Incidence Of Deep Infection Research Articles

Preoperative prognostic nutritional index predicts postoperative surgical site infections in gastrointestinal fistula patients undergoing bowel resections.

Recent studies have implied a prognostic value of the prognostic nutritional index (PNI) in postoperative septic complications of elective colorectal surgeries. However, the evaluation of PNI in contaminated surgeries for gastrointestinal (GI) fistula patients is lack of investigation. The purpose of this study was to explore the predictive value of PNI in surgical site infections (SSIs) for GI fistula patients undergoing bowel resections.A retrospective review of 290 GI patients who underwent intestinal resections between November 2012 and October 2015 was performed. Univariate and multivariate analyses were conducted to identify risk factors for SSIs, and receiver operating characteristic cure was used to quantify the effectiveness of PNI.SSIs were diagnosed in 99 (34.1%) patients, with incisional infection identified in 54 patients (18.6%), deep incisional infection in 13 (4.5%), and organ/space infection in 32 (11.0%). receiver operating characteristic curve analysis defined a PNI cut-off level of 45 corresponding to postoperative SSIs (area under the curve [AUC] = 0.72, 76% sensitivity, 55% specificity). Furthermore, a multivariate analysis indicated that the PNI < 45 [odd ratio (OR): 2.24, 95% confidence interval (CI): 1.09-4.61, P = 0.029] and leukocytosis (OR: 3.70, 95% CI: 1.02-13.42, P = 0.046) were independently associated with postoperative SSIs.Preoperative PNI is a simple and useful marker to predict SSIs in GI fistula patients after enterectomies. Measurement of PNI is therefore recommended in the routine assessment of patients with GI fistula receiving surgical treatment.

The Value of Abdominal Drainage After Laparoscopic Cholecystectomy for Mild or Moderate Acute Calculous Cholecystitis: A Post Hoc Analysis of a Randomized Clinical Trial.

Although the preoperative management of mild and moderate (Grade I-II) acute calculous cholecystitis (ACC) has been standardized, there is no consensus on the value of abdominal drainage after early cholecystectomy. In a post hoc analysis of a randomized controlled trial (NCT01015417) focused on the value of postoperative antibiotic therapy in patients with ACC, we determined the value of abdominal drainage in patients having undergone laparoscopic cholecystectomy for Grades I-II ACC. All postoperative complications were analyzed after using a propensity score. A post hoc test was used to assess the statistical robustness of our results. Of the 414 enrolled patients, 178 did not have abdominal drainage (forming the no-drainage group) and 236 had drainage (the drainage group). After matching on PS, the deep incisional site infection was 1.1 versus 0.8%, p=0.78. This result is similar for the superficial incisional site infections; the distant infections; the overall morbidity, and the readmission rate. Only the hospital length of stay was significantly longer in the drainage group (3.3 vs. 5.1days, p=0.003). Neither abdominal drainage nor the absence of postoperative antibiotic therapy was found to be a risk factor for deep incisional site infections. The use of abdominal drainage depends on the surgeon's personal preferences but is often used in high-risk populations. However, abdominal drainage does not appear to be of any benefit (in terms of postoperative outcomes) and may even compromise recovery in patients having undergone early laparoscopic cholecystectomy for mild or moderate ACC.

The pre-operative levels of haemoglobin in the blood can be used to predict the risk of allogenic blood transfusion after total knee arthroplasty.

The pre-operative level of haemoglobin is the strongest predictor of the peri-operative requirement for blood transfusion after total knee arthroplasty (TKA). There are, however, no studies reporting a value that could be considered to be appropriate pre-operatively. This study aimed to identify threshold pre-operative levels of haemoglobin that would predict the requirement for blood transfusion in patients who undergo TKA. Analysis of receiver operator characteristic (ROC) curves of 2284 consecutive patients undergoing unilateral TKA was used to determine gender specific thresholds predicting peri-operative transfusion with the highest combined sensitivity and specificity (area under ROC curve 0.79 for males; 0.78 for females). Threshold levels of 13.75 g/dl for males and 12.75 g/dl for females were identified. The rates of transfusion in males and females, respectively above these levels were 3.37% and 7.11%, while below these levels, they were 16.13% and 28.17%. Pre-operative anaemia increased the rate of transfusion by 6.38 times in males and 6.27 times in females. Blood transfusion was associated with an increased incidence of early post-operative confusion (odds ratio (OR) = 3.44), cardiac arrhythmia (OR = 5.90), urinary catheterisation (OR = 1.60), the incidence of deep infection (OR = 4.03) and mortality (OR = 2.35) one year post-operatively, and increased length of stay (eight days vs six days, p < 0.001). Uncorrected low pre-operative levels of haemoglobin put patients at potentially modifiable risk and attempts should be made to correct this before TKA. Target thresholds for the levels of haemoglobin pre-operatively in males and females are proposed. Low pre-operative haemoglobin levels put patients at unnecessary risk and should be corrected prior to surgery.

Up Close and Personal: A Statewide Collaborative's Effort to Get Individual Surgeon Quality Improvement Data to the Practitioner

Ranking of surgeons and hospitals focuses on procedure volume and hospitality. The National Surgical Quality Improvement Program provides vetted outcomes of surgical quality and therefore can direct improvement. Our statewide collaborative's analysis creates personalized surgeon data to drive quality improvement. Statewide National Surgical Quality Improvement Program data generated specific measures from 103,656 general/vascular cases and identified individual surgeon's outcome of occurrences and length of procedure. We assumed a normal distribution and called the top 2.5 per cent as exemplars and the bottom 2.5 per cent as outliers. For length of operation, a standard duration was calculated, and identified outliers as longer than the 95th percentile of the upper confidence interval/procedure. Since 2009, sharing best practice reduced statewide mortality rate by 31.5 per cent and postoperative morbidity by 33.3 per cent. For length of surgery, long outliers have more complications (urinary tract infection, organ space/surgical site infection, sepsis, septic shock, prolonged intubation, pneumonia, deep venous thrombosis, deep incisional infection, and wound disruption). No significant trends in surgeon performance were seen over 24 months. A statewide collaborative has resulted in substantial risk-adjusted reductions in surgical morbidity and mortality. These results of the individual surgeon demonstrate best practices are shared, a proven tool for improvement in our collaborative.

Evidence for Replacement of an Infected Synthetic by a Biological Mesh in Abdominal Wall Hernia Repair.

The incidence of deep infection using a synthetic mesh in inguinal hernia repair is low and reported to be well below 1%. This is in contrast to incisional hernia surgery where the reported incidence is 3% respective 13% comparing laparoscopic to open mesh repair reported in a Cochrane review. Main risk factors were long operation time, surgical site contamination, and early wound complications. An infected mesh can be preserved using conservative treatment were negative pressure wound therapy (VAC(®)) could play an important role. If strategy fails, the mesh needs to be removed. This review aims to look at evidence for situations were a biological mesh would work as a replacement of a removed infected synthetic mesh. A literature search of the Medline database was performed using the PubMed search engine. Twenty publications were found relevant for this review. For studies reviewed three options are presented: removal of the infected synthetic mesh alone, replacement with either a new synthetic or a new biological mesh. Operations were all performed at specialist centers. Removal of the mesh alone was an option limited to inguinal hernias. In ventral/incisional hernias, the use of a biological mesh for replacement resulted in a very high recurrence rate, if bridging was required. Either a synthetic or a biological mesh seems to work as a replacement when fascial closure can be achieved. Evidence is though very low. When required, either a synthetic or a biological mesh seems to work as a replacement for an infected synthetic mesh if the defect can be closed. It is, however, not recommended to use a biological mesh for bridging. Mesh replacement surgery is demanding and is recommended to be performed in a specialist center.

Improved Accuracy of Caesarean Section Surgical Site Infection Surveillance Utilizing Post-Discharge Email

Conclusion As expected, post-discharge surveillance for patients who undergo C/S detected significantly more SSI, including deep incisional and organ space infections. However, improved post-discharge surveillance follow-up method and response rate did not correspond with an increase in SSI rate. Email follow-up was an efficient and effective method of post-discharge surveillance and should be included routinely in a SSI surveillance program for procedures associated with short hospital lengths of stay.

Incidence of postoperative wound infections after open tendo Achilles repairs.

Tendo Achilles (TA), which is the confluence of the gastrocnemius and soleus muscles, is one of the most commonly injured tendons. The surgical repair of TA ruptures is associated with a significant risk of infection. This study examined several factors (i.e. gender, age, body mass index, history of diabetes mellitus, steroid use, acute or chronic TA injuries, type of surgical incision and type of sutures used) that may be associated with postoperative wound infection after open TA repair. This was a retrospective study involving 60 patients who underwent open TA repair over an 18-month period. Patients who had prior TA surgery or open TA injuries, or who needed soft tissues flaps were excluded. Among the patients, 7 (11.7%) developed superficial wound infections that were successfully treated with oral antibiotics, while 3 (5.0%) developed deep wound infections that required at least one debridement procedure. No significant association was found between the risk of postoperative wound infection and gender, age, the presence of diabetes mellitus, acute or chronic ruptures, site of surgical incision and type of deep or superficial sutures used. While diabetes mellitus and age did not appear to be associated with postoperative wound infections after open TA repair, obese patients were found to be two times more likely to develop a wound infection than normal-weight patients. The incidence of superficial wound infections in this study was similar to previously published results (11.7% vs. 8.2%-14.6%), but the incidence of deep infections was higher (5% vs. 1%-2%).

Comparative study of single lateral locked plating versus double plating in type C bicondylar tibial plateau fractures.

Background:Bicondylar tibial plateau fractures are complex injuries and treatment is challenging. Ideal method is still controversial with risk of unsatisfactory results if not treated properly. Many different techniques of internal and external fixation are used. This study compares the clinical results in single locked plating versus dual plating (DP) using two incision approaches. Our hypothesis was that DP leads to less collapse and change in alignment at final followup compared with single plating.Materials and Methods:61 cases of Type C tibial plateau fractures operated between January 2007 and June 2011 were included in this prospective study. All cases were operated either by single lateral locked plate by anterolateral approach or double plating through double incision. All cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 10.0 to analyze the data.Results:Twenty nine patients in a single lateral locked plate and 32 patients in a double plating group were followed for minimum 2 years. All fractures healed, however there was a significant incidence of malalignment in the single lateral plating group. Though there was a significant increase in soft tissue issues with the double plating group; however, there was only 3.12% incidence of deep infection. There was no significant difference in Hospital for special surgery score at 2 years followup.Conclusion:Double plating through two incisions resulted in a better limb alignment and joint reduction with an acceptable soft tissue complication rate.

Intramedullary nail versus plate treatments for distal tibial fractures: A meta-analysis

IntroductionControversy remained on whether the optimal treatment for distal tibial fractures is intramedullary nail (IMN) or plate. MethodsDatabases including PubMed, Embase, Cochrane library, Wanfang and CNKI were retrieved up to May 31, 2014 for eligible studies. Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to evaluate literature qualities. Q and I2 test were applied to estimate heterogeneities. Moreover, subgroup analyses were performed and publication bias was detected. Mean difference (MD) and relative risk (RR), with their corresponding 95% confidence interval (CI) were used to calculate the pooled results. ResultsSixteen studies were included involving 1140 participants (IMN: 599; plate: 541). There were no significant differences between IMN and plate treatments in operation time (OT), hospital time (HT), union time (UT), and incidence of deep infection (DI) and union complications (UC). However, IMN achieved a significant lower superficial infection (SI) incidence (RR, 0.41; 95% CI, 0.23 to 0.71; P = 0.001) and a significant higher malunion incidence (RR, 2.27; 95% CI, 1.56 to 3.31; P < 0.001). In subgroup analyses, IMN had significant shorter OT than plate in randomized controlled trials (RCTs) (MD, -19.04; 95% CI, -24.86 to −13.21; P < 0.0001), but comparable incidence of SI to plate in non-Asia countries. No obvious publication bias was indicated in UT and malunion. ConclusionFor distal tibial fractures treatment, IMN might be advantageous over plate with lower SI incidence, and comparable UT, OT and HT. Meanwhile, IMN was related to higher risk of malunion. However, more RCTs are warranted.

National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis.

Patients undergoing surgical treatment of chronic ulcerative colitis usually undergo a staged approach to IPAA. The purpose of this work was to identify the national trends in approach to IPAA for chronic ulcerative colitis and to evaluate 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program. This was a retrospective review study : This study was conducted at a tertiary care cancer center. Patients with chronic ulcerative colitis who underwent IPAA from 2005 to 2011 were identified. Those who underwent colectomy with pouch procedure were placed in a 2-stage cohort, and those without simultaneous colectomy were part of a 3-stage cohort. Emergent operations were excluded. Trends in procedure mix, preoperative characteristics, and postoperative 30-day outcomes were compared. Multivariate analysis was used to identify independent risk factors for postoperative infection. Of 2002 patients who underwent IPAA, 1452 (72.5%) underwent 2-stage and 550 (27.5%) underwent 3-stage surgery. Since 2007, the distribution of 2- versus 3-stage procedures has not changed (p = 0.66). At the time of pouch surgery, patients who had undergone 3-stage surgery were less likely to have preoperative corticosteroid therapy, albumin <3 mg/dL, preoperative sepsis, and weight loss (all p < 0.05). Superficial surgical site infection was more common after 3-stage surgery (11.5% vs 7.3%; p < 0.01). After controlling for preoperative factors, wound classification was the only independent predictor of deep incisional or organ space infection (p < 0.01; OR, 1.76; 95% CI, 1.23-2.53). This was a retrospective study. National trends of 2- versus 3-stage IPAA have remained stable over the last 5 years. Patients who underwent a 3-stage approach were healthier at the time of pouch surgery, with decreased corticosteroid use, hypoalbuminemia, and weight loss. Mixed results were seen for infectious complications with either approach. Prospective research is needed to determine the best approach to IPAA for chronic ulcerative colitis.

IMpact of pocKet rEvision on the rate of InfecTion and other CompLications in patients rEquiring pocket mAnipulation for generator replacement and/or lead replacement or revisioN (MAKE IT CLEAN): A prospective randomized study.

The fibrous capsule around cardiac implantable device generators is known to promote bacterial colonization and latent infection. Removal of the capsule during device replacement procedures may reduce infection rates but may increase hemorrhagic complications. The purpose of this study was to evaluate the effect of pocket capsule decortication procedure on infection and bleeding rates in patients undergoing device replacement procedures. In a prospective randomized single-blind control study, patients undergoing device replacement, upgrade, or lead extraction were randomized to Group A "with pocket revision" (n = 131) and group B "without pocket revision" (n = 127). Deep and superficial infection rates, bleeding, and prolonged serous drainage were assessed during 12 months of follow-up. Data were analyzed according to intention-to-treat principle. A total of 258 patients were enrolled in the study. Rates of generator change, upgrade, and lead extraction/replacement were similar between both groups. There was no incidence of deep infection in either group at 12-month follow-up. There was no significant difference in the incidence of superficial infection between groups (1.5% vs 4.7%, P = .13) during 12-month follow-up. There was a significant increase in acute hematoma formation in group A compared to group B (6.1% vs 0.8%, P = .03). Two patients in group A had to undergo hematoma evacuation. There was increased incidence of hematoma formation in group A with no effect on infection rates. Our study suggests that there is no benefit to performing empiric pocket revision.

How Slow Is Too Slow? Correlation of Operative Time to Complications: An Analysis from the Tennessee Surgical Quality Collaborative

The Tennessee Surgical Quality Collaborative analyzes NSQIP data from 21 participating hospitals. The Tennessee Surgical Quality Collaborative has reduced surgical complications, but causative factors are unclear. We sought to correlate surgical duration with complications to reveal mitigating strategies. Risk-adjusted Tennessee Surgical Quality Collaborative data on 104,632 general and vascular cases had a standard duration for 35 procedures (eg, breast, colectomy) calculated and NSQIP outcomes complication rates recorded. We derived a marginal time risk for each extra hour of operative time and reported per 1,000 cases. Procedures taking <95% upper confidence standard time limit (n = 99,741) were deemed "not long" and had significantly fewer urinary tract infections, organ-space surgical site infection, sepsis/septic shock, prolonged intubation, and pneumonia. "Long" cases had increased rates of these complications and also deep venous thrombosis, deep incisional infection, and wound disruption. Per 1,000 cases, there were 116 occurrences per operating room hour. Surgical site infections occurred in 14.4/1,000 cases per hour; risk started at 42 minutes of operative time. Death, pneumonia, and prolonged intubation saw their risks begin before the operation. The highest marginal time risk was for sepsis, occurring 16.6 times per additional hour of operative time over standard. Studying only the 25,146 clean procedures, a significant correlation (p < 0.001) to operation duration persisted, despite an occurrence incidence of 4.5%. Duration of operation correlates with complications and time longer than a statewide established standard carries higher risk. To reduce risk of complications, these data support expeditious surgical technique and preoperative pulmonary training, and offer accurate outcomes assessment for patient counseling based on case duration. These data can be used directly to counsel individual surgeons to improve outcomes.

Particular Features of Surgical Site Infection in Posterior Lumbar Interbody Fusion.

BackgroundPrevious reports have observed differences only in infection rates between posterolateral fusion and posterior lumbar interbody fusion (PLIF). There have been no reports that describe the particular features of surgical site infection (SSI) in PLIF. In this study, we endeavor to identify the distinguishing characteristics and risk factors of SSI in PLIF.MethodsOur study undertook a review of a case series of an institute. Patients who had undergone PLIF consecutively in the author's hospital were reviewed. Two proactive procedures were introduced during the study period. One was irrigation of the autolocal bone, and the other was the intradiscal space irrigation with a nozzle. Infection rate and risk factors were analyzed. For subgroup analysis, the elapsed time to a diagnosis (ETD), clinical manifestations, hematologic findings, and causative bacteria were examined in patients with SSI.ResultsIn a total of 1,831 cases, there were 30 cases of SSI (1.6%). Long operation time was an independent risk factor (p = 0.008), and local bone irrigation was an independent protective factor (p = 0.001). Two cases of referred SSI were included in the subgroup analysis. There were 6/32 (19%) superficial incisional infections (SII), 6/32 (19%) deep incisional infections (DII), and 20/32 (62%) organ/space infections (O/SI). The difference of incidence among three groups was significant (p = 0.002).The most common bacteria encountered were methicillin-resistant Staphylococcus epidermidis followed by methicillin-resistant S. aureus in incisional infections, and no growth followed by S. epidermidis in O/SI. ETD was 8.5 ± 2.3 days in SII, 8.7 ± 2.3 days in DII and 164.5 ± 131.1 days in O/SI (p = 0.013).ConclusionsThe rate of SSI in PLIF was 1.6%, with the most common type being O/SI. The causative bacteria of O/SI was of lower virulence than in the incisional infection, and thus diagnosis was delayed due to its latent and insidious feature. Contamination of auto-local bone was presumed attributable to the progression of SSI. Irrigation of auto-local bone helped in the reduction of SSI.

All things not being equal: readmission associated with procedure type

BackgroundThere is an accelerated effort to reduce hospital readmissions despite minimal data detailing risk factors associated with this outcome. Materials and methodsWe analyzed National Surgical Quality Improvement Project data from January 1, 2011–December 31, 2011, evaluating all patients undergoing one of 34 targeted operative procedures across all surgical specialties. Multivariate regression models of risk for readmission were developed including targeted procedure codes, demographic variables, preoperative variables, intraoperative variables, and postoperative adverse events. Our main outcome measure was hospital readmission. ResultsA total of 217, 389 patients met study inclusion criteria. Minimal associations existed between patient factors and risk of readmission. Adverse events including unplanned operating room return (odds ratio [OR] 8.5; confidence interval [CI] 8.0–9.0), pulmonary embolism (OR 8.2; CI 7.1–9.6), deep incisional infection (OR 7.5; CI 6.7–8.5), and organ space infection (OR 5.8; CI 5.3–6.3) were associated with increased risk of readmission. Our data suggest the type of procedure performed is significantly associated with risk of readmission. Furthermore, multivariate analysis revealed procedures, involving the pancreas, rectum, bladder, and lower extremity vascular bypass, were associated with the highest risk of readmission. ConclusionsPostoperative complications demonstrated stronger association with readmission than patient factors. Focused analysis of higher risk procedures may provide insight into strategies for risk reduction.

The utilization of laparoscopy in ventral hernia repair: an update of outcomes analysis using ACS-NSQIP data.

Numerous prospective studies and randomized controlled trials have demonstrated shorter length of stay, lower morbidity rates, and similar recurrence rates with laparoscopic ventral hernia repair (VHR) when compared to open VHR. Despite these promising results, previous data showed low utilization of laparoscopic VHR. The aim of our study was to evaluate the utilization of laparoscopic VHR using the most updated information from the American College of Surgeons-National Surgical Quality Improvement Project (NSQIP) dataset. The secondary aim was to evaluate the outcomes from NSQIP for patients undergoing open versus laparoscopic VHR for the outcome of 30-day mortality and the peri-operative morbidities listed in the NSQIP dataset. We performed this study using 2009-2012 data from the ACS-NSQIP database. The study population included patients who had undergone an open or laparoscopic ventral hernia repair as their primary procedure based on CPT codes. Demographic characteristics, overall morbidity, and complications were compared using Chi-square tests for categorical variables and two-sided t tests for continuous variables. Secondary outcomes (mortality and any complications) were further analyzed using logistic regression. Utilization of laparoscopic VHR was 22%. While adjusted mortality was similar, overall morbidity was increased in the open VHR group (OR 1.63; CI 95% 1.38-1.92). The open group had a higher rate of return to the OR, pneumonia, re-intubation, ventilator requirement, renal failure/insufficiency, transfusion, DVT, sepsis, and superficial and deep incisional wound infections. The utilization of laparoscopic VHR remained low from 2009 to 2012 and continued to lag behind the use of laparoscopy in other complex surgical procedures. The mortality rate between laparoscopic and open VHR was similar, but laparoscopic repair was associated with lower overall complication rates.

Evidence-Based Approach to Reduce Surgical Site Infections After Cesarean Delivery

INTRODUCTION: The objective of this study was to determine if implementing infection control policies and an evidence-based checklist would reduce surgical site infection rate after cesarean delivery and identify which surgical site infection Centers for Disease Control and Prevention (CDC) classification will improve the most. METHODS: Infection control policies and a presurgical checklist of seven different evidence-based practices (ie, chlorhexidine, etc) were bundled and implemented at our institution. This is a retrospective chart review of 2,436 patients who had cesarean deliveries from January 2008 to September 2012. Patients were allocated into: group A (January 1, 2008, to January 31, 2010): 1,250 patients without intervention, group B (February 1, 2010, to September 31, 2012): intervention with checklist including 1,186 patients. Patients with surgical site infections were identified and then subdivided into CDC classifications: superficial incisional (SSI-1), deep incisional (SSI-2), and organ or space (SSI-3). Groups and surgical site infection subgroups were compared with χ2 test, Fisher's exact test, and standard Z test for statistical analyses. RESULTS: Our baseline surgical site infection rate after cesarean delivery was 6.2% with most infections being SSI-1 (84%) followed by SSI-3 (10.4%) and SSI-2 (5.2%). By implementing the checklist, the surgical site infection rate was 3.0%, a 51.61% reduction. If broken down into surgical site infection CDC classifications, we observed a 61.54% decrease in SSI-1 and 34.68% in SSI-3; SSI-2 had no reduction (Table 1). Implementation of our checklist can potentially reduce 95.92% of surgical site infections.CONCLUSIONS: Our evidence-based checklist effectively reduces the incidence of surgical site infections after cesarean deliveries. Most SSIs are SSI-1, primarily decreased with the checklist. The checklist did not affect deep incisional infections (SSI-2). Research geared toward identifying risk factors may be useful in establishing best practices to further decrease SSI-2.

Risk Factors for Infection Following Total Joint Arthroplasty in Rheumatoid Arthritis

Objectives: Determine risk factors for infection following hip or knee total joint arthroplasty in patients with rheumatoid arthritis.Methods: All rheumatoid arthritis patients with a hip or knee arthroplasty between years 2000 and 2010 were identified from population-based administrative data from the Calgary Zone of Alberta Health Services. Clinical data from patient charts during the hospital admission and during a one year follow-up period were extracted to identify incident infections. Results: We identified 381 eligible procedures performed in 259 patients (72.2% female, mean age 63.3 years, mean body mass index 27.6 kg/m2). Patient comorbidities were hypertension (43.2%), diabetes (10.4%), coronary artery disease (13.9%), smoking (10.8%) and obesity (32%). Few infectious complications occurred: surgical site infections occurred within the first year after 5 procedures (2 joint space infections, 3 deep incisional infections). Infections of non-surgical sites (urinary tract, skin or respiratory, n=4) complicated the hospital admission. The odds ratio for any post-arthroplasty infection was increased in patients using prednisone doses exceeding 15 mg/day (OR 21.0, 95%CI 3.5-127.2, p=<0.001), underweight patients (OR 6.0, 95%CI 1.2-30.9, p=0.033) and those with known coronary artery disease (OR 5.1, 95%CI 1.3-19.8, p=0.017). Types of disease-modifying therapy, age, sex, and other comorbidities were not associated with an increased risk for infection.Conclusion: Steroid doses over 15 mg/day, being underweight and having coronary artery disease were associated with significant increases in the risk of post-arthroplasty infection in rheumatoid arthritis. Maximal tapering of prednisone and comorbidity risk reduction must be addressed in the peri-operative management strategy.

Answer to the Letter to the Editor of Zafar Ahmad et al. concerning “Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized controlled trial of efficacy” by Albert HB et al., Eur Spine J (2013) 22:697–707

Thank you for your comments; we are happy that our papers have stimulated scientific discussions in the world of back science. Your question as to which drug to use is a very important and crucial question. You find it, “odd that we used co-amoxiclav to treat the infection, when clavulanic acid has little disc penetration. Amoxicillin would have been more logical, as it has a narrower spectrum, and is known to be effective against Propionibacterium acnes, although it too has poor penetration of the intervertebral disc” The answer is twofold. First, three independent international experts in infectious diseases were presented with the bacterial culture results of Stirling’s study [1] and all three recommended Amoxicillin-clavulanate. Second, we agree with you that clavulanic acid is most probably superfluous, but at the time of the planning of the study we were not able to obtain pure Amoxicillin. We therefore had no choice but to use co-amoxiclav. In the question regarding penetration, your reference 7 our Ref. [2] did find levels of both amoxicillin and clavulanic acid in the discs. The paper concludes that these antibiotics do not penetrate into discs as well as gentamicin, but we believe that levels of amoxicillin achieved would be effective against P. acnes. We based this view on an earlier study by Housden and Sullivan [3] that showed that augmentin (Amoxicillin-clavulanate) does penetrate discs, although to a limited extent. In making our choice of antibiotics we needed safe oral agents. Although we were aware that gentamicin penetrates discs well, it would not have been suitable for the study and not for P. acnes (an anaerobic organism). Similarly injectable cephalosporins (the accepted choice for prophylaxis in spinal surgery) would not have been suitable for the study where extended periods of oral delivery were needed. We agree that in the perfect study we could have taken skin swabs during surgery, but we relied on the efficacious skin cleansing techniques (2 % chlorhexidine in 70 % isopropanol) that have been developed at Aston University where this cleansing technique has shown in thesis by Crosby [4] to be more significantly more efficacious than other skin cleansing techniques in both superficial and deep incisional infections. This was confirmed by the main clinical trial that was carried out in USA comparing chloraprep with aqueous chlorhexidine and was published in the New England Journal of Medicine in 2010 [5]. These techniques were used in both Stirling’s study and ours. We therefore consider the risk of contamination to be minimal.

Answer to the letter to the editor of A. Sotto et al. concerning “Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized controlled trial of efficacy” by Albert HB et al., Eur Spine J (2013) 22:697–707

Thank you for your comments; we are happy that our papers have stimulated scientific discussions in the world of back science. Your question as to which drug to use is a very important and crucial question. You find it, “odd that we used co-amoxiclav to treat the infection, when clavulanic acid has little disc penetration. Amoxicillin would have been more logical, as it has a narrower spectrum, and is known to be effective against Propionibacterium acnes, although it too has poor penetration of the intervertebral disc” The answer is twofold. First, three independent international experts in infectious diseases were presented with the bacterial culture results of Stirling’s study [1] and all three recommended Amoxicillin-clavulanate. Second, we agree with you that clavulanic acid is most probably superfluous, but at the time of the planning of the study we were not able to obtain pure Amoxicillin. We therefore had no choice but to use co-amoxiclav. In the question regarding penetration, your reference 7 our Ref. [2] did find levels of both amoxicillin and clavulanic acid in the discs. The paper concludes that these antibiotics do not penetrate into discs as well as gentamicin, but we believe that levels of amoxicillin achieved would be effective against P. acnes. We based this view on an earlier study by Housden and Sullivan [3] that showed that augmentin (Amoxicillin-clavulanate) does penetrate discs, although to a limited extent. In making our choice of antibiotics we needed safe oral agents. Although we were aware that gentamicin penetrates discs well, it would not have been suitable for the study and not for P. acnes (an anaerobic organism). Similarly injectable cephalosporins (the accepted choice for prophylaxis in spinal surgery) would not have been suitable for the study where extended periods of oral delivery were needed. We agree that in the perfect study we could have taken skin swabs during surgery, but we relied on the efficacious skin cleansing techniques (2 % chlorhexidine in 70 % isopropanol) that have been developed at Aston University where this cleansing technique has shown in thesis by Crosby [4] to be more significantly more efficacious than other skin cleansing techniques in both superficial and deep incisional infections. This was confirmed by the main clinical trial that was carried out in USA comparing chloraprep with aqueous chlorhexidine and was published in the New England Journal of Medicine in 2010 [5]. These techniques were used in both Stirling’s study and ours. We therefore consider the risk of contamination to be minimal.

A Comparative Assessment of Surgeons' Tracking Methods for Surgical Site Infections

The incidence of surgical site infections (SSI) is considered increasingly to be an indicator of quality of care. We conducted a study in which daily inspection of the surgical incision was performed by an independent, trained team to monitor the incidence of SSI using U.S. Centers for Disease Control and Prevention (CDC) definitions, as a gold-standard measure of care. In the department of surgery, two registration systems for SSI were used routinely by the surgeon: An electronic and a plenary tracking system. The results of the independent team were compared with the outcomes provided by two registration systems for SSI, so as to evaluate the reliability of these systems as a possible alternative for indicating quality of care. The study was an incidence study conducted from May 2007 to January 2009 that included 1,000 adult patients scheduled to undergo open abdominal surgery in an academic teaching hospital. Surgical incisions were inspected daily to check for SSI according to definitions of health care-associated infections established by the CDC. Follow-up after discharge was done at the outpatient clinic of the hospital by telephone or letter in combination with patient diaries and reviews of patient charts, discharge letters, electronic files, and reported complications. Univariate and multivariable analyses were done to identify putative risk factors for missing registrations. Of the 1,000 patients in the study, 33 were not evaluated. Surgical site infections were diagnosed in 26.8% of the 967 remaining patients, of which 18.0% were superficial incisional infections, 5.4% were deep incisional infections, and 3.4% were organ/space infections. More than 60% of SSIs were unreported in either of the department's two tracking systems for such infections. For these two systems, independent major risk factors for missing registrations were (1) the lack of occurrence of an SSI, (2) transplantation surgery, and (3) admission to non-surgical departments. Most SSIs were not tracked with the department's two systems. These systems proved poor alternatives to the gold-standard method of quantifying the incidence of Surgical Site Infection SSI and, therefore, the quality of care. Both protocolized wound assessment and on-site documentation are mandatory for realistic quantification of the incidence of SSI.