30-day Postoperative Surgical Site Infection Research Articles

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis

Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship. To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics. This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023. Continuation of antibiotics after appendectomy. Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering. A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70). Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting

Background Surgical site infection (SSI), albeit infrequent, drastically impacts the quality of care. This article endeavors to investigate the predictive factors of SSIs following surgical interventions that involve the gastrointestinal (GI) tract within a single institution in a resource-limited setting. Methods Over seven years from June 2015 to June 2022, patients who underwent GI surgery and developed SSI were retrospectively matched with an unaffected case-control cohort of patients. Standardized techniques for wound culture, laboratory evaluation of bacterial isolates, and antibiotic susceptibility tests were employed. Logistic regression analysis was utilized to investigate the predictive factors associated with 30-day postoperative SSI occurrence. Results A total of 525 patients who underwent GI surgical procedures were included, among whom, 86 (16.4%) developed SSI and the majority of SSIs were superficial (74.4%). Escherichia coli was the most commonly isolated bacterium (54.4%), and a high percentage of multidrug-resistant organisms were observed (63.8%). In multivariate Cox regression analysis, illiteracy (Odds ratio [OR]:40.31; 95% confidence interval [CI]: 9.54-170.26), smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI:1.62-26.09), longer operation duration (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and extending antibiotic prophylaxis duration (OR: 3.01; 95% CI: 1.28-7.10) were the independent risk factors for SSI (all p < 0.05). Conclusions This study highlights significant predictors of SSI, including illiteracy, smoking, diabetes, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operative time, emergency operations, and extending antibiotic prophylaxis duration. Identifying these risk factors can help surgeons adopt appropriate measures to reduce postoperative SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI.

Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting

Background: Surgical site infection (SSI), albeit infrequent, drastically impact the quality of care. This article endeavors to investigate the predictive factors of SSIs following surgical interventions that involve the gastrointestinal (GI) tract within a single institution in a resource-limited setting. Methods: Over seven years from June 2015 to Oct 2022, patients who underwent GI surgery and developed SSI were retrospectively matched with an unaffected case-control cohort of patients. Standardized techniques for wound culture, laboratory evaluation of bacterial isolates, and antibiotic susceptibility tests were employed. Logistic regression analysis was utilized to investigate the predictive factors associated with 30-day postoperative SSI. Results: A total of 525 patients who underwent GI surgical procedures were included, among whom, 79 (15%) developed SSI. The majority of SSIs were superficial (67.10%), Escherichia coli was the most commonly isolated bacterium (54.4%), and a high percentage of multidrug-resistant organisms were observed (63.8%). In multivariate Cox regression analysis, illiteracy (Odds ratio [OR]:40.31; 95% confidence interval [CI]: 9.54-170.26), smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI:1.62-26.09), longer operative time (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and extending antibiotic prophylaxis duration (OR: 3.01; 95% CI: 1.28-7.10) were the independent risk factors for SSI (all p < 0.05). Conclusions: This study highlights significant predictors of SSI, including illiteracy, smoking, diabetes, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operative time, emergency operations, and extending antibiotic prophylaxis duration. Identifying these risk factors can help surgeons adopt appropriate measures to reduce postoperative SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery

Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized. To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery. This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery. Continuation of antimicrobial prophylaxis beyond time of incision closure. Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures. Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85). Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis

The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis. To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization. This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020. The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports. The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals. Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001). In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.

Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis.

In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction. We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space). We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48-0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42-0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46-0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50-0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions. Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.

The association of preoperative haemoglobin A1c with 30-day postoperative surgical site infection following non-cardiac surgery.

Diabetes has been shown to be associated with postoperative infections; however, the association of haemoglobin A1c (HbA1c) with postoperative surgical site infections (SSI) is unclear. All HbA1c data from patients receiving general, vascular, or orthopaedic surgeries between 1 January 2014 and 1 December 2016 were identified from hospital records. The primary outcome was 30-day SSI. Multivariable logistic regression was performed to determine if HbA1c was associated with infection. The cohorts assessed were: (1) HbA1c < 6.5% (reference group); (2) greater than or equal to 6.5% and less than 8.0%; (3) greater than or equal to 8.0% and less than 10.0%; and (4) greater than or equal to 10.0%. There were 3064 patients included in the final analysis. The overall rate of 30-day SSI was 2.42%. After adjusting for confounders, when compared to the reference group, HbA1c ≥ 8.0% and less than 10.0% (OR 2.4, 95% CI 1.2-4.7, p = 0.015) and HbA1c ≥ 10.0% (OR 3.0, 95% CI 1.2-7.3, p = 0.016) had increased odds ratio for 30-day SSI. A HbA1c of 8.0% or higher significantly increased the odds ratio of developing postoperative SSI (p < 0.05). This may aid in the development of guidelines for optimising diabetic patients.

Association of Hospital Altitude and Postoperative Infectious Complications After Major Operations.

Introduction: The relationship between altitude during treatment and common postoperative infections remains to be established. Based on the inverse relationship between oxygen partial pressure and altitude, we hypothesized that hospital elevation would correlate positively with postoperative infectious complication rates, including surgical site infection (SSI), urinary tract infection (UTI), and pneumonia. Methods: We used an event-enriched population of general, urologic, vascular, plastic-reconstructive, orthopedic, and thoracic patients within the 2016 ACS National Surgical Quality Improvement Program (NSQIP) dataset who underwent procedures with high risk of infectious complications. This yielded 82,172, 175,409, and 88,856 patients from 571, 577, and 570 hospitals for the study of 30-day postoperative SSI, UTI, and pneumonia outcomes respectively. Hospital altitudes were determined using Google Maps. Data were analyzed using univariate (altitude) and multivariate logistic regression, with altitude forced into the model, and forward-selection of NSQIP variables, with adjustment for clustering by hospital. Results: When compared in 1000-foot increments above sea level, hospital altitude had no significant effect on SSI or UTI (odds ratio [OR] = 1.0, p > 0.05). The risk of postoperative pneumonia decreased with increased altitude (OR = 0.93, 95% confidence interval: 0.87-0.99, p = 0.03). Conclusions: Patients and providers should be reassured that there is no increased risk of SSI or UTI at higher altitudes. The decreased risk of postoperative pneumonia was surprising and there exist potential explanations warranting future investigation.

Comparison of olanexidine versus povidone-iodine for preventing surgical site infection in gastrointestinal surgery: study protocol for a multicentre, single-blind, randomised controlled clinical trial

IntroductionThe prevalence of surgical site infection (SSI) remains higher in gastrointestinal surgery than in other surgeries. Although several guidelines have indicated the efficacy of chlorhexidine and povidone-iodine in reducing the...

Utilization of a specimen retrieval bag during laparoscopic appendectomy for both uncomplicated and complicated appendicitis is not associated with a decrease in postoperative surgical site infection rates

BackgroundTo determine whether utilization of a retrieval bag during laparoscopic appendectomy for uncomplicated and complicated appendicitis (perforation/abscess) is associated with postoperative surgical site infection rates. MethodsWe studied patients presented in the database of the 2016 Appendectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program who underwent laparoscopic appendectomy for pathology-confirmed appendicitis. The primary predictor variable was intraoperative utilization of a specimen retrieval bag for removal of the appendix from the peritoneal cavity. The primary outcome variable was 30-day postoperative surgical site infection. Logistic regression analysis was used to determine the association between use of a specimen retrieval bag and postoperative surgical site infection rate after adjustment for patient- and disease-related variables. ResultsA total of 10,357 patients were included for analysis. Of these procedures, 9,585 (92.6%) included the use of a specimen bag and 772 (7.5%) did not. The 30-day incidence of postoperative surgical site infection was 4.2% in the group in which no bag was used and 3.6% in the group in which a bag was used (adjusted odds ratio of surgical site infection with no bag utilization was 1.15 [95% confidence interval 0.78–1.69; P = .49]). The lack of a statistically significant association between bag utilization and postoperative surgical site infection incidence was also demonstrated for a subgroup of patients with perforated appendicitis. ConclusionUtilization of a retrieval bag during laparoscopic appendectomy is not associated with a statistically significant decrease in postoperative surgical site infection for either uncomplicated or complicated acute appendicitis.

The Obese Colorectal Surgery Patient: Surgical Site Infection and Outcomes

Obese patients undergoing colorectal surgery are at increased risk for adverse outcomes. It remains unclear whether these risks can be further defined with more discriminatory stratifications of obesity. The purpose of this study was to understand the association between BMI and 30-day postoperative outcomes, including surgical site infection, among patients undergoing colorectal surgery. This was a retrospective cohort study. The 2011-2013 American College of Surgeons National Surgical Quality Improvement Program database was used. Patients included those undergoing elective colorectal surgery in 2011-2013 who were assessed by the American College of Surgeons National Surgical Quality Improvement Program. BMI was categorized into World Health Organization categories. Primary outcome was 30-day postoperative surgical site infection. Secondary outcomes included all American College of Surgeons National Surgical Quality Improvement Program-assessed 30-day postoperative complications. Our cohort included 74,891 patients with 4.4% underweight (BMI <18.5), 29.0% normal weight (BMI 18.5-24.9), 33.0% overweight (BMI 25.0-29.9), 19.8% obesity class I (BMI 30.0-34.9), 8.4% obesity class II (BMI 35.0-39.9), and 5.5% obesity class III (BMI ≥40.0). Compared with normal-weight patients, obese patients experienced incremental odds of surgical site infection from class I to class III (I: OR = 1.5 (95% CI, 1.4-1.6); II: OR = 1.9 (95% CI, 1.7-2.0); III: OR = 2.1 (95% CI, 1.9-2.3)). Obesity class III patients were most likely to experience wound disruption, sepsis, respiratory or renal complication, and urinary tract infection. Mortality was highest among underweight patients (OR = 1.3 (95% CI, 1.0-1.8)) and lowest among overweight (OR = 0.8 (95% CI, 0.6-0.9)) and obesity class I patients (OR = 0.8 (95% CI, 0.6-1.0)). Retrospective analysis of American College of Surgeons National Surgical Quality Improvement Program hospitals may not represent patients outside of the American College of Surgeons National Surgical Quality Improvement Program and cannot assign causation or account for interventions to improve surgical outcomes. Patients with increasing BMI showed an incremental and independent risk for adverse 30-day postoperative outcomes, especially surgical site infections. Strategies to address obesity preoperatively should be considered to improve surgical outcomes among this population. See Video Abstract at http://links.lww.com/DCR/A607.

Risk Factors and Predictive Model Development of Thirty-Day Post-Operative Surgical Site Infection in the Veterans Administration Surgical Population.

Surgical site infection (SSI) complicates approximately 2% of surgeries in the Veterans Affairs (VA) hospitals. Surgical site infections are responsible for increased morbidity, length of hospital stay, cost, and mortality. Surgical site infection can be minimized by modifying risk factors. In this study, we identified risk factors and developed accurate predictive surgical specialty-specific SSI risk prediction models for the Veterans Health Administration (VHA) surgery population. In a retrospective observation study, surgical patients who underwent surgery from October 2013 to September 2016 from 136 VA hospitals were included. The Veteran Affairs Surgical Quality Improvement Program (VASQIP) database was used for the pre-operative demographic and clinical characteristics, intra-operative characteristics, and 30-day post-operative outcomes. The study population represents 11 surgical specialties: neurosurgery, urology, podiatry, otolaryngology, general, orthopedic, plastic, thoracic, vascular, cardiac coronary artery bypass graft (CABG), and cardiac valve/other surgery. Multivariable logistic regression models were developed for the 30-day post-operative SSIs. Among 354,528 surgical procedures, 6,538 (1.8%) had SSIs within 30 days. Surgical site infection rates varied among surgical specialty (0.7%-3.0%). Surgical site infection rates were higher in emergency procedures, procedures with long operative duration, greater complexity, and higher relative value units. Other factors associated with increased SSI risk were high level of American Society of Anesthesiologists (ASA) classification (level 4 and 5), dyspnea, open wound/infection, wound classification, ascites, bleeding disorder, chemotherapy, smoking, history of severe chronic obstructive pulmonary disease (COPD), radiotherapy, steroid use for chronic conditions, and weight loss. Each surgical specialty had a distinct combination of risk factors. Accurate SSI risk-predictive surgery specialty-specific models were developed with number of variables ranging from 9 to 21 and the C-index ranging from 0.63 to 0.81, indicating acceptable discrimination. The decile plot of predicted versus observed SSI rates showed strong calibration. Surgery specialty-specific risk factors of 30-day post-operative SSI rates have been identified for a variety of surgery specialties. Accurate SSI risk-predictive surgery specialty-specific SSI predictive models have been developed and validated for the VHA surgery population. These models can be used to develop optimal preventive measures for high-risk patients, patient-centered care planning, and surgical quality improvement.

Postoperative outcomes in vedolizumab-treated Crohn's disease patients undergoing major abdominal operations.

Up to 80% of patients with Crohn's disease require an abdominal operation in their lifetime. As the use of vedolizumab is increasing for the treatment of Crohn's disease, it is important to understand its potential association with post-operative complications. We sought to compare 30-day postoperative infectious complication rate among vedolizumab-treated Crohn's disease patients vs those who had received TNFα inhibitors or no biologic therapy. A retrospective review of all Crohn's disease patients who received vedolizumab within 12weeks of a major abdominal or pelvic operation was performed. Two control cohorts consisted of Crohn's disease patients treated with TNFα inhibitors or no biologic therapy. One hundred Crohn's disease patients received vedolizumab within 12weeks of an abdominal operation. Vedolizumab-treated patients underwent an equivalent rate of laparoscopic surgery (P=.25), had fewer anastomoses performed (P=.0002), and had equally frequent diversion in the setting of anastomoses (P=.47). Thirty-two vedolizumab-treated patients experienced postoperative infectious complications (32%), 26 of which were surgical site infections (26%). The vedolizumab-treated group experienced no difference in nonsurgical site infections (6% vs 5% anti-TNFα and 2% nonbiologic; P=.34), but significantly higher rates of surgical site infections (26% vs 8% and 11%; P<.001). On univariate and multivariate analysis, exposure to vedolizumab remained a significant predictor of postoperative surgical site infection (P<.001 and P=.002). Twenty-six per cent of Crohn's disease patients who received vedolizumab within 12weeks prior to a major abdominal operation experienced a 30-day postoperative surgical site infection, significantly higher than that of patients receiving TNFα inhibitors or no biologic therapy. Vedolizumab within 12weeks of surgery remained a predictor of 30-day postoperative surgical site infection on multivariable analysis. While vedolizumab-treated Crohn's disease patients may be a sicker cohort of patients, it is important to consider these findings with regard to preoperative counselling, operative timing and primary closure of wounds.

Postoperative outcomes in vedolizumab-treated pediatric patients undergoing abdominal operations for inflammatory bowel disease

IntroductionRecent studies have found vedolizumab to be an independent predictor of increased rates of postoperative complications and surgical site infections (SSIs) in adults with inflammatory bowel disease (IBD), but studies in the pediatric surgical population are lacking. We sought to determine the 30-day postoperative infectious complication rate among pediatric IBD patients who received vedolizumab within 12weeks of a major abdominal operation. MethodsA retrospective chart review was performed on pediatric IBD patients who underwent an abdominal operation between 5/20/2014 and 6/1/2017. The study cohort was comprised of pediatric patients (≤18years) who received vedolizumab within 12weeks prior to their abdominal operation. The control cohort was all patients operated on for IBD during the same time on anti-TNF therapy within 12weeks of their abdominal operation. ResultsThirteen pediatric patients (5 female) received vedolizumab within 12weeks of an abdominal operation and 36 patients received anti TNF therapy (20 female). There were no differences in the vedolizumab and anti-TNF therapy with regard to sex, median age of diagnosis or operation, IBD type, body mass index (BMI), smoking status, diabetes mellitus (DM), preoperative serum laboratory values, steroid or immunomodulatory use. The number of biologics previously exposed to was significantly higher in the vedolizumab treated patients (p<0.0001). There were no significant differences in operative characteristics including laparoscopic versus open surgery, construction of an anastomosis, or diversion of an anastomosis. There were also no significant differences found in 30-day postoperative complications including nonsurgical site infections (SSIs), all SSIs, small bowel obstruction (SBO)/ileus, hospital readmission, or return to the operating room (ROR). There were four RORs in total: one in the vedolizumab group was for a missed enterotomy and stoma revision; three in the anti-TNF cohort were for ileostomy revisions. ConclusionsNone of the thirteen pediatric patients who received vedolizumab within 12weeks of an abdominal operation experienced a 30-day postoperative SSI or non SSI infectious complication, suggesting that vedolizumab is safe in the perioperative period for pediatric patients with IBD. Owing to the small sample size, future study, perhaps multi-institutional, will be important to confirm these findings. Level of evidenceRetrospective comparative study, Level III.

Quality Check of a Quality Measure: Surgical Wound Classification Discrepancies Impact Risk-Stratified Surgical Site Infection Rates in Pediatric Appendicitis

The impact of quality measures in health care and reimbursement is growing. Ensuring the accuracy of quality measures, including any risk-stratification variables, is necessary. Surgical site infection rates, risk stratified by surgical wound classification (SWC) among other variables, are increasingly considered as quality measures. We hypothesized that hospital-documented and diagnosis-based SWCs are frequently discordant and that diagnosis-based SWCs better predict surgical site infection rates. All pediatric patients (ie, younger than 18 years old) at a single institution who underwent an appendectomy for appendicitis between October 1, 2010 and August 31, 2011 were included. Each chart was reviewed to determine the hospital-documented SWC, which is recorded by the circulating nurse (options included clean, clean-contaminated, contaminated, and dirty); SWC based on the surgeons' postoperative diagnosis, including contaminated (ie, acute nonperforated, nongangrenous appendicitis), dirty (ie, gangrenous and perforated appendicitis), and 30-day postoperative surgical site infections. Of the 312 evaluated appendicitis cases, the diagnosis-based and circulating nurse-based SWCs differed in 288 (92%) cases. The circulating nurse-based and diagnosis-based SWCs differed by more than one SWC in 176 (56%) cases. Surgical site infections were associated with worsening diagnosis-based SWC, but not with circulating nurse-based SWC. Significant discordance exists between hospital documentation by the circulating nurse- and surgeon diagnosis-based SWCs. Inconsistency in risk-stratified quality measures can have a significant effect on outcomes measures, which can lead to misdirection of quality-improvement efforts, incorrect inter-hospital rating, reduced reimbursements, and public misperceptions about quality of care.

Continuous versus Intermittent Infusion of Prophylactic Cefoxitin After Colorectal Surgery: A Pilot Study

To compare 30-day postoperative surgical site infections (SSIs) and rates of antibiotic discontinuation within 24 hours after surgery in patients receiving continuous-infusion versus intermittent-infusion cefoxitin for postoperative antibiotic prophylaxis. Retrospective, cohort-matched pilot study. Tertiary-care medical center. One hundred sixteen adults undergoing colorectal surgery between August 1, 2004, and February 28, 2007. Cefoxitin prophylaxis was administered as a continuous infusion in 58 patients and as an intermittent infusion in 58 patients (controls). The controls received weight-based doses of cefoxitin (1 g if < or = 80 kg or 2 g if > 80 kg) every 8 hours for three doses, starting 3 hours after surgery and completed within 24 hours. The continuous-infusion group were given weight-based doses of cefoxitin (3 g if < or = 80 kg, 6 g if > 80 kg), started immediately after surgery and infused over 20 hours. Patients and controls were matched according to colorectal procedure and risk index category. They were stratified by medium risk (50 patients) and low risk (66 patients) for the end point of 30-day postoperative SSI. For the 25 medium-risk patients who received the continuous infusion, a 50% relative reduction in the 30-day postoperative SSI rate was observed with continuous versus intermittent infusion (4% vs 8%, p=0.55). For the 66 low-risk patients, 30-day postoperative SSI rates were equal (3%) with both intermittent and continuous infusions. Risk stratification was not performed for the proportion of patients who discontinued antibiotic prophylaxis within 24 hours after surgery. All patients receiving the continuous infusion met this end point compared with 47 (83.9%) of the 56 controls (p=0.0015) included in the analysis. Compared with intermittent infusion, continuous infusion of cefoxitin for postoperative prophylaxis resulted in a nonsignificant reduction in 30-day postoperative SSI rates in medium-risk patients undergoing colorectal surgery. Continuous infusion also resulted in reliable discontinuation of postoperative prophylaxis within 24 hours.