions.

Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital

BACKGROUND

Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures.

AIM

We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital.

METHODS

We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners.

FINDINGS

A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease.

CONCLUSIONS

With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.