The impact of surgical site infection on hospitalisation, treatment costs, and health-related quality of life after vascular surgery

Usability and outcomes of self-monitored surgical wound healing using a smartphone-based application by patients following neurosurgery

BACKGROUND

The Radboudumc developed a smartphone application (WondGezond) to collect surgical wound-healing information provided by the patient.

AIM

To evaluate usability and outcomes to assess its potential for early surgical site infection (SSI) detection.

METHODS

Patients surgically treated for degenerative spinal disorders or carpal tunnel syndrome between August 2020 and February 2023 were enrolled one day post surgery and asked to download the app via a quick-response (QR) code. Participants uploaded a photo and answered four questions about their wound daily, for 14 days. Afterwards, participants indicated whether they received treatment for a suspected SSI (participant-reported outcome). Two neurosurgeons independently assessed photos and questionnaire answers for suspected SSIs (physician-assessed outcome). The association between both outcomes was determined by calculating sensitivity, specificity, and positive and negative predictive value (PPV/NPV).

FINDINGS

After 2009 surgeries, 1695 QR-codes were distributed and 412 (21%) were activated. In all, 232 (56%) participants completed the 14-day period of whom 22 (10%) reported SSI treatment. Physician assessment identified 15 (7%) SSIs. Concordance was reached in 88% of cases. Among 27 discordant cases were 17 false-positives and 10 false-negatives, resulting in low sensitivity (33%) and PPV (23%), but high NPV (95%).

CONCLUSION

WondGezond provides clinicians with information regarding wound healing and SSIs to follow-up on patients at risk, while possibly also reducing antibiotic (over)treatment and unnecessary visits for patients without issues in wound healing. However, the low participation and false-positive results render the app in its current form unsuitable for surveillance purposes. Further validation of WondGezond is required.

The Specialist Treatment of Inpatients: Caring for Diabetes in Surgery (STOIC-D Surgery) Trial: A Randomized Controlled Trial of Early Intervention With an Electronic Specialist-Led Model of Diabetes Care

OBJECTIVE

To investigate the effect of early intervention with an electronic specialist-led "proactive" model of care on glycemic and clinical outcomes.

RESEARCH DESIGN AND METHODS

The Specialist Treatment of Inpatients: Caring for Diabetes in Surgery (STOIC-D Surgery) randomized controlled trial was performed at the Royal Melbourne Hospital. Eligible participants were adults admitted to a surgical ward during the study with either known diabetes or newly detected hyperglycemia (at least one random blood glucose result ≥11.1 mmol/L). Participants were randomized 1:1 to standard diabetes care or the intervention consisting of an early consult by a specialist inpatient diabetes team using electronic tools for patient identification, communication of recommendations, and therapy intensification. The primary outcome was median patient-day mean glucose (PDMG). The key secondary outcome was incidence of health care-associated infection (HAI).

RESULTS

Between 12 February 2021 and 17 December 2021, 1,371 admissions met inclusion criteria, with 680 assigned to early intervention and 691 to standard diabetes care. Baseline characteristics were similar between groups. The early intervention group achieved a lower median PDMG of 8.2 mmol/L (interquartile range [IQR] 6.9-10.0 mmol/L) compared with 8.6 mmol/L (IQR 7.2-10.3 mmol/L) in the control group for an estimated difference of -0.3 mmol/L (95% CI -0.4 to -0.2 mmol/L, P < 0.0001). The incidence of HAI was lower in the intervention group (77 [11%] vs. 110 [16%]), for an absolute risk difference of -4.6% (95% CI -8.2 to -1.0, P = 0.016).

CONCLUSIONS

In surgical inpatients, early diabetes management intervention with an electronic specialist-led diabetes model of care reduces glucose and HAI.

Evaluating antibiotic prophylaxis adherence: Implications for surgical site infections and wound care management

AIM

This study aimed to evaluate adherence to an antibiotic prophylaxis protocol and its impact on incidence of surgical site infection (SSI).

MATERIALS AND METHOD

A prospective observational cohort study was conducted at a teaching hospital in São Paulo, Brazil, from September to November 2015. The population were adults who underwent surgery with surgical antibiotic prophylaxis. The main outcomes measured were incidence of SSI at 30-days postoperatively, protocol adherence and surgical wound complications. STROBE guidelines were followed.

RESULTS

Among the 527 participants recruited, a 30-day follow-up was completed by 78.7 % (n = 415). Within this cohort, 57.6 % were females aged over 60 years (36.4 %). The incidence of SSI stood at 9.4 % (n = 39), with dehiscence being the most prevalent complication at 64.1 % (n = 25), followed by increased exudate at 51.3 % (n = 20). Notably, full adherence to the antibiotic prophylaxis protocol was low at 1.7 % (n = 7). The study observed a 60 % increased risk of SSI for every protocol mistake made. Alarmingly, 17.8 % (n = 74) of participants received antibiotic treatment exceeding the stipulated protocol duration. The overall mortality rate stood at 13.5 % (n = 56), with 1 % (n = 4) of these deaths attributed to SSI.

CONCLUSION

There is a pressing global necessity to enhance antibiotic management, as underscored by this study's revelation of low adherence to the antibiotic prophylaxis protocol. This lack of adherence correlated with a notable incidence of SSI and subsequent wound complications. Nearly 20 % of participants received prolonged antibiotic treatment. Adhering strictly to the protocol could substantially impact SSI-related outcomes and enhance global antibiotic management.

A comprehensive qualitative investigation of the factors that affect surgical site infection prevention in cardiac surgery in England using observations and interviews

BACKGROUND

Interview and questionnaire studies have identified barriers and challenges to preventing surgical site infections (SSIs) by focusing on compliance with recommendations and care bundles using interviews, questionnaires and expert panels. This study proposes a more comprehensive investigation by using observations of clinical practice plus interviews which will enable a wider focus.

AIM

To comprehensively identify the factors which affect SSI prevention using cardiac surgery as an exemplar.

METHODS

The study consisted of 130 h of observed clinical practice followed by individual semi-structured interviews with 16 surgeons, anaesthetists, theatre staff, and nurses at four cardiac centres in England. Data were analysed thematically.

FINDINGS

The factors were complex and existed at the level of the intervention, the individual, the team, the organization, and even the wider society. Factors included: the attributes of the intervention; the relationship between evidence, personal beliefs, and perceived risk; power and hierarchy; leadership and culture; resources; infrastructure; supplies; organization and planning; patient engagement and power; hospital administration; workforce shortages; COVID-19 pandemic; 'Brexit'; and the war in Ukraine.

CONCLUSION

This is one of the first studies to provide a comprehensive overview of the factors affecting SSI prevention. The factors are complex and need to be fully understood when trying to reduce SSIs. A strong evidence base was insufficient to ensure implementation of an intervention.

Surgical site infection rates in open versus endoscopic lumbar spinal decompression surgery: A retrospective cohort study

Background

Lumbar decompression is a commonly performed procedure for the operative management of several degenerative lumbar spinal pathologies. Although open approaches are considered the traditional method, endoscopic techniques represent a relatively novel, less-invasive option to achieve neural element decompression. Here within, we examine if the use of endoscopic techniques decreases the risk of post operative infections.

Methods

We performed a retrospective cohort analysis to directly compare patients who underwent either open or endoscopic lumbar decompression at a single institution. Rates of postoperative outcomes such as surgical site infection, hospital length of stay, estimated blood loss, and others were compared between the two treatment groups. A multivariate logistic regression model was constructed using patient comorbidities and procedural characteristics to identify the risk factors for surgical site infection.

Results

150 patients were identified as undergoing lumbar spine decompression surgeries that met inclusion criteria for the study, of whom 108 (72.0%) underwent open and 61 (28.0%) underwent endoscopic approaches. Unpaired analysis revealed positive associations between operative duration, estimated blood loss, drain placement rates. Multivariate logistic regression did not reveal an association between surgical approach (open versus endoscopic) and the development of surgical site infection.

Conclusions

Surgical site infections following endoscopic lumbar spine decompression are relatively uncommon, however, after adjusting for baseline differences between patient populations, surgical approach does not independently predict the development of postoperative infection.

Cohort study to characterise surgical site infections after open surgery in the UK's National Health Service

OBJECTIVE

To characterise surgical site infections (SSIs) after open surgery in the UK's National Health Service.

DESIGN

Retrospective cohort analysis of electronic records of patients from Clinical Practice Research Datalink, linked with Hospital Episode Statistics' secondary care datasets.

SETTING

Clinical practice in the community and secondary care.

PARTICIPANTS

Cohort of 50 000 adult patients who underwent open surgery between 2017 and 2022.

OUTCOME MEASURES

Incidence of SSI, clinical outcomes, patterns of care and costs of wound management.

RESULTS

11% (5281/50 000) of patients developed an SSI a mean of 18.4±14.7 days after their surgical procedure, of which 15% (806/5281) were inpatients and 85% (4475/5281) were in the community after hospital discharge. The incidence of SSI varied according to anatomical site of surgery. The incidence also varied according to a patient's risk and whether they underwent an emergency procedure. SSI onset reduced the 6 months healing rate by a mean of 3 percentage points and increased time to wound healing by a mean of 15 days per wound. SSIs were predominantly managed in the community by practice and district nurses and 16% (850/5281) of all patients were readmitted into hospital. The total health service cost of surgical wound management following SSI onset was a mean of £3537 per wound ranging from £2542 for a low-risk patient who underwent an elective procedure to £4855 for a high-risk patient who underwent an emergency procedure.

CONCLUSIONS

This study provides important insights into several aspects of SSI management in clinical practice in the UK that have been difficult to ascertain from surveillance data. Surgeons are unlikely to be fully aware of the true incidence of SSI and how they are managed once patients are discharged from hospital. Current SSI surveillance services appear to be under-reporting the actual incidence.

Comparing the Efficacy of Povidone-Iodine Versus Normal Saline in Laparotomy Wound Irrigation to Prevent Surgical Site Infections: A Meta-Analysis

Surgical site infections (SSIs) are a known complication of laparotomies and intra-abdominal surgical operations leading to remarkable consequences on mortality, morbidity, and expenses. The study aims to assess the efficiency of irrigating laparotomy incision sites with povidone-iodine (PVI) or normal saline (NS) in diminishing the rate of SSIs in patients undergoing gastrointestinal operations for varying indications. Randomized controlled trials (RCTs) highlighting the contribution of laparotomy wound irrigation with PVI in opposition to NS in patients planned for laparotomy addressing numerous gastrointestinal issues, and their role in reducing SSI risk were obtained via searching of standard electronic medical databases. The analysis was conducted by utilizing meta-analysis principles procured by statistical software RevMan version 5.3 (Cochrane Collaboration, London, UK). The yield of medical databases exploration and inspection was 13 RCTs on 3816 patients who underwent laparotomy for different gastrointestinal operations. There were 1900 patients in the PVI group whereas 1916 patients received NS wound irrigations preceding closure of the laparotomy skin wound. In the random effects model analysis, the use of PVI for laparotomy wound irrigation was associated with the reduced risk (odds ratio = 0.54, 95% CI (0.30, 0.98), Z = 2.04, P = 0.04) of SSIs. Nevertheless, there was outstanding heterogeneity (Tau2 = 70; chi2 = 40.19, df = 12; P = 0.0001; I2 = 70%) among the included studies. According to the comprehensive analysis outcomes, it has been clinically proven that the use of PVI is highly effective in reducing the occurrence of SSIs, as well as their subsequent implications.

Are There Racial Differences in the Rate of Surgical Site Infection Based on Surgical Subspecialty?

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery: A qualitative study

BACKGROUND

Closed-incision negative pressure therapy may lower the risk of surgical site infections in patients after peripheral arterial surgery.

AIM

To explore patient experience of negative pressure therapy applied to groin incisions after discharge following peripheral arterial surgery, and to study their perception and attitudes toward the self-care information sheet they received at the vascular department.

METHODS

A qualitative study underpinned by Gadamer's philosophical hermeneutics was conducted semi-structured interviews by telephone around day seven after therapy ended with ten participants. All had received self-care information sheet at the discharge and been home with closed-incision negative pressure therapy for 3-6 days. The participants had open peripheral arterial surgery in the groin in form of femoral thromboendarterectomy. Kvale and Brinkmann's research guided the data collection, analysis, and interpretation.

FINDINGS

Patients found themselves coping with an unfamiliar situation after peripheral arterial surgery and the need arose to conceal the pump and tubing that were part of their incision treatment to protect their self-image. Their treatment became a constant companion, with some patients viewing the equipment as an extension of their bodies and others feeling its impact on activities of daily living. Patients perceived the treatment as providing reassurance, albeit with constraints, leading to feelings of manageability and an increasing sense of control. They viewed the written information as informative but with room for improvement.

CONCLUSIONS

Patient experiences of closed-incision negative pressure therapy on groin incisions after discharge following peripheral arterial surgery showed that they perceived it as safe and manageable. Patients need support, however, in learning how to hide the treatment and to expand their own involvement and improve self-care. The study found that patient involvement and individually tailored information is essential to facilitating a healthy transition from hospital to self-care at home and that written information must be improved further.

The incidence and cost implications of surgical site infection following lymph node surgery for skin malignancy

BACKGROUND

Lymph node surgery is commonly performed in the staging and treatment of metastatic skin cancer. Previous studies have demonstrated sentinel lymph node biopsy (SLNB) and, particularly, lymph node dissection (LND) to be plagued by high rates of wound complications, including surgical site infection (SSI) and seroma formation. This study evaluated the incidence of wound complications following lymph node surgery and provided the first published cost estimate of SSI associated with lymph node surgery in the UK.

PATIENTS AND METHODS

A retrospective cohort study of 169 patients with a histological diagnosis of primary skin malignancy who underwent SLNB or LND of the axilla and/or inguinal region at a single tertiary centre over a 2 year period was conducted. Demographic, patient risk factor, and operation characteristics data were collected and effect on SSI and seroma formation was analysed. Cost-per-infection was estimated using National Health Service (NHS) reference and antibiotic costs.

RESULTS

A total of 146 patients underwent SLNB with a SSI rate of 4.1% and a seroma incidence of 12.3%. Twenty-three patients underwent LND with a SSI rate of 39.1% and a seroma incidence of 39.1%. Seroma formation was strongly associated with the development of SSI in both the SLNB (odds ratio (OR) = 18.0, p < 0.001) and LND (OR = 21.0, p = 0.007) group. The median additional cost of care events and treatment of SSI in the SLNB and LND groups was £199.46 and £5187.04, respectively.

CONCLUSION

SSI remains a troublesome and costly event following SLNB and LND. Further research into perioperative care protocols and methods of reducing lymph node surgery morbidity is required and could result in significant cost savings to the NHS.

PRESS survey: PREvention of surgical site infection-a global pan-specialty survey of practice protocol

Background

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices.

Methods

This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses.

Discussion

Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Experimental and clinical evidence for DACC-coated dressings: an update

OBJECTIVE

To update the evidence in relation to the use of dialkylcarbamoyl chloride (DACC)-coated wound dressings in the prevention, treatment and management of wounds.

METHOD

PubMed and PubMed Central databases were searched to identify articles published since 2020 describing the experimental and clinical evidence for DACC-coated dressings, and their antimicrobial effect, as well as their impact on the prevention and treatment of infected wounds. The identified articles were then narratively reviewed.

RESULTS

The search yielded 113 articles (plus references from ad hoc sources), of which nine met the inclusion criteria. Of the nine included studies, five related to clinical aspects and four were laboratory studies.

CONCLUSION

A number of new studies have provided further evidence for the mode of action of the antimicrobial effect of DACC-coated dressings and its wide spectrum effect (including World Health Organization-prioritised microorganisms). Additional clinical studies have provided evidence of new applications, such as in treating wounds in paediatric patients, and extended the evidence relating to their use in treating surgical site infections. Evidence also shows that DACC-coated wound dressings can aid in the binding of biofilms, and how this technology can align and support antimicrobial stewardship in the prevention of antimicrobial resistance.

Clinical prediction models and risk tools for early detection of patients at risk of surgical site infection and surgical wound dehiscence: a scoping review

OBJECTIVE

Despite advances in surgical techniques, intraoperative practice and a plethora of advanced wound therapies, surgical wound complications (SWCs), such as surgical site infection (SSI) and surgical wound dehiscence (SWD), continue to pose a considerable burden to the patient and healthcare setting. Predicting those patients at risk of a SWC may give patients and healthcare providers the opportunity to implement a tailored prevention plan or potentially ameliorate known risk factors to improve patient postoperative outcomes.

METHOD

A scoping review of the literature for studies which reported predictive power and internal/external validity of risk tools for clinical use in predicting patients at risk of SWCs after surgery was conducted. An electronic search of three databases and two registries was carried out with date restrictions. The search terms included 'prediction surgical site infection' and 'prediction surgical wound dehiscence'.

RESULTS

A total of 73 records were identified from the database search, of which six studies met the inclusion criteria. Of these, the majority of validated risk tools were predominantly within the cardiothoracic domain, and targeted morbidity and mortality outcomes. There were four risk tools specifically targeting SWCs following surgery.

CONCLUSION

The findings of this review have highlighted an absence of well-developed risk tools specifically for SSI and/or SWD in most surgical populations. This review suggests that further research is required for the development and clinical implementation of rigorously validated and fit-for-purpose risk tools for predicting patients at risk of SWCs following surgery. The ability to predict such patients enables the implementation of preventive strategies, such as the use of prophylactic antibiotics, delayed timing of surgery, or advanced wound therapies following a procedure.

Impact of surgical-site infection on health utility values: a meta-analysis

BACKGROUND

Surgical-site infections (SSIs) are recognized as negatively affecting patient quality of life. No meta-analysis of SSI utility values is available in the literature to inform estimates of this burden and investment decisions in prevention.

METHODS

A systematic search of PubMed, MEDLINE, CINAHL, and the National Health Service Economic Evaluation Database was performed in April 2022 in accordance with PROSPERO registration CRD 42021262633. Studies were included where quality-of-life data were gathered from adults undergoing surgery, and such data were presented for those with and without an SSI at similar time points. Two researchers undertook data extraction and quality appraisal independently, with a third as arbiter. Utility values were converted to EuroQol 5D (EQ-5D™) estimates. Meta-analyses were conducted using a random-effects model across all relevant studies, with subgroup analyses on type and timing of the SSI.

RESULTS

In total, 15 studies with 2817 patients met the inclusion criteria. Six studies across seven time points were used in the meta-analysis. The pooled mean difference in EQ-5D™ utility in all studies combined was -0.08 (95 per cent c.i. -0.11 to -0.05; prediction interval -0.16 to -0.01; I2 = 40 per cent). The mean difference in EQ-5D™ utility associated with deep SSI was -0.10 (95 per cent c.i. -0.14 to -0.06; I2 = 0 per cent) and the mean difference in EQ-5D™ utility persisted over time.

CONCLUSION

The present study provides the first synthesized estimate of SSI burden over the short and long term. EQ-5D™ utility estimates for a range of SSIs are essential for infection prevention planning and future economic modelling.

Severe local wound infections after vascular exposure in the groin and other body areas: Prevention, treatment and prognosis

Severe surgical site infections (SSIs) are a frequent nosocomial complication after vascular interventions, an important cause of postoperative morbidity, and a substantial burden to the health care system. Patients undergoing arterial interventions are at elevated risk of SSIs, possibly because of the presence of several risk factors in this patient population. In this review, we examined the available clinical evidence for the prevention, treatment, and prognostication of postoperative severe SSIs after vascular exposure in the groin and other body areas. Results from studies evaluating preoperative, intraoperative, and postoperative preventive strategies and several treatment options are reviewed. In addition, risk factors for surgical wound infections are analyzed in detail and related evidence from the literature is highlighted. Although several measures have been implemented over the time to prevent them, SSIs continue to pose a substantial health care and socioeconomic challenge. Therefore, strategies to decrease the risk and improve the treatment of SSIs for the high-risk vascular patient population should be the focus of continuing improvement and critical review. This review aimed at identifying and reviewing the current evidence for preventing, treating, and performing stratification according to the prognosis of postoperative severe SSIs after vascular exposure in the groin and other body areas.

The burden of surgical site infections in Australia: A cost-of-illness study

OBJECTIVE

To estimate the cost of surgical site infections in Australian public hospitals in 2018-19, to demonstrate the economic burden of hospital-associated infection in a well-resourced health system.

METHODS

A cost-of-illness analysis was conducted over a 1-year time horizon based on data from published literature extrapolated using simulation techniques. The direct and indirect costs of SSI were estimated for Australia and each of its states and territories.

RESULTS

An estimated 16,541 cases of SSI occurred in Australian public hospitals in 2018-19, resulting in a total direct cost of A$323.5 million. The average cost per case was A$18,814, which was 2.5 times the average per capita spending on health. The indirect costs of absenteeism and premature death were valued at A$23.0 million and A$2 948.1 million per annum, respectively.

CONCLUSION

SSI is a significant but preventable cost with most of the financial burden coming from premature deaths but underreporting means our costs are likely underestimated.

Cost-Utility Analysis of the Caresyntax Platform to Identify Patients at Risk of Surgical Site Infection Undergoing Colorectal Surgery

BACKGROUND

Surgical site infections (SSIs) account for up to 18% of all healthcare-associated infections (HAIs). The Caresyntax data-driven surgery platform incorporates the most common risk factors for SSI, to identify high-risk surgical patients before they leave the operating theatre and treat them prophylactically with negative pressure wound therapy (NPWT). An economic analysis was performed to assess the costs and health outcomes associated with introduction of the technology in the English healthcare setting.

METHODS

A hybrid decision tree/Markov model was developed to reflect the treatment pathways that patients undergoing colorectal surgery would typically follow, both over the short term (30-day hospital setting) and long term (lifetime). The analysis considered implementation of Caresyntax's platform-based SSI predictive algorithm in the hospital setting, compared with standard of care, from an English National Health Service (NHS) perspective. The base-case analysis presents results in terms of cost per quality-adjusted life-year (QALY) gained, as well as operational impact.

RESULTS

The base-case analysis indicates that the intervention leads to a cost saving of £55.52m across the total NHS colorectal surgery patient population in 1 year. In addition, the intervention has a 98.36% probability of being cost effective over a lifetime horizon. The intervention results in the avoidance of 19,744 SSI events, as well 191,911 excess hospital bed days saved.

CONCLUSION

Caresyntax's platform-based SSI predictive algorithm has the potential to result in cost savings and improved patient quality of life. Additionally, operational gains for the healthcare provider, including reduced infection rates and hospital bed days saved, have been shown through the economic modeling.

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.

The detection and prediction of surgical site infections using multi-modal sensors and machine learning: Results in an animal model

Introduction

Surgical Site Infection (SSI) is a common healthcare-associated infection that imposes a considerable clinical and economic burden on healthcare systems. Advances in wearable sensors and digital technologies have unlocked the potential for the early detection and diagnosis of SSI, which can help reduce this healthcare burden and lower SSI-associated mortality rates.

Methods

In this study, we evaluated the ability of a multi-modal bio-signal system to predict current and developing superficial incisional infection in a porcine model infected with Methicillin Susceptible Staphylococcus Aureus (MSSA) using a bagged, stacked, and balanced ensemble logistic regression machine learning model.

Results

Results demonstrated that the expression levels of individual biomarkers (i.e., peri-wound tissue oxygen saturation, temperature, and bioimpedance) differed between non-infected and infected wounds across the study period, with cross-correlation analysis indicating that a change in bio-signal expression occurred 24 to 31 hours before this change was reflected by clinical wound scoring methods employed by trained veterinarians. Moreover, the multi-modal ensemble model indicated acceptable discriminability to detect the presence of a current superficial incisional SSI (AUC = 0.77), to predict an SSI 24 hours in advance of veterinarian-based SSI diagnosis (AUC = 0.80), and to predict an SSI 48 hours in advance of veterinarian-based SSI diagnosis (AUC = 0.74).

Discussion

In sum, the results of the current study indicate that non-invasive multi-modal sensor and signal analysis systems have the potential to detect and predict superficial incisional SSIs in porcine subjects under experimental conditions.

The diagnostic test accuracy of telemedicine for detection of surgical site infection: A systematic review protocol

Since the COVID-19 pandemic there has been a rapid uptake and utilisation of telemedicine in all aspects of healthcare. This presents a key opportunity in surgical site infection surveillance. Remote follow up methods have been used via telephone, with photographs and questionnaires for post-operative reviews with varying results. This review therefore aims to comprehensively synthesise available evidence for the diagnostic accuracy of all forms of SSI telemedicine monitoring. The protocol has been established as per both PRISMA-P (S1 Table) and the Cochrane handbook for reviews of diagnostic test accuracy. Medline, Embase, CENTRAL and CINAHL will be searched using a complete search strategy developed with librarian input, in addition to google scholar and hand searching. All study designs with patients over 18 and undergone a primarily closed surgical procedure will be eligible. Index tests will include all forms of telemedicine and a subgroup analysis performed for each of these. Comparative tests must include face to face review, and all reference standards will be included again for sub-group analyses. Search results will be screened by two investigators independently with a third providing consensus review on disagreements. Methodological quality will be assessed using the QUADAS-2 tool, first validated by two investigators as per the Cochrane handbook. Exploratory analysis will formulate summary receiver operating characteristic curves and forest plots with estimates of sensitivity and specificity of the included studies. Sources of heterogeneity will be identifying and investigated through further analysis. Potential benefits of telemedicine integration in surgical practice will reduce cost and travel time to patients in addition to avoiding wasted clinic appointments, important considerations in a peri-pandemic era. To avoid missed or further complications, there must be confidence in the ability to diagnose infection. This review will systematically determine whether telemedicine is accurate for surgical site infection diagnosis, which methods are well established and if further research is indicated.

Risk Factors and Consequences of Graft Infection after Femoropopliteal Bypass: A 25-year Experience

INTRODUCTION

In this multi-institutional series, we aimed to determine the incidence, risk factors, and long-term outcomes of graft infection in patients post-femoropopliteal bypass.

METHODS

A multi-institutional database was retrospectively queried for all femoropopliteal bypass procedures from 1995-2020. Cumulative incidence function estimated the long-term rate of bypass graft infection (BGI) and Fine-Gray model was used to determine independent risk factors for BGI to account for death as a competing risk.

RESULTS

Over the 25-year period, 1315 femoral popliteal bypasses were identified with a median follow-up of 2.89 years (IQR 0.75-6.55). BGI was diagnosed in 34 (2.6%) patients. BGI occurred between 9 days and 11.2 years postoperatively, with a median 109 days. Estimated 1- and 5-year incidence of BGI was 2.1% (95% CI, 1.4-3.1%) and 2.8% (95% CI, 1.9-3.9%) respectively. Medical comorbidities, indications for bypass, and popliteal bypass targets (above- vs below-knee) were similar between BGI patients and all patients (p=NS each). Patients with BGI were more frequently complicated by postoperative hematoma (14.7% vs 3.7%), superficial wound infection (38.2% vs 19.2%), lymphocele/lymphorrhea (8.8% vs 2.1%), and 30-day readmission rates (47.1% vs 21.3%) (p<0.05 each). Most commonly isolated pathogens were Staphylococcus aureus (n=19, 55.9%) and polymicrobial cultures (n=5, 14.7%). Reoperation for BGI involved incision and drainage (n=7, 20.6%), graft excision without reconstruction (n=12, 35.3%), graft excision with in-line reconstruction (n=11, 32.4%), and graft excision with extra-anatomic reconstruction (n=2, 5.9%). Nine BGI patients (26.5%) ultimately required major amputation. Prosthetic bypass (subdistribution hazard ratio [SHR] 3.73 [1.64-8.51], p=0.002), postoperative hematoma (SHR 3.44 [1.23-9.61], p=0.018), and 30-day readmission (SHR 2.75 [1.27-5.44], p=0.010) were independently associated with BGI. One-year amputation-free survival was 50% (95% CI, 31.9-65.7%) after BGI.

CONCLUSIONS

BGI is a rare complication of femoral-popliteal bypass with significant morbidity. Graft infection is associated with the use of prosthetic grafts, postoperative hematoma, and unplanned hospital readmission. Mitigation of these risk factors may decrease the risk of this dreaded complication.

Estimated Costs Associated with Surgical Site Infections in Patients Undergoing Cholecystectomy

Among healthcare-associated infections, surgical site infections (SSIs) are the most frequent in Spain. The aim of this work was to estimate the costs of SSIs in patients who underwent a cholecystectomy at the Hospital General Universitario de Alicante (Spain) between 2012-2017. This was a prospective observational cohort study. The Active Epidemiological Surveillance Program at our hospital recorded all the cholecystectomies performed. Risk factors associated with the development of SSIs were determined by multivariate analysis and two homogeneous comparison groups were obtained by using the propensity score. The number of extra days of hospital stay were recorded for patients with an SSI and with the cost per hospitalised day data, the additional cost attributed to SSIs was calculated. A total of 2200 cholecystectomies were considered; 110 patients (5.0%) developed an SSI. The average length of hospital stay was 5.6 days longer among patients with an SSI. The cost per SSI was EUR 1890.60 per patient, with the total cost for this period being EUR 207,961.60. SSIs after cholecystectomy lead to a prolongation of hospital stay and an increase in economic costs. It is essential to implement infection surveillance and control programs to reduce SSIs, improve patient safety, and reduce economic burden.

Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial

OBJECTIVE

To compare the early results of mass and layered closure of upper abdominal transverse incisions.

SUMMARY OF BACKGROUND DATA

Contrary to midline incisions, data on closure of transverse abdominal incisions are lacking.

METHODS

This is the first analysis of a randomized controlled trial primarily designed to compare mass with layered closure of transverse incisions with respect to incisional hernias. Patients undergoing laparotomy through upper abdominal transverse incisions were randomized to either mass or layered closure with continuous sutures. Incisional surgical site infection (incisional-SSI) was the primary end-point. Secondary end-points comprised suture-to-wound length ratio (SWLR), closure duration, and fascial dehiscence (clinicatrials.gov NCT03561727).

RESULTS

A total of 268 patients were randomized to either mass (n=134) or layered (n=134) closure. Incisional-SSIs occurred in 24 (17.9%) and 8 (6.0%) patients after mass and layered closure, respectively (P =0.004), with crude odds ratio (OR) of 0.29 [95% confidence interval (95% CI) 0.13-0.67; P =0.004]. Layered technique was independently associated with fewer incisional-SSIs (OR: 0.29; 95% CI 0.12-0.69; P =0.005). The number needed to treat, absolute, and relative risk reduction for layered technique in reducing incisional-SSIs were 8.4 patients, 11.9%, and 66.5%, respectively. Dehiscence occurred in one (0.8%) patient after layered closure and in two (1.5%) patients after mass closure (P >0.999). Median SWLR were 8.1 and 5.6 (P <0.001) with median closure times of 27.5 and 25.0 minutes (P =0.044) for layered and mass closures, respectively.

CONCLUSIONS

Layered closure of upper abdominal transverse incisions should be preferred due to lower risk of incisional-SSIs and higher SWLR, despite clinically irrelevant longer duration.

Single use negative pressure wound therapy in vascular patients: clinical and economic outcomes

OBJECTIVE

Surgical site complications (SSCs) such as dehiscence and infection are a common issue within vascular surgeries and are a key concern to payers and clinicians. It is estimated that occurrence of complications in vascular surgery can increment length of stay by 9.72 days and costs by £3776 per episode. The objective of this research was to determine the clinical and economic impact of the prophylactic use of single use negative pressure wound therapy (sNWPT) in postoperative femoral endarterectomy incisions within a single centre in the Netherlands.

METHOD

Data were extracted retrospectively from the medical notes of patients consecutively treated for femoral endarterectomy between January 2013 and December 2019 in a single centre in the Netherlands. Since August 2016, patients were treated with the sNPWT device and their data were compared with that of patients treated before the introduction of the device. Data were extracted on SSCs and associated healthcare resource use, with comparisons made between the two patient groups.

RESULTS

The study included a cohort of 108 patients. Data of patients treated by standard care (n=64) showed 32 (50%) patients developed complications. This reduced significantly in patients treated with the sNPWT device (n=44) of whom eight (18.2%) developed a postoperative complication (p=0.0011). Average postoperative costs per patient were €3119 for those in the standard care group and €2630 where the sNPWT device was used.

CONCLUSION

sNPWT provided clinical and economic benefits over standard care in the treatment of femoral endarterectomy patients, significantly reducing rate of complication and their associated costs.

The impact of surgical site infection on hospitalisation, treatment costs, and health-related quality of life after vascular surgery

Surgical site infections (SSI) substantially increase costs for healthcare providers because of additional treatments and extended patient recovery. The objective of this study was to assess the cost and health-related quality of life impact of SSI, from the perspective of a large teaching hospital in England. Data were available for 144 participants undergoing clean or clean-contaminated vascular surgery. SSI development, length of hospital stay, readmission, and antibiotic use were recorded over a 30-day period. Patient-reported EQ-5D scores were obtained at baseline, day 7 and day 30. Linear regressions were used to control for confounding variables. A mean SSI-associated length of stay of 9.72 days resulted in an additional cost of £3776 per patient (including a mean antibiotic cost of £532). Adjusting for age, smoking status, and procedure type, SSI was associated with a 92% increase in length of stay (P < 0.001). The adjusted episode cost was £3040. SSI reduced patient utility between baseline and day 30 by 0.156 (P = 0.236). Readmission rates were higher with SSI (P = 0.017), and the rate to return to work within 90 days was lower. Therefore, strategies to reduce the risk of surgical site infection for high-risk vascular patients should be investigated.