Nurses’ reports of staffing adequacy and surgical site infections: A cross-sectional multi-centre study

Trends in surgical site infection and periprosthetic joint infection after primary total hip arthroplasty in two national health registers 2013-2022.

AimTwo types of national registers surveil infections after primary total hip arthroplasty (THA) in Norway: The National surveillance system for surgical site infections (NOIS) that surveil all primary THAs 30 days postoperatively for surgical site infections (SSI), and the Norwegian Arthroplasty Register (NAR) that follow all THAs until any surgical reoperation/revision or the death of the patient. Since these registers report on the same THAs we assessed correspondence between and time trends for the two registers in period 2013 to 2022. All reported THAs were included.MethodThe THAs were matched on a group level according to sex, age and ASA-class. In addition to descriptive statistics, adjusted Cox regression analyses were performed with adjustment for sex, age group (<45, 45-54, 55-64, 65-74, 75-84, >85 years) and ASA-class (1, 2, 3, 4 and missing). Changes in annual incidence and adjusted hazard rate (aHR) was calculated. Endpoints in the NOIS were 30-Days SSI and 30-Days reoperation for SSI. Endpoints in the NAR were 30-Days and 1-Year reoperation for periprosthetic joint infection (PJI).ResultsThe NOIS had registered 87,923 THAs with 1,393 (1.58%) SSIs and 765 (0.87%) reoperations for SSI within 30 postoperatively. The NAR had registered 91,194 THAs with 725 (0.80%) reoperations for infection after 30 days, and 1,019 (1.21%) reoperations for infections after one year. The distribution of sex, age and ASA-class was near identical in the two registers. There was a mean annual reduction in risk of both SSI (aHR 0.92 (95% CI 0.90-0.93)) and reoperation for SSI (0.95(0.92-0.97)) and PJI (30-Days: 0.96 (0.94-0.99), 1-Year: 0.95-0.99)) over the period 2013-2022.ConclusionsThe NOIS and the NAR have excellent completeness and the registrations in both registers may be considered representative for the Norwegian population. Not all SSI are reoperated. The incidence and risk of SSI (NOIS) and reoperation for PJI (NAR) is declining and may reflect a true reduction in incidence of PJI after primary THA.

What's New in Musculoskeletal Infection.

Prophylactic antibiotics have significantly led to a reduction in the risk of post-operative surgical site infections (SSI) in orthopaedic surgery. The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed, for the duration of the operation, the minimum inhibitory concentration of the likely organisms that are encountered. Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4% and 8% to between 1% and 3%. Controversy, however, still surrounds the optimal frequency and dosing of antibiotic administration. To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime, combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty. Following ethical approval, patients undergoing primary total hip arthroplasty (THA)/total knee arthroplasty (TKA) with the old regime (OR) of a preoperative dose [cefazolin 2 g intravenously (IV)], and two subsequent doses (2 h and 8 h), were compared to those after a change to a new regime (NR) of a weight-adjusted preoperative dose (cefazolin 2 g IV for patients < 120 kg; cefazolin 3g IV for patients > 120 kg) and a post-operative dose at 2 h. The primary outcome in both groups was SSI rates during the 2 years post-operatively. A total of n = 1273 operations (THA n = 534, TKA n = 739) were performed in n = 1264 patients. There was no statistically significant difference in the rate of deep (OR 0.74% (5/675) vs NR 0.50% (3/598); fishers exact test P = 0.72), nor superficial SSIs (OR 2.07% (14/675) vs NR 1.50% (9/598); chi-squared test P = 0.44) at 2 years post-operatively. With propensity score weighting and an interrupted time series analysis, there was also no difference in SSI rates between both groups [RR 0.88 (95%CI 0.61 to 1.30) P = 0.46]. A weight-adjusted regime, with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Surveillance of surgical site infections cases in prosthetic orthopedics in a French University Hospital, from 2013 to 2016

BackgroundSurgical site infections following total hip or knee arthroplasties have a reported rate of 0.49%-2.5% and can cause significant morbidity as well as tripling the cost of health care expenses. Both methicillin sensitive and methicillin resistant strains of Staphylococcus aureus surgical site infections have been established as a major risk factor for postoperative surgical site infections. S. aureus colonizes the nose, axillae, and perineal region in up to 20%-30% of individuals. Although the literature has reported a higher prevalence of methicillin resistant S. aureus in the South Asian population, routine preoperative screening and prophylaxis have not yet been implemented.ObjectiveThe primary objective of our study is to identify the relationship between preoperative colonization status of S. aureus and incidence of postoperative surgical site infections in patients undergoing following total hip and knee arthroplasties. As part of the secondary objectives of this study, we will also investigate patient characteristics acting as risk factors for S. aureus colonization as well as the outcomes of total hip and knee arthroplasty patients which are affected by surgical site infections.MethodsThis prospective cohort study will comprise of screening all patients older than 18 years of age admitted to the Aga Khan University Hospital for a primary total hip or knee arthroplasty for preoperative colonization with S. aureus. The patients will be followed postoperatively for up to one year following the surgery to assess the incidence of surgical site infections. The study duration will be 2 years (March 2018 to March 2020). For the purpose of screening, pooled swabs will be taken from the nose, axillae, and groin of each patient and inoculated in a brain heart infusion, followed by subculture onto mannitol salt agar and sheep blood agar. For methicillin resistant S. aureus identification, a cefoxitin disk screen will be done. Data will be analyzed using SPSS v23 and both univariate and multivariate regression analysis will be conducted.ResultsData collection for this study will commence at the Aga Khan University Hospital, Pakistan during March 2018.ConclusionsThis study will not only estimate the true burden caused by S. aureus in the population under study but will also help identify the patients at a high risk of surgical site infections so that appropriate interventions, including prophylaxis with antibiotics such as muciprocin ointment or linezolid, can be made. Given the differences in lifestyle, quality, and affordability of health care and the geographical variation in patterns of antibiotic resistance, this study will contribute significantly to providing incentive for routine screening and prophylaxis for S. aureus including methicillin resistant S. aureus colonization in the South Asian population.Registered Report IdentifierRR1-10.2196/10219

IntroductionIncisional surgical site infection is an important cause of postoperative morbidity which results in extended hospital stay and may result in future incisional hernia. We intended to evaluate the thickness of subcutaneous fat with a cut-off value of 2.5cm as a risk factor in causing surgical site infection using a simple, cost-effective, and direct intraoperative method for measuring subcutaneous fat thickness.MethodsA total of 147 patients who underwent abdominal surgeries from September 2017 to April 2019 were included in this prospective study. A proforma was used to collect information of all patients regarding various variables. Abdominal subcutaneous fat thickness was measured in the supine position intraoperatively with a measuring scale from below dermis to rectus sheath at 1cm caudal to umbilicus level.ResultsThe study's overall incidence of incisional surgical site infection (SSI) in laparotomy surgeries was 10.8%. Subcutaneous fat thickness was independently associated with incisional SSI. Subcutaneous fat thickness association with SSI was more statistically significant than that of BMI. The other associated risk factors were found to be obesity, diabetes, and emergency surgery.ConclusionOur results suggest that the risk of incisional SSI increases with the increased subcutaneous fat thickness of more than 2.5cm. Placement of subcutaneous drain in patients undergoing laparotomy with increased subcutaneous fat thickness plays a significant role in reducing the incidence of surgical site infection. Risk of SSI increases in obesity, diabetes, increased age group, dirty surgery, and emergency surgeries. Subcutaneous fat thickness is an independent risk factor for surgical site infection and subcutaneous drain decreases the risk of SSI in thick subcutaneous fat.

IN this issue of Anesthesiology, Stæhr et al. 1report the lack of effect of perioperative hyperoxia on preventing surgical site infection (SSI) in obese patients undergoing laparotomy. The study was a secondary analysis of data from the PROXI Trial, a Danish multicenter study of 1,400 patients undergoing elective or emergency laparotomy who were randomized to receive a 30% or 80% oxygen concentration intraoperatively and for the first 2 h after surgery.2Although no significant reduction in the frequency of SSI was observed in the high-concentration group in that trial, it was hypothesized that the results for the subpopulation of 213 obese patients (body mass index ≥30 kg/m2, 15% of the sample) might be different. However, on reanalysis the researchers again found no significant differences in the rates of SSI or pulmonary complications.Surgical site infection, which accounts for 15–20% of all healthcare-associated infections, is the second most common preventable adverse outcome of major surgery.3The incidence of SSI, which differs according to surgical procedure, is highest for gastrointestinal interventions.4If we are to decrease the SSI rates in the various surgical settings and attenuate the consequences, it will be necessary to identify risk factors as a first step. Age, duration of surgery, hypoalbuminemia, obesity, diabetes mellitus, and a history of chronic obstructive pulmonary disease are some of the predictors that have been linked with SSI.4,5Obesity is associated with a higher incidence of SSI.6Glance et al. 7recently studied a population of 310,208 patients in the American College of Surgeons National Surgical Quality Improvement Program database, more than 95,000 of whom were overweight. Obese and morbidly obese patients with metabolic syndrome (obesity, hypertension, and diabetes), who accounted for 19% of all the obese patients in the study, had higher risk of postoperative complications, including death and SSI, in comparison with normal-weight and obese patients without metabolic syndrome. In addition, percentage of body fat8and thickness of subcutaneous fat9have been shown to be better predictors of SSI than body mass index, suggesting that obesity is not a homogeneous clinical state and body mass index may be too simplistic a measure for this complex illness. In other words, individuals classified as obese may be more or less healthy and have different levels of risk.In recent years, interest has grown in identifying factors amenable to management to reduce the risk of SSI, and anesthesiologists may have partial control over some of them.3Measures such as the avoidance of hypothermia10and the careful timing and selection of antibiotics11seem to be effective in preventing SSI.The rationale for proposing hyperoxia as another manageable factor for preventing SSI is well established.3Neutrophils safeguard against infection through nonspecific phagocytosis and elimination of bacteria from wounds; the oxygen tension in subcutaneous tissue is critical for these functions. Tissue oxygen tension12and concentration13have been shown to predict SSI after colorectal surgery, and supplemental oxygen (e.g. , 80%) can double oxygen partial pressure in tissue.14In vitro studies have shown that hyperoxia exerts significant influence on multiple cellular and immune system parameters, improving the functional capacity of the innate immune response as reflected by increasing concentrations of reactive oxygen species, a major component of the bactericidal defense.15Adequate wound oxygen tension is also important in the development of collagen and epithelium required for healing.3Hyperoxia increases the availability of molecular oxygen to tissues by increasing oxygen dissolved in plasma and enhancing the driving force between capillary blood and cells.16Achieving a subcutaneous oxygen tension greater than 90 mmHg seems to protect against infection,12and at least 40 mmHg would be needed to support the leukocyte-mediated oxidative burst and collagen formation. Good capillary perfusion of tissue also determines cell oxygenation, and helpful actions that can be managed by anesthesiologists are fluid replacement and the avoidance of vasoconstriction triggered by activation of the sympathetic nervous system by hypothermia and pain.3However, all actions intended to increase cell oxygen tension can be offset if tissue perfusion is compromised (e.g. , in diabetes or peripheral vascular disease) or when the oxygen pressure gradient along the axial capillary drops rapidly.16The results of the clinical translation of this rationale, in controlled trials testing perioperative hyperoxia, have been mixed. Two randomized trials comparing 30% and 80% oxygen in a total of almost 800 patients undergoing colorectal surgery reported significant reductions in the rate of SSI.14,17A large trial to test the effect of nitrous oxide on events after major surgery indirectly compared high (80%) and low (30%) oxygen concentrations and found significantly fewer cases of SSI in patients breathing the high concentration.18In contrast, 165 patients undergoing major abdominal surgery, including laparoscopically assisted procedures, were randomized to breathe 35% or 80% oxygen, and no improvement in SSI outcome was observed.19Finally, the multicenter PROXI Trial likewise found no significant reduction in risk of SSI with hyperoxia; however, the study included many different elective and emergency surgical procedures, ranging from high-risk colorectal interventions (fewer than 50% of all patients) to cholecystectomies, appendectomies, and hernia repair.2This heterogeneity could partly explain the negative findings.The secondary analysis of data for the PROXI Trial's high-risk subgroup of obese patients in this issue1is therefore welcome. It was hypothesized that the subcutaneous oxygen tension might be reduced in this subpopulation because of their anatomic, histologic, functional, and immune status. We know that in obese patients tissue oxygen tension is significantly increased when 80% oxygen is given,20favoring the defense mechanisms against an SSI. However, the authors observed no reduction in the incidence of SSI. Two sampling characteristics could have created bias leading to this negative result. First, the mean body mass index of the obese patients in this trial was relatively low (33.5 kg/m2), and hypertension was present in fewer than half the patients, suggesting that a large proportion did not have metabolic syndrome and probably had less risk. Second, the patients had undergone a large variety of procedures, and only 45% were operations such as colorectal surgery, which is associated with high risk for SSI.Thus, the issue of a clinical role for hyperoxia remains unsettled. Should we routinely administer high oxygen concentration perioperatively in the hope of reducing the risk of SSI? This intervention is attractive because oxygen therapy does not significantly increase costs, and the potential benefits might be great. But SSIs develop as the result of very complex circumstances, and prevention does not appear to be possible by taking a single step because a variety of other surgical, anesthetic, functional, and immune factors also play important roles. Even genetic factors seem to increase risk for severe infections.21Our poor understanding of those factors probably explains the conflicting results of trials to date. The answer to the question posed above seems to be that hyperoxia should not be provided routinely and individualized clinical vigilance is essential. Probably in some patients who are theoretically at high risk of infection (e.g. , in colorectal surgery) but whose tissue perfusion is well preserved, hyperoxia with 80% oxygen concentration may be beneficial. Additional research with high-risk patients undergoing high-risk procedures is needed. New studies on general populations probably will yield negative results because the beneficial effect of hyperoxia by itself can be marginal, or at least not comparable to antibiotic prophylaxis.11Thus, to reduce risk of SSI, we would argue in favor of a multimodal approach, including several surgical and anesthetic factors amenable to management. In such an approach, hyperoxia might well be one of the tools to select.*Department of Anesthesiology and Postoperative Care, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain. jcanet.germanstrias@gencat.cat. †Department of Anesthesia and Critical Care, Hospital Clínico Universitario, Valencia, Spain.

Surgical site infection (SSI) is one of the most challenging and costly complications associated with total joint arthroplasty. Our primary aim in this case-controlled trial was to compare the risk of SSI within a year of surgery for patients undergoing primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) and revision TKA or THA under general anesthesia versus neuraxial anesthesia. Our secondary aim was to determine which patient, anesthetic, and surgical variables influence the risk of SSI. We hypothesized that patients who undergo neuraxial anesthesia may have a lesser risk of SSI compared with those who had a general anesthetic. We conducted a retrospective, case-control study of patients undergoing primary or revision TKA and THA between January 1, 1998, and December 31, 2008, who subsequently were diagnosed with an SSI. The cases were matched 1:2 with controls based on type of joint replacement (TKA versus THA), type of procedure (primary, bilateral, revision), sex, date of surgery (within 1 year), ASA physical status (I and II versus III, IV, and V), and operative time (<3 vs >3 hours). During the 11-year period, 202 SSIs were identified. Of the infections identified, 115 (57%) occurred within the first 30 days and 87 (43%) occurred between 31 and 365 days. From both univariate and multivariable analyses, no significant association was found between the use of central neuraxial anesthesia and the postoperative infection (univariate odds ratio [OR] = 0.92; 95% confidence interval [CI], 0.63-1.34; P = 0.651; multivariable OR = 1.10; 95% CI, 0.72-1.69; P = 0.664). The use of peripheral nerve block also was not found to influence the risk of postoperative infection (univariate OR = 1.41; 95% CI, 0.84-2.37; P = 0.193; multivariable OR = 1.35; 95% CI, 0.75-2.44; P = 0.312). The factors that were found to be associated with postoperative infection in multivariable analysis included current smoking (OR = 5.10; 95% CI, 2.30-11.33) and higher body mass index (BMI) (OR = 2.68; 95% CI, 1.42-5.06 for BMI ≥ 35 kg/m compared with those with BMI < 25 kg/m). Recent studies using large databases have concluded that the use of neuraxial compared with general anesthesia is associated with a decreased incidence of SSI in patients undergoing total joint arthroplasty. In this retrospective, case-controlled study, we found no difference in the incidence of SSI in patients undergoing total joint arthroplasty under general versus neuraxial anesthesia. We also concluded that the use of peripheral nerve blocks does not influence the incidence of SSI. Increasing BMI and current smoking were found to significantly increase the incidence of SSI in patients undergoing lower extremity total joint arthroplasty.

This study aimed to evaluate whether the implementation of extra perioperative safety measures and precautions through adopted standard operating procedures (SOPs) to ensure optimal anti-microbial conditions has led to less surgical site infections (SSI) after alloplastic breast reconstruction (BR). This retrospective study compared two Cohorts of patients treated before and after the implementation of new SOPs (2009-2014: Cohort 1 versus 2014-2019: Cohort 2). Multivariate logistic regression analyses, adjusting for patient confounders, were implemented to compare SSI incidence between both Cohorts. Overall, SSI incidence was equal in both groups (10%, p=0.545). The incidence of deep SSI was 9% for Cohort 1 and 5% for Cohort 2 (p=0.074). Incidence of SSI-related explantation was 8% and 5%, respectively (p=0.136). After adjusting for patient confounders, no statistically significant difference was seen between both Cohorts in overall SSI, deep SSI incidence, and explantation due to SSI (ORadjusted: -0.31, p=0.452, ORadjusted: 0.16, p=0.747 and ORadjusted: 0.18, p=0.712). Higher BMI, smoking, one-stage BR, and immediate BR were associated with the risk for SSI (p<0.001, p=0.036, p<0.001, and p=0.022, respectively). Extra safety measures to assure optimal anti-microbial conditions did not contribute to lower SSI incidence or SSI-related explantation after alloplastic BR. Confounders such as BMI, smoking, immediate BR, and one-stage BR were correlated to an increased risk for overall SSI, deep SSI, and SSI-related explantation of TE/implants.

A systematic review and meta-analysis. The objective of this study was to investigate the incidence of surgical site infection (SSI) in patients following spine surgery and the rate of microorganisms in these cases. Many studies have investigated the incidence and risk factors of SSI following spinal surgery, whereas no meta-analysis studies have been conducted regarding the comprehensive epidemiological incidence of SSI after spine surgery. We searched the PubMed, Embase, and Cochrane Library databases for relevant studies that reported the incidence of SSI after spine surgery, and manually screened reference lists for additional studies. Relevant incidence estimates were calculated. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed. Our meta-analysis included 27 studies, with 603 SSI cases in 22,475 patients. The pooled SSI incidence was 3.1%. Subgroup analysis revealed that the incidence of superficial SSI was 1.4% and the incidence of deep SSI was 1.7%. Highest incidence (13.0%) was found in patients with neuromuscular scoliosis among the different indications. The incidences of SSI in cervical, thoracic, and lumbar spine were 3.4%, 3.7%, and 2.7%, respectively. Compared with posterior approach surgery (5.0%), anterior approach showed a lower incidence (2.3%) of SSI. Instrumented surgery had a higher incidence of SSI than noninstrumented surgery (4.4% vs. 1.4%). Patients with minimally invasive surgery (1.5%) had a lower SSI incidence than open surgery (3.8%). Lower incidence of SSI was found when vancomycin powder was applied locally during the surgery (1.9%) compared with those not used (4.8%). In addition, the rates of Staphylococcus aureus, Staphylococcus epidermidis, and methicillin-resistant Staphylococci in microbiological culture results were 37.9%, 22.7%, and 23.1%, respectively. The pooled incidence of SSI following spine surgery was 3.1%. These figures may be useful in the estimation of the probability of SSI following spine surgery. 3.

Background The effect of the number of door openings in the operating room (OR) on surgical site infections (SSI) risk remains a controversial topic. Many SSI prevention bundles include a restriction on the maximum number of door openings as intervention, often to ten per hour. However, existing evidence is limited and heterogeneous. This individual participant data (IPD) meta-analysis aims to evaluate the effect of the number of door openings in the OR on SSI occurrence. Methods We searched MEDLINE (Pubmed) and Embase (Ovid) up to 15 January 2024, for studies investigating the effect of the number of door openings on SSI incidence. Authors of eligible studies were invited to collaborate. IPD were merged and analysed with a logistic regression model with mixed-effects. This study is registered with PROSPERO, CRD42022309958. Findings IPD from eight observational studies, encompassing 4412 patients, revealed a 6.0% overall SSI incidence. The logistic regression model with mixed-effects indicated a difference in SSI risk for each extra door opening per hour (OR 1.01 [95% c.i. 1.004–1.02]; very low certainty of evidence). To enhance the practical applicability, door openings were categorised. Inconclusive evidence was found regarding SSI risk difference for 10 to 31.7 door openings per hour (OR 1.11 [95% c.i. 0.77–1.59]) compared to 10 or fewer. While for more than 31.7 door openings per hour (OR 1.52 [95% c.i. 1.02–2.26]) a conclusive difference in SSI risk was found compared to 10 or fewer. Interpretation Very low certainty of evidence indicated a marginal increase in SSI risk for each extra door opening per hour. However, a restriction on the number of door openings in the OR to a maximum of 10 per hour has little to no effect on SSI risk. Funding This systematic review is funded by the Dutch Stichting Kwaliteitsgelden Medisch Specialisten (SKMS, Foundation Quality Funds Medical Specialists).

Category: Midfoot/Forefoot Introduction/Purpose: Diabetes mellitus has been associated with an increased risk for postoperative surgical site infection (SSI) following foot and ankle surgery; however, among patients with diabetes, the level of perioperative glycemic control may affect the risk of postoperative SSI. There remains little evidence to support a perioperative hemoglobin A1c (HbA1c) level that could serve as a threshold for a significantly increased risk of postoperative SSI following foot surgery. The primary goal of the present study was to evaluate the association of perioperative glycemic control as demonstrated by hemoglobin a1c (HbA1c) in patients with diabetes with the incidence of postoperative SSI following elective foot surgery. Our secondary objective was to calculate a threshold level of HbA1c above which the risk of postoperative SSI after foot surgery increases significantly in patients with diabetes. Methods: A national administrative database was queried for patients who underwent common elective foot surgeries, including hallux valgus corrections, hallux rigidus correction and hammertoe corrections among others. Patients who underwent more complex procedures and patients with concomitant hindfoot procedures were excluded. Patients with diabetes mellitus who had a perioperative HbA1c level recorded within 3 months of surgery were identified; and were then stratified into thirteen mutually exclusive groups based on their hemoglobin a1c in 0.5 mg/dl increments from &lt; 5.49 mg/dl to &gt; 11.5 mg/dl. The incidence of SSI was determined by either a diagnosis or procedure for SSI within 1 year postoperatively using CPT and ICD-9 codes, and was calculated for each HbA1c patient group. A receiver operating characteristic (ROC) analysis was performed to determine an optimal threshold value of the HbA1c above which the risk of postoperative SSI was significantly increased. Results: 4,744 patients who underwent forefoot surgery with diabetes and a perioperative HbA1c recorded within 3 months of surgery in the database were included in the study. The rate of deep SSI requiring irrigation and debridement within one year postoperatively stratified by HbA1c is pictured in Figure 1, which ranged from a low of 2.5% to a high of 11.8% and was significantly correlated with increasing HbA1c levels (P &lt; 0.0001). The results of ROC analysis determined that the inflection point of the ROC curve corresponded to an HbA1c level above 7.5 mg/dL (P &lt; 0.0001, AUC = 0.622, spec. = 75%, sens. = 44%). Conclusion: The risk of postoperative SSI following elective foot surgery in patients with diabetes mellitus increases significantly as the perioperative HbA1c increases. ROC analysis determined that a perioperative HbA1c above 7.5 mg/dL could serve as a threshold for a significantly increased risk of postoperative SSI following elective foot surgery.

Health Care-Associated Infections in Surgical Patients Undergoing Elective Surgery: Are Alcohol Use Disorders a Risk Factor?

Healthcare associated infections (HAI) are unnecessary adverse events as they are preventable with proper implementation of the best evidence about the topic. The surgical site infections (SSI) account the 17% of HAI in the U.S. In South Asian countries the pooled estimate of SSI incidence according to a recently published meta-analysis was 8.6%, meanwhile a report of Rosenthal and colleagues describes higher incidence in low-income countries compared with U.S. data. In addition to the patient safety issues, the economic impact of these infections should be considered. In U.S. the total annual costs for the 5 major infections were $9.8 billion, with SSI contributing the most to overall costs (33.7% of the total), followed by the devices associated infections and Clostridium difficile infections. In European university hospital, the mean additional postoperative length of hospital stay was 16.8 days; and the mean additional in-hospital duration of antibiotic therapy was 7.4 days. The perioperative antibiot...