Reducing surgical site infection in arthroplasty of the lower limb: A multi-disciplinary approach

Real-World Evidence of the Impact of a Novel Surgical Irrigant on Surgical Site Infections in Primary Total Knee Arthroplasty Performed at an Ambulatory Surgery Center

Background: Total knee arthroplasty (TKA) is one of the most common inpatient and outpatient surgical procedures performed in the United States and is predicted to increase 401% by 2040. Surgical site infections (SSIs) at an incidence rate of approximately 2% are costly post-operative complications in TKA. Intra-operative surgical irrigants are used to decrease contaminating microbial bioburden within the surgical site to prevent SSI. The primary objective of this retrospective study was to evaluate the impact of a novel surgical irrigant called XPERIENCE® Advanced Surgical Irrigation (XP; Next Science, Jacksonville, FL) on SSI incidence in primary TKA performed at an ambulatory surgery center (ASC). Patients and Methods: Primary TKAs were performed at a free-standing ASC. The novel surgical irrigant was used intra-operatively to rinse away debris and micro-organisms from the surgical site. Retrospective data collation included SSI rates, complication rates, and re-admissions due to SSI within 90 days of index surgery. Results: Among the 524 primary TKA surgeries, one peri-prosthetic joint infection (PJI) was diagnosed within 90 days of index surgery and one superficial incisional SSI was diagnosed within 30 days of index surgery. The PJI was attributed to an exogenously acquired upper respiratory tract infection rather than due to the failure of intra-operative regimes. The 0.19% PJI incidence rate indicated significant efficacy of XP in decreasing PJI. An overall complication rate of 7.82% was noted with none of the complications associated with usage of the novel surgical irrigant. Conclusions: XPERIENCE is a promising intra-operative antimicrobial irrigant that can be easily incorporated into a broader infection prevention strategy.

Incidence and impact of surgical site complications on length of stay and cost of care for patients undergoing open procedures

Background

Surgical site complications (SSCs) can have serious and life-threatening consequences for patients; however, their frequency and impact on healthcare utilization across surgical procedures, particularly for non-infectious SSCs, are unknown. This study examined incidence of overall SSCs and non-infectious SSCs in patients undergoing open surgical procedures in the United States and their effect on length of stay (LOS) and costs.

Methods

This retrospective study utilizing 2019-2020 data from Medicare and Premier Health Database identified patients with SSCs during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSCs. Mean LOS and costs attributable to SSCs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSC on LOS and costs across healthcare settings.

Results

Overall and non-infectious SSC rates were 7.3 % and 5.3 % respectively for 2,696,986 Medicare and 6.7 % and 5.0 % for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSC were 7.8 days and $15,339 for Medicare patients and 6.2 days and $17,196 for Premier patients. Incremental LOS and cost attributable to non-infectious SSCs were 6.5 days and $12,703 and 5.2 days and $14,477 for Medicare and Premier patients respectively.

Conclusions

This study utilizing two large national databases provides strong evidence that SSCs, particularly non-infectious SSCs, are not uncommon in open surgeries and result in increased healthcare utilization and costs. These findings demonstrate the need for increased adoption of evidence-based interventions that can reduce SSC rates.

Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures

Background

Surgical site infections (SSIs) are associated with increased morbidity and mortality; however, current SSI rates across open procedures and their effect on healthcare delivery are unknown. The objective of this study was to examine incidence of SSIs for open surgical procedures in the United States and impact on length of stay (LOS) and costs.

Methods

This retrospective study utilizing 2019-2020 data from Medicare and Premier identified patients with SSIs occurring during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSIs. Mean LOS and costs attributable to SSIs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSI on LOS and costs across healthcare settings.

Results

SSI rates were 2.0% for 2,696,986 Medicare and 1.8% for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSI, including index admission, readmissions, and outpatient visits were 9.3 days and $18,626 for Medicare patients and 7.8 days and $20,979 for Premier patients. SSI rates were higher for urgent/emergency surgeries compared to overall SSI rates. Although less common that superficial SSIs, deep SSIs resulted in higher incremental LOS and index costs for the index admission and for SSI-related readmissions.

Conclusions

This study of SSIs utilizing two large national databases provides robust data and analytics reinforcing and bolstering current evidence that SSIs occur infrequently but are detrimental to patients in terms of increased LOS and care costs.

Preoperative bacteriuria positivity on urinalysis increases wound complications in primary total hip arthroplasty regardless of the urine culture result

BACKGROUND

Current evidence does not recommend screening urine culture and curing asymptomatic bacteriuria (ASB) before joint arthroplasty. The bacteriuria count on pre-operative urinalysis is a more common clinical parameter. We aimed to investigate whether the bacteriuria count on preoperative urinalysis can increase postoperative wound complications in primary total hip arthroplasty (THA).

METHODS

We conducted a retrospective study that included patients who underwent primary THA in our institution from 2012 to 2018. We obtained preoperative urinalysis results before THA during the same hospitalization and identified patients with abnormal urinalysis. Receiver operating characteristic (ROC) curves were first generated to evaluate the predicted value of leukocyte esterase (LE), nitrite, bacteriuria, and pyuria in the urinalysis for superficial wound infection. Then, all included patients were divided into two groups according to the preoperative urinalysis: a bacteriuria-positive group and a bacteriuria-negative group. The primary outcome was the superficial wound infection rate within 3 months postoperatively, and the secondary outcomes included wound leakage, prosthetic joint infection (PJI), pulmonary infection, urinary tract infection (UTI), readmission rate within 3 months postoperatively, and length of stay (LOS) during hospitalization. We utilized univariable analyses to compare the outcomes between the two groups. A multivariable logistic regression model was generated to explore the potential association between bacteriuria and the risk of superficial wound infection, wound leakage, and readmission rate controlling for baseline values.

RESULTS

A total of 963 patients were included in the study. One hundred sixty patients had abnormal urinalysis. The AUCs for LE, nitrite, bacteriuria, and pyuria were 0.507 (95% confidence interval (CI), 0.315 to 0.698), 0.551 (0.347 to 0.756), 0.675 (0.467 to 0.882), and 0.529 (0.331 to 0.728), respectively. Bacteriuria was diagnostically superior to LE, nitrite, and pyuria. Among the 963 patients, 95 had a positive bacteriuria on preoperative urinalysis, and only 9 (9.5%) had a positive urine culture. Compared with the bacteriuria-negative group, the bacteriuria-positive group had a higher superficial wound infection rate (4.2% vs. 0.6%, P = 0.008), higher wound leakage rate (11.6% vs. 4.5%, P = 0.007), higher readmission rate (5.3% vs. 1.3%, P = 0.015) within 3 months postoperatively and longer LOS (6.19 ± 2.89 days vs. 5.58 ± 2.14 days, P = 0.011). After adjustment, the bacteriuria-positive group had a significantly increased risk of superficial wound infection (OR = 7.587, 95%CI: 2.002 to 28.755, P = 0.003), wound leakage (OR = 3.044, 95%CI: 1.461 to 6.342, P = 0.003), and readmission (OR = 4.410, 95%CI: 1.485 to 13.097, P = 0.008).

CONCLUSION

Preoperative bacteriuria positivity on urinalysis significantly increased the risk of postoperative wound complications, readmission, and LOS in primary THA regardless of the result of the urine culture. Urinalysis is a fast and cost-acceptable test whose advantages have been underestimated.

LEVEL OF EVIDENCE

Level III, observational study.

Decreased complication profile and improved clinical outcomes of primary reverse total shoulder arthroplasty after 2010: A systematic review

The purpose of this review was to update the complication profile of reverse total shoulder arthroplasty (rTSA) post-2010, given greater procedural familiarity, improved learning curves, enhanced implant designs, and increased attention to the nuances of patient selection. Three electronic databases were searched and screened in duplicate from 1 January 2010 to 16 December 2018 based on predetermined criteria. Twenty-two studies examining 1455 patients (26% male; mean age: 73.4 ± 3.6; mean follow-up: 23.4 ± 14.3 months) were reviewed. Post-operative motion ranged a mean 122.4° ± 11.5° flexion, 109° ± 19.4° abduction, and 33° ± 11.2°/41° ± 5° external/internal rotation. Post-operative mean Constant score was 58.9 ± 10.1, American Shoulder Elbow Surgeon score was 73.4 ± 6.1, Simple Shoulder Test score was 63.5 ± 6.5, and a Visual Analog Scale pain score was 1.6 ± 0.9. The overall complication rate was 18.2% and major complication rate was 15.4%. Compared to pre-2010, the overall complication rate of 18.2% is lower than previous rates of 19%-68%, with the rate of "major" complications dropping three-fold from 15.4% to 4.6%. The data suggest that rTSA is a safe and efficacious alternative to aTSA and HA, and the "stale" nature of previous complication profiles are points fundamental to perioperative discussions surrounding rTSA.

The Influence of Iodine-Impregnated Incision Drapes on the Bacterial Contamination of Scalpel Blades in Joint Arthroplasty

BACKGROUND

Prosthetic joint infections (PJI) are a disastrous and feared complication in arthroplasty. Over the past decades, surgeons have tried to lower infection rates through all sorts of improvements. At present, it is impossible to reduce the risk to zero. As the contamination of surgical instruments and the surgical field has been identified as a remaining gap prone for infection, scalpel blades among others have become a focal point of several studies. This study is the first to compare the effect of adhesive incision drapes on contamination rates of scalpel blades in primary arthroplasty of the hip and knee.

METHODS

A total of 344 microbiologic blade culture results from 2 study groups with and without drape usage and 1 group with known PJI were analyzed and compared to histopathologic and microbiologic tissue results.

RESULTS

In 78% of all positive cultures, the bacteria were part of the local skin flora. The contamination rate for the skin blades with a drape was 3.81% vs 12.19% without drape usage. A significant difference was determined between positive skin blade culture results incision drape usage (P = .031). The different pathogens likely responsible for the PJI correlated with the deep blade cultures (P ≤ .01). The overall contamination rate of surgical blades (1.37%) is comparatively low to the results obtained from other surgical equipment in literature. None of those blade-positive patients developed a surgical site infection during 12-month follow-up.

CONCLUSION

Iodine-impregnated incision drapes are able to reduce surgical skin blade contamination. Further studies may be needed to assess the relationship between blade contamination and surgical site infections.

The Impact of Running, Monofilament Barbed Suture for Subcutaneous Tissue Closure on Infection Rates in Total Hip Arthroplasty: A Retrospective Cohort Analysis

BACKGROUND

Recently, running, monofilament barbed suture has become more popular as an efficient and economical alternative to traditional braided interrupted suture for wound closure following total joint arthroplasty. Its overall association with wound complications following surgery remains unknown at this time. Several studies have investigated its use in total knee arthroplasty (TKA), but there is limited literature surrounding use in total hip arthroplasty (THA). In this retrospective cohort study, our primary objective was to determine whether the use of monofilament barbed suture in THA was associated with reduced rates of postoperative infection when compared to traditional braided suture.

METHODS

Patients who underwent primary unilateral THA between November 2011 and December 2017 by a single senior surgeon with closure using either monofilament barbed suture (162 patients) or braided interrupted suture (429 patients) were retrospectively reviewed for postoperative wound complications during the first 90 days after surgery. Demographics, comorbidities, and perioperative data were also included to assess for risk factors for infection.

RESULTS

There was no difference between braided and barbed suture in overall rates of major complication, including periprosthetic joint infection (PJI) (0.47% vs 0.62%, P = .82) or revisions (1.86% vs 1.23%, P = .60). The overall rate of minor, superficial wound complications was also similar between both groups (6.1% vs 3.1%, P = .15). However, when superficial complications were categorized by type (dehiscence vs infection), the use of barbed suture was associated with a decreased rate of superficial wound infection (0% vs 5.4%, P = .003) and an increased rate of wound dehiscence (3.1% vs 0.7%, P = .04).

CONCLUSION

The use of monofilament barbed suture for superficial skin closure in THA leads to similar overall rates of both major and minor wound complications when compared to traditional interrupted braided suture. However, while barbed suture was associated with fewer superficial infections, there was an increased incidence of wound dehiscence. Overall, barbed suture demonstrated a cumulatively equivalent rate of superficial wound complications compared to braided suture. Based on this investigation, barbed suture appears safe to use in THA and may represent an efficient and effective alternative to braided suture for wound closure.

LEVEL OF EVIDENCE

Level IV; retrospective cohort study.

A Randomized Control Trial Comparing Transparent Film Dressings and Conventional Occlusive Dressings for Elective Surgical Procedures

BACKGROUND:

Surgical site infection is one of the major health-care-associated problems causing substantial morbidity and mortality and constituting a financial burden on hospitals as well. The wound management is one of the crucial evidence-based strategies in the reduction of surgical site infection rates

AIM:

To study the impact of standardisation of transparent semipermeable dressing procedure on the rate of surgical site infection in comparison with conventional dressing in clean and clean-contaminated surgeries.

METHODS:

The study included 100 patients who were admitted to surgical wards in Cairo university hospitals, for clean and clean-contaminated operations, in the period from February 2017 to August 2017. Immunocompromised and uncontrolled diabetic patients were excluded. Patients were randomly allocated into two groups; in the first group, patients wounds were covered using transparent semipermeable dressing, while the second group patients’ wounds were covered using conventional occlusive gauze dressing. Patients were followed up for criteria of infection every other day during the first week then at two weeks, three weeks and four weeks.

RESULTS:

In clean and clean-contaminated operations, the transparent dressing group showed a significantly lesser rate of surgical site infection at (2%), compared with the conventional occlusive gauze dressing group with a surgical site infection rate of (14%) (p-value of 0.02).

CONCLUSION:

The transparent semipermeable dressing is effective in reducing surgical site infection rate in clean and clean-contaminated operations.

Surgical site infection surveillance for elective primary total hip and knee arthroplasty in Winnipeg, Manitoba, Canada

BACKGROUND

Surgical site infections (SSIs) increase morbidity and mortality after primary hip and knee arthroplasty. We evaluated a surveillance program that tracked risk factors associated with infection after primary hip and knee arthroplasty in the Winnipeg Regional Health Authority.

METHODS

Surveillance data from April 2010 to March 2015 were reviewed for all 12,636 primary hip or knee arthroplasties, including 1-year follow-up. Procedures were evaluated in earlier (April 2010 to December 2012) and later periods (January 2013 to March 2015). Risk factors for postoperative infection were evaluated.

RESULTS

There were 154 SSIs in 12,636 operations (1.22%) (earlier, 98 infections in 6,613 operations [1.48%]; later, 56 infections in 6,023 operations [0.93%]). The frequency of primary hip arthroplasty deep infection decreased from earlier to later periods; the frequency of primary knee arthroplasty infection was similar between the time periods. Independent risk factors associated with increased SSI risk included higher body mass index. SSI frequency was inversely associated with maintaining immediate postoperative temperature between 36°C and 38°C and surgery in the later period.

CONCLUSIONS

Surveillance was effective in decreasing the frequency of deep infection after primary total hip arthroplasties but not after knee arthroplasties. Surveillance of orthopedic surgery with feedback of SSI rates to the front-line staff may result in improvement in surgical outcomes.

Improving surgical antibiotic prophylaxis adherence and reducing hospital readmissions: a bundle of interventions including health information technologies

OBJECTIVES

Infection following orthopaedic surgery is a feared complication and an indicator of the quality of the hospital. Surgical antibiotic prophylaxis (SAP) guidelines are not always properly followed. Our aim was to describe and evaluate the impact of a multidisciplinary intervention on antibiotic prophylaxis adherence to hospital guidelines and 30-day postoperative outcomes.

METHODS

The study was carried out from January to May 2016 and consisted of creating a multidisciplinary team, updating institutional guidelines and embedding the recommendations in the computerised physician order entry system which is linked to dose and renal function alerts, educational activities and pharmaceutical bedside care of patients in the orthopaedic department. A prospective pre-post study was carried out in accordance with the Declaration of Helsinki. The following information was recorded: patient and surgery characteristics, adherence to SAP guidelines, surgical site infections, length of hospital stay and rate of readmission 30 days after discharge. Statistical analyses were performed using SPSS 18.0.

RESULTS

Eighty three orthopaedic patients of mean±SD age 68.2±17.0 years (44.6% male, 40 in the pre-intervention group and 43 in the intervention group) were included. Cefazolin was the recommended and most commonly administered antibiotic agent. In the intervention group, an improvement in global adherence to guidelines was achieved (76.7% vs 89.9%; p=0.039): antibiotic duration (75.0% vs 97.7%), correct dosage post-surgery (55.0% vs 76.7%), timing of administration (57.5% vs 72.1%), antibiotic pre-surgery prescription (92.5% vs 97.7%). Three surgical site infections were detected in the pre-intervention group and none in the intervention group (p>0.05). Length of hospital stay was reduced by 1 day and readmission decreased by 15% (p=0.038).

CONCLUSIONS

SAP is used in daily practice in most orthopaedic patients. The implementation of a multidisciplinary programme based on health technology improved the adherence to guidelines and appeared to reduce the readmission rate.

Risk Factors for Surgical Site Infection Following Lower Limb Arthroplasty: A Retrospective Cohort Analysis of 3932 Lower Limb Arthroplasty Procedures in a High Volume Arthroplasty Unit

BACKGROUND

Surgical site infection (SSI) is a debilitating complication of lower limb arthroplasty with significant morbidity and increased costs. Numerous risk factors are associated with SSI.

METHODS

In an effort to identify novel risk factors for SSI, we undertook a retrospective cohort study of 1832 primary total hip arthroplasties and 2100 primary total knee arthroplasties performed in our high volume arthroplasty unit over a 2-year period.

RESULTS

Two risk factors were identified for SSI following total hip arthroplasty: body mass index ≥30 and peri-operative blood transfusion. Eight risk factors were identified for SSI following total knee arthroplasty: hypertension, peri-operative blood transfusion, skin closure using 2-octyl cyanoacrylate, use of oral steroids, reduced serum mean cell volume, reduced mean cell hemoglobin, elevated serum neutrophil count, and use of warfarin or rivaroxaban for venous thromboembolism prophylaxis.

CONCLUSIONS

Our work proposes a number of previously undocumented risk factors in relation to SSI. Further investigation is required to ascertain the magnitude of their effect.

What is the incidence of inadvertent hypothermia in elderly hip fracture patients and is this associated with increased readmissions and mortality?

Background

Globally the incidence of fragility hip fractures is rising with increasingly elderly and co-morbid patients. These injuries are associated with a high morbidity and mortality.

Aims

This clinical study's primary outcome is to establish the rate of operative inadvertent hypothermia (<36 °C) in elderly hip fracture patients (>65 years old). We also aimed to identify risk factors and outcomes in patients with inadvertent hypothermia.

Patients and Methods

A single centre, retrospective study of 929 hip fracture patients managed operatively between June 2015 and July 2017 was conducted. Patients' demographic, anaesthetic and surgical variables were analysed together with outcomes for length of stay (LoS), 30-day re-admissions, and 30-day mortality.

Results

Overall rates of inadvertent hypothermia in elderly hip fracture patients undergoing surgery were 10%, with increasing age (p = 0.006) and pre-operative hypothermia (p < 0.0001) as risk factors. Patient's hypothermic pre-operatively compared with normothermic patients were 1.9 times more likely to be <36 °C on leaving theatre. There was a trend towards a higher 30-day mortality (χ²(1) = 2.818, p = 0.093), and a significantly higher mortality in patients undergoing SHS (p = 0.03). No survival differences for LoS were observed between hypothermic and ≥36 °C patients (χ2(1) = 0.069, p = 0.79). 30-day re-admissions were higher in hypothermic patients (χ2(1) = 16.301, p < 0.0001).

Conclusion

Rates of inadvertent hypothermia are high in operatively managed hip fracture patients and are significantly associated with a higher 30-day readmission rate with a trend towards higher 30-day mortality.

Reducing surgical site infections following total hip and knee arthroplasty: an Israeli experience

PURPOSE

To assess the changes observed in surgical site infection (SSI) rates following total joint arthroplasty (TJA) after the introduction of an infection control programme and evaluate the risk factors for the development of these infections.

DESIGN

Prospective cohort study.

SETTING

Large tertiary medical centre in Israel.

METHODS

Data about SSIs and potential prophylaxis-, patient-, and procedure-related risk factors were collected for all patients who underwent elective total hip and total knee arthroplasty during the study period. Multivariant analyses were conducted to determine which significant covariates affected the outcome.

RESULTS

During the 76-month study period, SSIs (superficial and deep) occurred in 64 (4.4%) of 1554 patients. As compared with the 34 (7.7%) SSIs that occurred in the first 25 months, there were 23 (4.7%) SSIs in the following 25 months, and only 7 (1.3%) SSIs in the last third of the study (p = 0.058 and <0.001, respectively). A multiple logistic regression model indicated that risk factors for prosthetic joint infection were a National Nosocomial Infections Surveillance (NNIS) System surgical patient risk index score of 1 (OR 1.8; 95% CI 1.1-3.1) or 2 (OR 2.8; 95% CI 1.2-11.8). The incidence of SSI was not correlated with the timing, nor the duration of antibiotic prophylaxis.

CONCLUSIONS

The introduction of preventive measures and surveillance coincided with a significant reduction in SSIs following TJA in our institution. The risk of infection correlated with higher scores in the NNIS System surgical patient risk.

Prophylactic antibiotics in elective hip and knee arthroplasty: an analysis of organisms reported to cause infections and National survey of clinical practice

Objectives

We wanted to investigate regional variations in the organisms reported to be causing peri-prosthetic infections and to report on prophylaxis regimens currently in use across England.

Methods

Analysis of data routinely collected by Public Health England’s (PHE) national surgical site infection database on elective primary hip and knee arthroplasty procedures between April 2010 and March 2013 to investigate regional variations in causative organisms. A separate national survey of 145 hospital Trusts (groups of hospitals under local management) in England routinely performing primary hip and/or knee arthroplasty was carried out by standard email questionnaire.

Results

Analysis of 189 858 elective primary hip and knee arthroplasty procedures and 1116 surgical site infections found statistically significant variations for some causative organism between regions. There was a 100% response rate to the prophylaxis questionnaire that showed substantial variation between individual trust guidelines. A number of regimens currently in use are inconsistent with the best available evidence.

Conclusions

The approach towards antibiotic prophylaxis in elective arthroplasty nationwide reveals substantial variation without clear justification. Only seven causative organisms are responsible for 89% of infections affecting primary hip and knee arthroplasty, which cannot justify such widespread variation between prophylactic antibiotic policies.

Cite this article: Bone Joint Res 2015;4:181–189.

Prophylactic antibiotic regimens in tumour surgery (PARITY): a pilot multicentre randomised controlled trial

Objective

Clinical studies of patients with bone sarcomas have been challenged by insufficient numbers at individual centres to draw valid conclusions. Our objective was to assess the feasibility of conducting a definitive multi-centre randomised controlled trial (RCT) to determine whether a five-day regimen of post-operative antibiotics, in comparison to a 24-hour regimen, decreases surgical site infections in patients undergoing endoprosthetic reconstruction for lower extremity primary bone tumours.

Methods

We performed a pilot international multi-centre RCT. We used central randomisation to conceal treatment allocation and sham antibiotics to blind participants, surgeons, and data collectors. We determined feasibility by measuring patient enrolment, completeness of follow-up, and protocol deviations for the antibiotic regimens.

Results

We screened 96 patients and enrolled 60 participants (44 men and 16 women) across 21 sites from four countries over 24 months (mean 2.13 participants per site per year, standard deviation 2.14). One participant was lost to follow-up and one withdrew consent. Complete data were obtained for 98% of eligible patients at two weeks, 83% at six months, and 73% at one year (the remainder with partial data or pending queries). In total, 18 participants missed at least one dose of antibiotics or placebo post-operatively, but 93% of all post-operative doses were administered per protocol.

Conclusions

It is feasible to conduct a definitive multi-centre RCT of post-operative antibiotic regimens in patients with bone sarcomas, but further expansion of our collaborative network will be critical. We have demonstrated an ability to coordinate in multiple countries, enrol participants, maintain protocol adherence, and minimise losses to follow-up.

Cite this article: Bone Joint Res;4:154–162

The Role of MDR-Acinetobacter baumannii in Orthopedic Surgical Site Infections

BACKGROUND

Gram-positive microorganisms were the main causative organisms of orthopedic surgical site infections (SSI); however the rising incidence of multiple drug resistant Acinetobacter baumannii (MDR-AB) infections in orthopedic operations causes a great concern because of their limited array of therapeutic options.

OBJECTIVE

Our objective was to remark the changing microbiology in orthopedic SSI and to evaluate the MDR CHROMagar Acinetobacter media for screening of MDR-AB.

METHODS

Aspirated pus samples were collected from infected wounds of 100 patients in the orthopedics unit of El-Helal Hospital, samples were cultured on conventional media and MDR CHROMagar Acinetobacter media, the reveled MDR-AB colonies were subjected to polymerase chain reaction (PCR) to detect blaOXA-51 like gene.

RESULTS

Out of 100 infected wounds SSI cases represented 90/100 (90%) according to CDC 2013 definitions. Staphylococcus aureus was the dominant organism 40/90 (44.4%) (P value 0.038), all S. aureus isolates were methicillin-resistant Staphylococcus aureus (MRSA), followed by Klebsiella pneumoniae 22/90 (24.44%) and Acinetobacter 15/90 (16.67%). Implant was highly associated with SSI cases 80/90 (89%). Also, prolonged hospital stay>7 d was significantly associated with SSI 69/90 (77%) (p=0.001).

CONCLUSION

Staphylococcus aureus was the main causative organism of orthopedic SSI (44.4%), whereas A. baumannii represented only (16.67%) of the causative organisms. MDR Acinetobacter CHROMagar reduced the turnaround time for screening of MDR-AB.

The effect of triclosan coated sutures on rate of surgical site infection after hip and knee replacement: a protocol for a double-blind randomised controlled trial

Background

187,000 hip and knee joint replacements are performed every year in the National Health Service (NHS). One of the commonest complications is surgical site infection (SSI), and this represents a significant burden in terms of patient morbidity, mortality and cost to health services around the world. The aim of this randomised controlled trial (RCT) is to determine if the addition of triclosan coated sutures to a standard regimen can reduce the rate of SSI after total knee replacement (TKR) and total hip replacement (THR).

Methods

2400 patients due to undergo a total hip or knee replacement are being recruited into this two-centre RCT. Participants are recruited before surgery and randomised to either standard care or intervention group. Participants, outcome assessors and statistician are blind to treatment allocation throughout the study. The intervention consists of triclosan coated sutures vs. standard non-coated sutures. The primary outcome is the Health protection Agency (HPA) defined superficial surgical site infection at 30 days. Secondary outcomes include HPA defined deep surgical site infection at 12 months, length of hospital stay, critical care stay, and payer costs.

Discussion

To date there are no orthopaedic randomised controlled trials on this scale assessing the effectiveness of a surgical intervention, particularly those that can be translated across the surgical specialities. The results from this trial will inform evidence-based recommendations for suture selection in the management of patients undergoing total hip or knee replacement. If triclosan coated sutures are found to be an effective intervention, implementation into clinical practice could improve long-term outcomes for patients undergoing hip and knee replacement.

Trial registration

Current Controlled Trials ISRCTN 17807356.