Increase In Surgical Site Infections Research Articles

Increase in Surgical Site Infections Caused by Gram-Negative Pathogens in Warmer Weathers Data From More Than 2 Million Surgeries

Background: Various studies have linked periods of warmer temperatures to an increased occurrence of surgical site infections (SSIs) and healthcare-associated infections in general. In an observational study, we sought to determine the pathogens for which this association was especially strong. Method: Patient- and procedure-related data of the SSI-module of the German nosocomial infection surveillance system were linked with monthly aggregated meteorological data from the German Meteorological Service for a period from 2000 to 2016. Due to high correlation with other meteorological parameters, analyses were executed focusing on the outside ambient temperature. Temperature was regarded as both a continuous variable and a categorical variable with different temperature intervals (5°C steps ranging from <5°C to ≥20°C). Through multivariable logistic regression analysis, adjusted odds ratios (OR) with 95% confidence intervals were calculated for SSI rates relating to temperature. SSIs were stratified by pathogen and depth of infiltration. Result: Altogether, 2,004,793 procedures, conducted in 1,455 German surgical departments and resulting in 32,118 SSIs, were included. A general association of warmer mean temperatures in the month of surgery with an increased SSI-risk was observed, particularly for SSIs caused by gram-negative pathogens. Stratification by pathogen revealed that the association was especially prominent for Acinetobacter spp, Pseudomonas aeruginosa, and certain Enterobacteriaceae. Per additional 1°C, we observed a 6% increase in the risk for SSIs caused by Acinetobacter spp (OR, 1.06; 95% CI, 1.04–1.09), and a 4% increase in the risk for SSIs caused by Enterobacter spp (OR, 1.04; 95% CI, 1.03–1.05). Among gram-positive pathogens, temperature-association was strongest for Staphylococcus aureus. Superficial SSIs showed a higher temperature-association than deeper SSIs. The risk for superficial SSIs with Acinetobacter spp significantly increased >10-fold after surgeries conducted in months with a mean temperature of ≥20°C in reference to <5°C. For Pseudomonas aeruginosa, we observed a >2-fold statistically significant increase in the risk for superficial SSIs, when comparing the same temperature categories (≥20°C vs <5°C). Conclusions: Our study demonstrated that higher temperatures were associated with increased SSI-rates caused by gram-negative bacteria. As a consequence, future SSI-prevention measures should place a higher emphasis on the parameter season as part of a more tailormade, personalized approach at infection prevention. For instance, it may be conceivable to seasonally adjust decolonizing regimes and certain prophylaxes. Underlying shifts in microbiome composition due to meteorological factors should be considered in further analyses. Given the expected rise of global temperatures until the end of the century, the topic gains relevance from multiple perspectives.Funding: NoneDisclosures: None

Is antibiotic prophylaxis necessary in mid-urethral sling surgery?

Introduction and hypothesisAntibiotic prophylaxis is commonly used when implanting a mid-urethral sling (MUS) for female stress urinary incontinence. Use of antibiotics may lead to adverse events and the development of antibiotic resistance. This study compared a variety of outcomes after MUS surgery with and without antibiotic prophylaxis using data from the national Norwegian Female Incontinence Registry.MethodsPreoperative and 6–12 months postoperative subjective and objective data from 28,687 patients who received MUS surgery from 1998 through 2017 were extracted from the registry. Categorical outcomes were compared between women with or without antibiotic prophylaxis using chi-square test for independence. Primary outcome was incidence of postoperative surgical site infection (SSI). Secondary outcomes were incidence of tape exposure, de novo or persistent urgency urinary incontinence, postoperative pain > 3 months, subjective and objective cure rates, and patient satisfaction.ResultsAntibiotic prophylaxis was used in 9131 and not used in 19,556 patients. SSIs and prolonged postoperative pain occurred significantly more often without antibiotic prophylaxis. Subjective and objective cure rates were significantly higher and tape exposures significantly lower in women not receiving prophylactic antibiotics. There were no significant differences in other outcomes.ConclusionsAntibiotic prophylaxis resulted in fewer women developing postoperative infections or prolonged postoperative pain after MUS surgery, but did not offer protection against tape exposure. The differences in cure rates were small and probably without clinical relevance. If a small increase in surgical site infections is accepted, the routine use of antibiotic prophylaxis can probably be omitted.

Outcomes in patients with late debridement of open long bone fractures of the lower extremities in penetrating trauma: a retrospective review of the National Trauma Data Bank.

The morbidity and mortality associated with open long bone fractures have been greatly reduced due to antibiotics and early surgical washout and debridement. Guidelines recommend early washout and debridement within 6-8h; however, newer studies have shown that delaying surgical washout and debridement up to 24h can be done safely without an increase in surgical site infection, wound nonunion or sepsis. All studies thus far have looked at combined blunt and penetrating open long bone fractures, without distinguishing between mechanism or type of injury. Our study looked specifically at open long bone fractures of the lower extremity caused by a penetrating mechanism of injury. We utilized the US National Trauma Data Bank and included patients who had diagnosis of lower extremity open long bone fracture from a penetrating mechanism and underwent irrigation and debridement (I&D) within 24h of arriving to the hospital. A total of 1014 patients qualified for the study. Of those, 736 (72.6%) patients underwent an I&D within 8h and 278 (27.4%) underwent an I&D between 8 and 24h after hospital arrival. When examining the patient outcomes, there were few cases and no significant differences in the occurrence of surgical site infections, sepsis or wound disruptions between the two groups. The majority of the open long bone fractures were due to firearm injury. I&D of penetrating open long bone fracture can be performed within 24h without any added infective morbidity.

Increase in Post-Coronary Artery Bypass Graft Surgical Site Infections (SSIs) Following Cease of Active Surveillance Demonstrates Need for Continued Active Surveillance for SSIs Following Cardiac Procedures

BACKGROUND Surveillance and prevention of surgical site infections (SSIs) is becoming increasingly important as the number of surgical procedures performed in the United States rise. Despite improvements in technology and infection prevention best practices, SSI's are major cause of morbidity and mortality. It is estimated that half of SSIs are preventable by applying evidence-based strategies, including systemic surveillance with attention to multiple factors, including patient risk factors, procedural risk factors, and risk factors related to the hospital environment. In one Minnesota hospital active surveillance for infections following coronary artery bypass grafts ceased at the end of 2017 due to low incidence of infection. The following fall, through passive surveillance, Infection Preventionists detected an increase in surgical site infections following cardiac procedures. Cases were analyzed for similarities and active surveillance was reinitiated. METHODS Through surveillance for methicillin-susceptible Staphylococcus aureus (MSSA) in sterile sites, two deep incisional primary SSI's were detected in patients in September 2018 following coronary artery bypass grafts (CBGs). Using the definitions provided by the National Healthcare Safety Network (NHSN) all cardiac procedures performed at this facility between April 1st and September 30th, 2018 were reviewed for additional infections. RESULTS The review revealed an additional four SSI's following CBGs: Two superficial incisional primary infections and one superficial incisional secondary infection. As a result, the SSI rate associated with CBG surgeries for that time period increased to 4.84/100 procedures, above the target rate of ≤1.0/100 procedures. Four of 6 (67%) infections were a result of Staphylococcus aureus raising concern for improper nasal decolonization practices prior to surgery. Infection Preventionists engaged the Cardiac Surgery Council to discuss infection prevention best practices before and during surgical procedures. CONCLUSIONS Continued surveillance for SSI's following cardiac procedures is a necessary means of preventing infections in a facility and detecting breaches in infection control during surgical procedures.

A standardized guideline for antibiotic prophylaxis in surgical neonates,

Infection following surgical procedures leads to increased morbidity and mortality in all populations. Guidelines to aid providers in the proper use of prophylactic antibiotics exist for adults, but are rare in the neonatal surgical population. A recent emphasis on appropriate antibiotic stewardship had led to the development of more guidelines without a coincident increase in surgical site infection. Robust data from randomized, controlled trials, however, remain sparse.

Outcomes After the Implementation of Practice Management Guidelines for the Treatment of Cardiovascular Implantable Device Pocket Infections

BackgroundTreatment of cardiovascular implantable device pocket infections (CIDPIs) requires a multimodal approach that includes antimicrobials, device explantation, and local wound care. Our institution implemented a practice management guideline (PMG) to standardize the care of CIDPIs and engage our acute care surgeons in 2013. Our PMG includes wound culture, complete capsulectomy, pulse lavage, and the placement of a negative pressure wound therapy appliance at the time of device extraction. Forty-eight hours later, wounds are irrigated and closed in a delayed primary fashion over drains. Our objective was to compare the outcomes of patients who underwent device extraction before and after the implementation of the PMG for the treatment of CIDPIs. MethodsAn IRB-approved retrospective review of 155 patients at our institution from 2012 to 2015 who underwent device explantation. Evaluated outcomes measured included days from device explant to wound closure, and postoperative complications. Outcomes data were analyzed before (pre-PMG) and after (post-PMG) enactment of the PMG. ResultsFifty-eight patients (42 males; mean age 68 years) were managed prior to PMG implementation; 97 (72 males; mean age 67) were managed after. Mean days from device explantation to wound closure were compared (pre-PMG 6 ± 3.5 and post-PMG 2.8 ± 1.8), and time to closure was reduced by 3-d post-PMG implementation (P < 0.05). No increase in surgical site infection, hematoma, or unplanned return to operating room was demonstrated between groups (P < 0.05). ConclusionsThe implementation of a PMG for the management of CIDPIs is effective in reducing the number of days to pocket wound closure; acute care surgeons are well equipped to participate in this practice and improve patient outcomes.

Microbiome Medicine: This Changes Everything

Microbiome Medicine: This Changes Everything

Reply: Late Surgical-Site Infection in Immediate Implant-Based Breast Reconstruction.

Sir: We thank Caviggioli et al. for their interest in our study1 and comments. As noted by the authors, implant-based breast reconstruction remains the most popular method with which to address postmastectomy defects. The analysis of surgical-site infections, and, in particular, identifying risk factors for reconstruction failure, is essential to identifying proper reconstructive candidates and counseling patients appropriately. Although we agree with the authors that a single-center study can reduce the institutional variability, large prospective multicenter trials such as our study have the strength of identifying overall trends of reconstruction, reducing bias, and describing generally applicable outcomes. Comparing outcomes among a large number of plastic surgeons and individual institutions allows further refinement of outcome analysis and can provide a more accurate “real-world” measure compared with the retrospective single-center series that predominate in the literature. As described by Caviggioli et al., their preliminary results from the retrospective review of 477 implant-based breast reconstructions similarly found that the majority of surgical-site infections occur more than 30 days after the initial operation and confirm obesity as a predictor. Interestingly, however, the authors noted no increase in surgical-site infection with radiation therapy. This may indeed be attributable to their study population being limited to first-stage reconstructions at this time. The authors report adopting routine autologous fat grafting in the setting of postmastectomy radiotherapy to reduce pain and complications. Given the progressive soft-tissue fibrosis and vascular compromise inevitable with radiotherapy, the concept of fat grafting as a “regenerative procedure” is logical, and it would be interesting to see the authors’ follow-up results after completion of second-stage exchange procedures to evaluate its clinical impact. We thank Dr. Caviggioli et al. for their thoughtful comments and discussion. Understanding the nuances of implant-based breast reconstruction and complications based on practices at different institutions is crucial to refine decision-making regarding breast reconstruction and optimizing patient outcome. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Indranil Sinha, M.D.Yoon S. Chun, M.D.Division of Plastic SurgeryBrigham and Women’s HospitalBoston, Mass.

The meteorological influence on seasonal alterations in the course of acute appendicitis

BackgroundSeveral diseases, including acute appendicitis (AA), have been known to undergo seasonal variations. Changes in the incidence and course of AA are attributed to seasonal weather differences, but this connection remains unproven. MethodsIn this retrospective, single-center analysis, we analyzed daily meteorological data over an 8-year period. A connection of day-by-day meteorological data with 680 consecutive appendectomies was performed. Patients' characteristics, intraoperative findings, and outcome parameters were analyzed. Seasons were classified meteorologically as 3-month periods (winter, spring, summer, and autumn). ResultsNonambient temperature (unusual warm or cold weather) is correlated with a higher rate of complicated (gangrenous or perforated) AA (P = 0.018). In summer and winter, days with nonambient temperatures were more frequent (P < 0.0001). A higher rate of complicated AA was seen during summer and winter (P = 0.009). In addition, patients operated on in summer and accordingly after warm days suffer more complications (P < 0.0001), especially more superficial surgical site infections (P < 0.048). ConclusionsThe concordant observation of more complicated AA and complications after AA with meteorological data and calendric seasonal variations makes it most likely that temperature is a cofactor in complicated AA and contributes to the seasonal variations in AA. Although an increase in the microbiome of the skin during warm seasons might explain the increase in surgical site infection, the functional connection between warmer temperatures and AA complications remains unclear.

Surgical Site Infections in Posterior Lumbar Surgery: A Controlled-Cohort Study of Epidural Steroid Paste.

A retrospective, single-center cohort study of consecutive patients undergoing posterior lumbar decompression between 2007 and 2013 was conducted. To compare rates of surgical site infection between matched cohorts of patients undergoing lumbar surgery with and without intraoperative application of epidural steroid pastes. Epidural steroid agents reduce postoperative pain and inflammation following lumbar surgery, reducing the use of postoperative narcotics and improving McGill pain scores. Preliminary studies have, however, suggested an increase in surgical site infections following the use of these steroid-containing pastes. We reviewed 758 patients undergoing decompression performed at a single center by surgeons who either routinely used or never used an analgesic steroid paste. Patients undergoing instrumentation or revision surgery were excluded, and surgical and postoperative protocols were uniform. Two hundred eighty-three patients met specific inclusion and exclusion criteria. Demographic, clinical, and surgical data were assessed and correlated to the incidence of postoperative infections. Multivariate logistic regression controlled for confounding characteristics and identified independent predictors of postoperative surgical-site infections. Patient demographics, comorbidities, and perioperative protocols were similar between groups. There were six acute infections among 103 patients receiving steroid paste (5.83%), and two infections among 180 patients not receiving paste (1.11%), a statistically significant difference which remained after controlling for confounding characteristics (odds ratio 6.74, P = 0.01). All but one infection occurred among patients with identifiable preoperative risk factors for infection. The observed increase in infection among patients receiving pain paste is clinically significant, but infection was primarily observed among at-risk patients. The present study confirms suspicions raised in preliminary studies, and we recommend caution when treating patients with identifiable, comorbid risk factors. 3.

Low skeletal muscle radiation attenuation and visceral adiposity are associated with overall survival and surgical site infections in patients with pancreatic cancer.

BackgroundCancer cachexia and skeletal muscle wasting are related to poor survival. In this study, quantitative body composition measurements using computed tomography (CT) were investigated in relation to survival, post‐operative complications, and surgical site infections in surgical patients with cancer of the head of the pancreas.MethodsA prospective cohort of 199 patients with cancer of the head of the pancreas was analysed by CT imaging at the L3 level to determine (i) muscle radiation attenuation (average Hounsfield units of total L3 skeletal muscle); (ii) visceral adipose tissue area; (iii) subcutaneous adipose tissue area; (iv) intermuscular adipose tissue area; and (v) skeletal muscle area. Sex‐specific cut‐offs were determined at the lower tertile for muscle radiation attenuation and skeletal muscle area and the higher tertile for adipose tissues. These variables of body composition were related to overall survival, severe post‐operative complications (Dindo–Clavien ≥ 3), and surgical site infections (wounds inspected daily by an independent trial nurse) using Cox‐regression analysis and multivariable logistic regression analysis, respectively.ResultsLow muscle radiation attenuation was associated with shorter survival in comparison with moderate and high muscle radiation attenuation [median survival 10.8 (95% CI: 8.8–12.8) vs. 17.4 (95% CI: 14.7–20.1), and 18.5 (95% CI: 9.2–27.8) months, respectively; P < 0.008]. Patient subgroups with high muscle radiation attenuation combined with either low visceral adipose tissue or age <70 years had longer survival than other subgroups (P = 0.011 and P = 0.001, respectively). Muscle radiation attenuation was inversely correlated with intermuscular adipose tissue (r p = −0.697, P < 0.001). High visceral adipose tissue was associated with an increased surgical site infection rate, OR: 2.4 (95% CI: 1.1–5.3; P = 0.027).ConclusionsLow muscle radiation attenuation was associated with reduced survival, and high visceral adiposity was associated with an increase in surgical site infections. The strong correlation between muscle radiation attenuation and intermuscular adipose tissue suggests the presence of ectopic fat in muscle, warranting further investigation. CT image analysis could be implemented in pre‐operative risk assessment to assist in treatment decision‐making.

Reflective Blankets Are as Effective as Forced Air Warmers in Maintaining Patient Normothermia During Hip and Knee Arthroplasty Surgery

BackgroundThe use of forced air warming devices in the operating room has been shown to cause disruption of laminar airflow and a potential for increase in surgical site contamination. In contrast, conductive warming devices such as reflective blankets do not disrupt airflow and therefore have no potential for this increase in surgical site infection. However, some studies have shown them to be inferior to forced air warming devices in maintaining normothermia. We tested the hypothesis that the use of reflective blankets is as effective as forced air warming devices in maintaining intraoperative normothermia after adequate prewarming. MethodsWe performed a randomized, controlled trial of 50 patients undergoing hip or knee arthroplasty using a protocol of prewarming followed by application of either forced air warming device or a reflective blanket and recording the patients sublingual temperature at a 15-minute interval till arrival in the post-anesthesia care unit. ResultsThere was no significant difference in the sublingual temperatures in the 2 groups at any time point. ConclusionOur study shows that after a period of adequate prewarming, the use of reflective blankets is as effective as the use of forced air warming devices in maintaining normothermia in patients undergoing hip or knee arthroplasty.

The Wisdom of Crowds.

The Wisdom of Crowds.

Changing glucose control target and risk of surgical site infection in a Southeast Asian population

Hyperglycemia is associated with surgical site infection and mortality in cardiac surgical patients. There is overriding evidence that glycemic control improves morbidity and mortality. However, the optimal glucose range in these patients remains controversial. Intensive glucose control can lead to mortality among critically ill adults because of episodic, moderate hypoglycemia. Therefore, we examined the effect of different glucose target control on the incidence of surgical site infection in our prospective cohort of diabetic and nondiabetic patients undergoing coronary artery bypass grafting. Data from 1442 patients who underwent elective coronary artery bypass grafting at a tertiary heart center in Singapore from 2009 to 2011 were obtained. The first glucose level on arrival in the cardiothoracic intensive care unit was set at 4 to 8 mmol/L in 2009 and 2010 and 4 to 10 mmol/L in 2011. Glucose control was achieved with intravenous insulin infusion with a strict glucose monitoring protocol. Clinical covariates were analyzed, with surgical site infection as the primary outcome. The majority of patients presenting for coronary artery bypass grafting were male, Chinese, and diabetic. Diabetic patients had significantly higher glucose levels on arrival in the cardiothoracic intensive care unit. The change in target glucose control was independently associated with an increase in surgical site infection (odds ratio, 2.280; 95% confidence interval, 1.250-4.162; P=.007). Subgroup analysis revealed that unlike in nondiabetic patients, a less stringent target was independently associated with a significant increase in surgical site infection incidence from 2.2% to 6.9% for the diabetic patients (odds ratio, 3.131; 95% confidence interval, 1.431-6.851; P=.004). A target blood glucose of less than 8 mmol/L was associated with a lower incidence of surgical site infection in diabetic patients presenting for elective coronary artery bypass grafting in the local Southeast Asian population.

Special Note

Retrospective cohort analysis of consecutive, case-matched patients. To determine the risk of acute postoperative complications in patients receiving epidural steroid paste. Epidural steroid agents reduce postoperative pain and inflammation after lumbar surgery, reducing postoperative narcotic use and improving McGill pain scores. Small studies have suggested an increase in surgical site infections after use of steroid-containing pain-paste. However, no larger study exists to address this concern. A total of 364 patients undergoing lumbar decompression by surgeons routinely or never using an analgesic steroid paste were reviewed. A total of 123 patients met specific inclusion criteria: 61 steroid-paste (StP) group, 62 in no-paste (NoP) group. Surgical procedures were laminectomy/laminotomy at 1 to 2 adjacent levels. Patients undergoing instrumentation or revision surgery were excluded. Surgical and postoperative protocols were uniform. Retrospective review of clinical data assessed the incidence of postoperative surgical site complications. Patient demographics, characteristics, and perioperative protocols were similar. Only in-patient admission differed—75% in the steroid-paste (StP) group versus 45% in the no-paste (NoP) group (P < 0.0001). There were 5 acute infections, 4 in the StP (6.7% [1.8%–15.9%]) and 1 in the NoP groups (1.67% [0.03%–8.7%]), P = 0.21. One additional StP patient had delayed wound healing. All StP group infections/complications occurred in patients with identifiable comorbid risk factors. The observed 4-fold increase in wound complications in the StP group is concerning, although the difference in infection rates was not significant. Stratifying patients by identifiable risk factors could account for some of this difference. The benefits of an epidural agent may outweigh the small risk of surgical site complications in most patients, but we recommend caution when treating patients with identifiable risk factors. A larger study is in progress. 3

Implementation of a Multidisciplinary Action Plan for the Reduction of Surgical Site Infection after Hip Replacement Surgery

A significant increase in surgical site infections (SSI) after hip replacement surgery (HPRO) was detected at one acute care hospital in a large multi-facility health system in the last half of 2010 and continued throughout 2011.

A Comprehensive Intervention Associated With Reduced Surgical Site Infections Among Pediatric Cardiovascular Surgery Patients, Including Those With Delayed Closure.

Surgical site infections (SSIs) cause significant morbidity and mortality in patients undergoing cardiovascular (CV) surgery. Following an increase in SSIs in this population, driven by a high rate in those with delayed closure, we implemented an intervention to reduce these infections and assessed the intervention using both population- and patient-level analyses. An intervention drawing from existing guidelines and targeting preoperative preparation of the patient, prophylactic antibiotics, and postoperative incision care was implemented. Special attention was paid to standardizing the care of the incision of patients with delayed closure. National Healthcare Safety Network criteria were used to prospectively identify SSIs. Population-level intervention effect was assessed using interrupted time series. To assess intervention adherence and effect in our patient population, retrospective chart review was performed on a cohort of patients undergoing cardiac procedures pre- and postintervention. Multivariate analysis was used to assess risk of SSI at the patient level. Timely preoperative prophylactic antibiotic dosing increased from 60% preintervention to 92% postintervention, and redosing during prolonged surgeries increased from 5% to 79% (both, P<.001). At the population-level, a decrease of 6.7 infections per 100 surgeries per 6 months was observed directly following the intervention (P=.002). The SSI rate decreased from 40% to 0.8% (P<.001) in patients with delayed closure and from 4.3% to 1.8% (P=.02) in patients with immediate closure. In multivariate analyses, surgery prior to the intervention was the strongest predictor for SSI (incidence rate ratio, 3.98; 95% confidence interval, 1.59 to 9.97). Our intervention decreased SSIs in pediatric CV surgery patients, particularly those with delayed closures.

Report Card on Surgical Care Improvement Project (SCIP): Nationwide Inpatient Sample Infection Data 2001–2006

The administration of appropriate antibiotics in a timely fashion with discontinuation post-operatively is the first of the Surgical Care Improvement Project (SCIP) initiatives and was expected to reduce post-operative infections significantly. This study aimed at determining whether SCIP has had an effect on surgical site infections (SSIs). A retrospective cohort study was conducted to evaluate the infection rates of adult patients (age≥18 years) having elective cholecystectomies, laparoscopic cholecystectomies, and colectomies from 2001-2006 using the Nationwide Inpatient Sample (NIS) database. The population consisted of all patients older than 18 years who had colon resection or cholecystectomy and were discharged from a hospital included in the NIS. Annual infection rates were determined for each of the operations. Post-operative infections rose steadily and significantly (p<0.0001) in colon surgery from 2001 to 2006. A significant increase in SSIs also was seen in open (p=0.0001) and laparoscopic (p<0.0001) cholecystectomy from 2001 to 2006. Length of stay was significantly longer in infected than in non-infected patients. The factors that contributed to the observed increase in the infection rate should be identified to improve the SCIP initiatives.

Decreased surgical site infection (SSI) rates for hip and knee arthroplasty following multiple infection control interventions

BACKGROUND/OBJECTIVES: In response to a perceived increase in SSIs following hip and knee arthroplasty, retrospective surveillance was performed at a 1442-bed tertiary care university hospital for procedures performed during 2003. This revealed a hip arthroplasty SSI rate of 2.6 SSI/100 procedures (12/465) and a knee arthroplasty SSI rate of 2.5 SSI/100 procedures (8/342). These rates are higher than the 2003 National Nosocomial Infections Surveillance System (NNIS) pooled means of 1.5 SSI/100 hip procedures and 1.2 SSI/100 knee procedures. SSIs are associated with increased morbidity and mortality rates and prolonged hospital stay, and can result in permanent disability. Active surveillance with feedback of rates, education regarding best practice, operating room (OR) observations to identify lapses in infection control (IC) procedures, and recommendations to improve practice were implemented to reduce hip and knee arthroplasty SSI rates. METHODS: Clean, Class I hip or knee arthroplasty SSIs were identified using NNIS definitions. Feedback of rates to surgical teams was accomplished through meetings with stakeholders and letters to surgeons. OR staff education was accomplished through inservices and a self-study SSI prevention module. IC specialists performed OR observations, and recommendations were shared with stakeholders and integrated into OR IC practices. These recommendations included improving preoperative prophylactic antibiotic timing, scheduling infected cases later in the day, decreasing flash sterilization, and ensuring that surgeons mask prior to entering the OR and donning Stryker helmets/hoods. Additional recommendations involved performing appropriate skin prep, decreasing OR room traffic, and wearing appropriate attire. RESULTS: The 2003 hip SSI rate was 2.6 SSI/100 procedures (12/465). The 2004 hip SSI rate was 1.5 SSI/100 procedures (7/433), a rate decrease of 42% (p=0.33). The 2003 knee SSI rate was 2.5 SSI/100 procedures (8/342). The 2004 knee SSI rate was 2.1 SSI/100 procedures (6/305), a rate decrease of 16% (p=0.75). CONCLUSIONS: Active surveillance combined with multiple SSI prevention interventions targeted at education, observation, and feedback to the surgical team measurably lowered SSI rates following hip and knee arthroplasty, although these decreases were not statistically significant. The next step is a case control study to determine risk factors specific to this institution for SSIs following hip and knee arthroplasty.