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Wolfhagen N, Boldingh QJJ, Boermeester MA, de Jonge SW. Perioperative care bundles for the prevention of surgical-site infections: meta-analysis. Br J Surg 2022; 109:933-942. [PMID: 35766252 PMCID: PMC10364698 DOI: 10.1093/bjs/znac196] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 05/03/2022] [Accepted: 05/12/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Care bundles are used widely to prevent surgical-site infections (SSIs). Recent systematic reviews suggested larger effects from bundles with more interventions. These reviews were largely based on uncontrolled before-after studies and did not consider their biases. The aim of this meta-analysis was to determine the effectiveness of care bundles to prevent SSIs and explore characteristics of effective care bundles. METHODS A systematic review, reanalysis, and meta-analysis of available evidence were undertaken. RCTs, controlled before-after studies, and uncontrolled before-after studies with sufficient data for reanalysis as interrupted time series studies (ITS) were eligible. Studies investigating the use of a care bundle, with at least one intraoperative intervention, compared with standard care were included. RESULTS Four RCTs, 1 controlled before-after study, and 13 ITS were included. Pooled data from RCTs were heterogeneous. Meta-analysis of ITS resulted in a level change of -1.16 (95 per cent c.i.-1.78 to -0.53), indicating a reduction in SSI. The effect was larger when the care bundle comprised a higher proportion of evidence-based interventions. Meta-regression analyses did not show statistically significant associations between effect estimates and number of interventions, number of evidence-based interventions, or proportion of evidence-based interventions. CONCLUSION Meta-analysis of ITS indicated that perioperative care bundles prevent SSI.This effect is inconsistent across RCTs. Larger bundles were not associated with a larger effect, but the effect may be larger if the care bundle contains a high proportion of evidence-based interventions. No strong evidence for characteristics of effective care bundles was identified.
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Affiliation(s)
- Niels Wolfhagen
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, the Netherlands
| | - Quirine J J Boldingh
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, the Netherlands
| | - Marja A Boermeester
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, the Netherlands
| | - Stijn W de Jonge
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, the Netherlands.,Amsterdam Gastroenterology Endocrinology & Metabolism (AGEM), Amsterdam, the Netherlands
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de Jonge SW, Boldingh QJJ, Koch AH, Daniels L, de Vries EN, Spijkerman IJB, Ankum WM, Kerkhoffs GMMJ, Dijkgraaf MG, Hollmann MW, Boermeester MA. Timing of Preoperative Antibiotic Prophylaxis and Surgical Site Infection: TAPAS, An Observational Cohort Study. Ann Surg 2021; 274:e308-e314. [PMID: 31663971 DOI: 10.1097/sla.0000000000003634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that surgical site infection (SSI) risk differs, after administration of surgical antibiotic prophylaxis (SAP) within 60-30 or 30-0 minutes before incision. BACKGROUND The importance of appropriate timing of SAP before surgery has long been recognized. However, available evidence is contradictive on the best timing within a 60-0 minutes time interval before incision. Here, we aim to evaluate previous contradictions with a carefully designed observational cohort. METHODS An observational cohort study was conducted in a Dutch tertiary referral center. For 2 years, consecutive patients with SAP indication undergoing general, orthopedic, or gynecologic surgery were followed for the occurrence of superficial and deep SSI as defined by the Center of Disease Control and Prevention. The association between timing of SAP and SSI was assessed using multivariable logistic regression. RESULTS After 3001 surgical procedures, 161 SSIs were detected. In 87% of the procedures, SAP was administered within 60 minutes before incision. Only antibiotics with short infusion time were used. Multivariable logistic regression indicated there was no conclusive evidence of a difference in SSI risk after SAP administration 60-30 minutes or 30-0 minutes before incision [odds ratio: 0.82; 95% confidence interval (0.57-1.19)]. CONCLUSIONS For SAP with short infusion time no clear superior timing interval within the 60-minute interval before incision could be identified in this cohort. We were unable to reproduce differences in SSI risk found in earlier studies.
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Affiliation(s)
- Stijn W de Jonge
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Quirine J J Boldingh
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anna H Koch
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Gynaecology, Tergooi Hospital, Location Blaricum, Blaricum, the Netherlands
| | - Lidewine Daniels
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Westfriesgasthuis, Hoorn, the Netherlands
| | - Eefje N de Vries
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Tergooi Hospital, Hilversum, the Netherlands
| | - Ingrid J B Spijkerman
- Department of Medical Microbiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wim M Ankum
- Department of Gynecologic Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marcel G Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
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de Jonge SW, Boldingh QJJ, Solomkin JS, Allegranzi B, Egger M, Dellinger EP, Boermeester MA. Systematic Review and Meta-Analysis of Randomized Controlled Trials Evaluating Prophylactic Intra-Operative Wound Irrigation for the Prevention of Surgical Site Infections. Surg Infect (Larchmt) 2017; 18:508-519. [PMID: 28448203 DOI: 10.1089/sur.2016.272] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgical site infections (SSIs) are one of the most common hospital-acquired infections. To reduce SSIs, prophylactic intra-operative wound irrigation (pIOWI) has been advocated, although the results to date are equivocal. To develop recommendations for the new World Health Organization (WHO) SSI prevention guidelines, a systematic literature review and a meta-analysis were conducted on the effectiveness of pIOWI using different agents as a means of reducing SSI. METHODS The PUBMED, Embase, CENTRAL, CINAHL, and WHO databases were searched. Randomized controlled trials (RCTs) comparing either pIOWI with no pIOWI or with pIOWI using different solutions and techniques were retrieved with SSI as the primary outcome. Meta-analyses were performed, and odds ratios (OR) and the mean difference with 95% confidence intervals (CI) were extracted and pooled with a random effects model. RESULTS Twenty-one studies were suitable for analysis, and a distinction was made between intra-peritoneal, mediastinal, and incisional wound irrigation. A low quality of evidence demonstrated a statistically significant benefit for incisional wound irrigation with an aqueous povidone-iodine (PVP-I) solution in clean and clean contaminated wounds (OR 0.31; 95% CI 0.13-0.73; p = 0.007); 50 fewer SSIs per 1,000 procedures (from 19 fewer to 64 fewer)). Antibiotic irrigation had no significant effect in reducing SSIs (OR 1.16; 95% CI 0.64-2.12; p = 0.63). CONCLUSION Low-quality evidence suggests considering the use of prophylactic incisional wound irrigation to prevent SSI with an aqueous povidone-iodine solution. Antibiotic irrigation does not show a benefit and therefore is discouraged.
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Affiliation(s)
- Stijn W de Jonge
- 1 Department of Surgery, Academic Medical Center Amsterdam , The Netherlands
| | | | - Joseph S Solomkin
- 2 Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, Ohio
| | - Benedetta Allegranzi
- 3 Infection Prevention and Control Global Unit, Service Delivery and Safety, World Health Organization , Geneva, Switzerland
| | - Matthias Egger
- 4 Institute of Social and Preventive Medicine, University of Bern , Bern, Switzerland
| | | | - Marja A Boermeester
- 1 Department of Surgery, Academic Medical Center Amsterdam , The Netherlands
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