Increased Surgical Site Infections Rate Research Articles

Antimicrobial prophylaxis administration after umbilical cord clamping in cesarean section and the risk of surgical site infection: a cohort study with 55,901 patients

BackgroundThe World Health Organization (WHO) recommends administration of surgical antimicrobial prophylaxis (SAP) in cesarean section prior to incision to prevent surgical site infections (SSI). This study aimed to determine whether SAP administration following cord clamping confers an increased SSI risk to the mother.MethodsStudy design: Cohort. Setting: 75 participating Swiss hospitals, from 2009 to 2018. Participants: A total of 55,901 patients were analyzed. Main outcome measures: We assessed the association between SAP administration relative to incision and clamping and the SSI rate, using generalized linear multilevel models, adjusted for patient characteristics, procedural variables, and health-care system factors.ResultsSAP was administered before incision in 26′405 patients (47.2%) and after clamping in 29,496 patients (52.8%). Overall 846 SSIs were documented, of which 379 (1.6% [95% CI, 1.4–1.8%]) occurred before incision and 449 (1.7% [1.5–1.9%]) after clamping (p = 0.759). The adjusted odds ratio for SAP administration after clamping was not significantly associated with an increased SSI rate (1.14, 95% CI 0.96–1.36; p = 0.144) when compared to before incision. Supplementary and subgroup analyses supported these main results.ConclusionsThis study did not confirm an increased SSI risk for the mother in cesarean section if SAP is given after umbilical cord clamping compared to before incision.

LOWER SEGMENT CESARIAN SECTION SURGICAL SITE INFECTION: RISK FACTOR AND MICROBIAL ETIOLOGY

INTRODUCTION: Lower Segment Cesarean Section (LSCS) delivery is a major obstetrical surgical procedure to save the lives of mothers and foetus. Surgical site infections (SSI) are the most common reason about 20% to be unplanned admitted after discharging of the patient to their home. Various risk factors in SSI following LSCS has been identified which includes subcutaneous hematoma, subcutaneous hematoma, tobacco use in pregnancy, incision length > 16.6 cm , body mass index >30 or 35 kg/m2, prolonged second stage (compared with first stage) , no antibiotic prophylaxis, duration of labour >12 h , premature rupture of membranes , gestational diabetes, previous cesarean delivery and emergency delivery.
 MATERIAL AND METHODS: A total of 646 patients were included in the study of which 27 were diagnosed as SSI. Risk factor for SSI was divided into three categories: 1) host-related factors, 2) pregnancy and intrapartum-related factors, and 3) procedure-related factors. Purulent discharge was obtained from the surgical incision site 48 hours postoperatively with sterile disposable swabs. Blood sample for blood culture was collected when the possibility of septicemia or bacteremia as suggested by the presence of fever, shock, or other signs and symptoms of sepsis associated with the surgical wound. The bacterial isolates obtained were identified as per standard identification procedures in time microbiology laboratory. Antibiotic susceptibility of the organisms done as per protocol.
 RESULTS: A total of 646 patients were included in the study of which 94 (14.55%) were diagnosed as SSI. mean age of patients who underwent LSCS was 24± 4.57 years. Of the 646 patients in 18 - 20 years 125 (19.3%),21-25 years 304 (47.1%), 26-30 years 189 (29.3%) and in > 30 years age group 28 (4.3%) cases were observed, of the total 94 SSI cases 11 (8.8%) were in the age group if 18 - 20 years, 39 (12.8%) were in the age group of 21-25 years, 32 (16.9%) were in 26-30 years age group and 12 (42.9%) were in the > 30 years age group. Acinetobacter spies was the commonest isolate 29(30.9%) followed by staphylococcus aureus 22 (23.4%), Escherichia coli 21 (22.3%) and Klebsiellapneumoniae. premature rupture of membrane (PROM), antibiotics given earlier than 2 hours and increased duration of stay in the hospital were found to be statistically significant. It was interpreted that PROM > 24 hrs is likely to increase the chances of infection. As the duration of hospital stay increases by 1 day, the chances of infection increase.
 CONCLUSION: Identification, management and proper assessment of risk factors are necessary to in reduction of SSI rates. Premature rupture of membrane (PROM), antibiotics given earlier than 2 hours, BMI >25 and increased duration of stay in the hospital were associated with increased SSI rate.

TO ASSESS THE SPECTRUM OF LESIONS IN LYMPH NODES IN HEAD AND NECK REGION

INTRODUCTION: Lower Segment Cesarean Section (LSCS) delivery is a major obstetrical surgical procedure to save the lives of mothers and foetus. Surgical site infections (SSI) are the most common reason about 20% to be unplanned admitted after discharging of the patient to their home. Various risk factors in SSI following LSCS has been identified which includes subcutaneous hematoma, subcutaneous hematoma, tobacco use in pregnancy, incision length > 16.6 cm , body mass index >30 or 35 kg/m2, prolonged second stage (compared with first stage) , no antibiotic prophylaxis, duration of labour >12 h , premature rupture of membranes , gestational diabetes, previous cesarean delivery and emergency delivery.
 MATERIAL AND METHODS: A total of 646 patients were included in the study of which 27 were diagnosed as SSI. Risk factor for SSI was divided into three categories: 1) host-related factors, 2) pregnancy and intrapartum-related factors, and 3) procedure-related factors. Purulent discharge was obtained from the surgical incision site 48 hours postoperatively with sterile disposable swabs. Blood sample for blood culture was collected when the possibility of septicemia or bacteremia as suggested by the presence of fever, shock, or other signs and symptoms of sepsis associated with the surgical wound. The bacterial isolates obtained were identified as per standard identification procedures in time microbiology laboratory. Antibiotic susceptibility of the organisms done as per protocol.
 RESULTS: A total of 646 patients were included in the study of which 94 (14.55%) were diagnosed as SSI. mean age of patients who underwent LSCS was 24± 4.57 years. Of the 646 patients in 18 - 20 years 125 (19.3%),21-25 years 304 (47.1%), 26-30 years 189 (29.3%) and in > 30 years age group 28 (4.3%) cases were observed, of the total 94 SSI cases 11 (8.8%) were in the age group if 18 - 20 years, 39 (12.8%) were in the age group of 21-25 years, 32 (16.9%) were in 26-30 years age group and 12 (42.9%) were in the > 30 years age group. Acinetobacter spies was the commonest isolate 29(30.9%) followed by staphylococcus aureus 22 (23.4%), Escherichia coli 21 (22.3%) and Klebsiellapneumoniae. premature rupture of membrane (PROM), antibiotics given earlier than 2 hours and increased duration of stay in the hospital were found to be statistically significant. It was interpreted that PROM > 24 hrs is likely to increase the chances of infection. As the duration of hospital stay increases by 1 day, the chances of infection increase.
 CONCLUSION: Identification, management and proper assessment of risk factors are necessary to in reduction of SSI rates. Premature rupture of membrane (PROM), antibiotics given earlier than 2 hours, BMI >25 and increased duration of stay in the hospital were associated with increased SSI rate.

Impact of Intra-Operative Adverse Events on the Risk of Surgical Site Infection in Abdominal Surgery.

Intra-operative adverse events (iAEs) recently were shown to correlate independently with an increased risk of post-operative death, morbidity, re-admissions, and length of hospital stay. We sought to understand further the impact of iAEs on surgical site infections (SSIs) in abdominal surgical procedures and delineate which patient populations are most affected. We hypothesized that all patients with iAEs have an increased risk for SSI, especially those with pre-existing risk factors for SSI. To identify iAEs, a well-described three-step methodology was used: (1) the 2007-2012 American College of Surgeons-National Surgical Quality Improvement Program database was merged with the administrative database of our tertiary academic center, (2) the merged database was screened for iAEs in abdominal surgical procedures using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "Accidental Puncture/Laceration," and (3) each flagged record was systematically reviewed to confirm iAE occurrence. Uni-variable and backward stepwise multi-variable analyses (adjusting for demographics, co-morbidities, type and complexity of operation) were performed to study the independent correlation between iAEs and SSIs (superficial, deep incisional, and organ-space). The correlation between iAEs and SSIs was investigated especially in patients deemed a priori at high risk for SSIs, specifically those older than age 60 and those with diabetes mellitus, obesity, cigarette smoking, steroid use, or American Society of Anesthesiologists class ≥III. A total of 9,288 operations were included, and iAEs were detected in 183 (2.0%). Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intra-operatively (92%). SSI occurred in 686 (7.4%) cases and included 331 (3.5%) superficial, 32 (0.34%) deep incisional, and 333 (3.6%) organ/space infections. iAEs were correlated independently with SSI (odds ratio [OR] = 1.67; 95% confidence interval [CI], 1.11-2.52, p = 0.013), and more severe iAEs were associated with a higher risk of infection. Analysis by SSI type revealed a significant association with organ/space SSI (OR = 1.81, 95% CI 1.07-3.05; p = 0.027), but not incisional infections. Most interestingly, the occurrence of an iAE was correlated with increased SSI rate in the low-risk but not the high-risk patient populations. Specifically, iAEs increased SSI in patients younger than 60 (OR = 2.69, 95% CI 1.55-4.67, p < 0.001), non-diabetic patients (OR = 1.64, 95% CI 1.04-2.58, p = 0.034), non-obese patients (OR = 2.9, 95% CI 1.81-4.66, p < 0.001), non-smokers (OR = 1.67, 95% CI 1.08-2.6, p = 0.022), with no steroid use (OR = 1.73, 95% CI 1.15-2.6, p < 0.008), and with ASA class <III (OR = 2.26, 95% CI 1.31-3.87, p = 0.003). The iAEs are associated independently with increased SSIs, particularly in patients with less pre-existing risk factors for SSI. Preventing iAEs or mitigating their impact, once they occur, may help decrease the rate of SSIs.

Outcomes are Local: Patient, Disease, and Procedure-Specific Risk Factors for Colorectal Surgical Site Infections from a Single Institution

BackgroundColorectal surgical site infections (SSIs) contribute to postoperative morbidity, mortality, and resource utilization. Risk factors associated with colorectal SSI are well-documented. However, quality improvement efforts are informed by national data, which may not identify institution-specific risk factors. MethodRetrospective cohort study of colorectal surgery patients uses institutional ACS-NSQIP data from 2006 through 2014. ACS-NSQIP data were enhanced with additional variables from medical records. Multivariable logistic regression identified factors associated with SSI development. ResultsOf 2376 patients, 213 (9.0%) developed at least one SSI (superficial 4.8%, deep 1.1%, organ space 3.5%). Age < 40, BMI > 30, ASA3+, steroid use, smoking, diabetes, pre-operative sepsis, higher wound class, elevated WBC or serum glutamic-oxalocetic transaminase, low hematocrit or albumin, Crohn’s disease, and prolonged incision-to-closure time were associated with increased SSI rate (all P < 0.01). After adjustment, BMI > 30, steroids, diabetes, and wound contamination were associated with SSI. Patients with Crohn’s had greater odds of SSI than other indications. ConclusionInstitutional modeling of SSI suggests that many previously suggested risk factors established on a national level do not contribute to SSIs at our institution. Identification of institution-specific predictors of SSI, rather than relying upon conclusions derived from external data, is a critical endeavor in facilitating quality improvement and maximizing value of quality investments.

Prevention of surgical site sternal infections in cardiac surgery: a two-centre prospective randomized controlled study.

Surgical site infection (SSI) of the sternum is a devastating complication in cardiac surgery. The aim of this prospective randomized controlled two-centre clinical study was to compare the use of a gentamicin-collagen sponge (Genta-Coll® resorb) and of a cyanoacrylate-based microbial skin sealant (InteguSeal®) on the SSI rate of the sternum. We analysed data from 996 consecutive patients following isolated coronary artery bypass grafting between 2012 and 2014. The patients were randomized into three groups: standard group (S-group), Genta-Coll group (G-group) and InteguSeal group (I-group). The primary study end-point was to analyse the incidence of superficial and deep sternal SSI. The secondary study end-point was to determine independent risk factors for an increased SSI rate. Of the 996 patients investigated, 332 patients were in S-group, 336 patients in G-group and 328 patients in I-group. The mean age was 67.7 ± 9.4 years, 18.6% were women and the overall SSI rate was 6.2% with 2.2% deep sternal wound infections. SSI rates were 8.3% (S-group), 5.4% (G-group) and 4.9% (I-group) (P 0.16). Multiple regression analysis demonstrated a preoperative body mass index (BMI) of >30 kg/m2 (P 0.047), re-thoracotomy for postoperative bleeding (P < 0.001) and sternum instability (P < 0.001) as independent predictors for an increased SSI rate. The application of InteguSeal® or Genta-Coll® resorb had no significant influence on the incidence of the sternal SSI rate in 996 consecutive cardiac surgery patients but demonstrated a trend towards a benefit from using these prophylactic approaches. Multiple regression analysis demonstrated a preoperative BMI of >30 kg/m2, re-thoracotomy for bleeding and sternum instability as independent predictors for an increased sternal SSI rate.

Medicaid status is associated with higher surgical site infection rates after spine surgery.

The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of Washington Medical Center and Harborview Medical Center. Insurance data were prospectively collected and used in multivariate analysis to determine risk of perioperative complications. Given the negative financial impact of surgical site infections (SSIs) and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher SSI rate. The medical literature demonstrates lesser outcomes and increased complication rates in patients who have public insurance than those who have private insurance. No one has shown that patients with a Medicaid payer status compared with Medicare and privately insured patients have a significantly increased SSI rate for spine surgery. The prospectively collected Spine End Results Registry provided data for analysis. SSI was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assessed against the exposure of payer status for the surgical procedure. The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% confidence interval: 1.19-3.58, P = 0.01) of having a SSI compared with the privately insured. The study highlights the increased cost of spine surgical procedures for patients with a Medicaid payer status with the passage of the Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act of 2010 provisions could cause a reduction in reimbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations. 3.

A preoperative stay in an intensive care unit is associated with an increased risk of surgical site infection in neonates

BackgroundNeonates are considered as immunologically immature. There are no specific guidelines for surgical antibiotic prophylaxis in this population since data concerning the risk factors for surgical site infection (SSI) are lacking. MethodsA 40-month retrospective single-center study that included all consecutive neonates undergoing surgery was performed. The variables that could influence the rate of SSI were analyzed by multivariate analysis in order to determine the independent risk factors for SSI. ResultsThe survey included 286 neonates (91F/195M). Median age, term, and weight were 10 (0–19) days, 38 (37–39) weeks, 3 (2.7–3.5) kg, respectively. Sixteen percent of the neonates were premature. Surgery was mostly abdominal (71%). Prophylactic antibiotic was given in 66.4% of the cases and was highly variable (amoxicillin–clavulanate 20.3%, first generation cephalosporin 26.2%, second generation cephalosporin 11.9%, imidazole derivatives 13.6%, aminoglycosides 12.6%, vancomycin 0.7%, and ticarcillin–clavulanate 3.1%). The rate of SSI was 3.8%. Only two variables were identified as independent risk factors for SSI: gestational age OR: 0.821 (0.690–0.977) and preoperative hospitalization in an intensive care unit OR: 8.433 (1.031–69.005). ConclusionPreoperative stay in an intensive care unit and, to a lesser degree, low gestational age are associated with an increased SSI rate.

Impact of a single perioperative dose of dexamethasone on the incidence of surgical site infections: A case–control study

Dexamethasone is recommended in several international guidelines to prevent postoperative nausea and vomiting, a problem especially frequent in gynecological patients. Despite the increasing use of dexamethasone for this indication there are limited data concerning potential harmful effects of corticosteroids in surgical patients, especially the potential negative impact on wound healing and surgical site infection (SSI). This case-control study was conducted to look for potentially harmful effects of a single perioperative dose of dexamethasone with respect to the occurrence of SSI in gynecological and obstetric surgery patients. We retrospectively analyzed 3449 patients undergoing inpatient gynecological or obstetric surgical procedures for the occurrence of deep SSI requiring surgical intervention or prolonged antibiotic treatment. These case patients were matched to control patients according to the surgeon performing the procedure, the type of surgery, biometric data, and known risk factors for SSI. Furthermore, timely linearity of dexamethasone use and SSI rate was exploratorily analyzed using several auto-regressive, integrated, moving-average models. Forty patients with deep SSI were matched to 158 controls. The risk profile for wound infections of both groups was comparable. Forty-five percent (95% confidence interval: 29-62%) of the case patients were treated with dexamethasone and 49% (95% confidence interval: 41-57%) of the control group received the drug. An increasing use of dexamethasone over time was not followed by an increased SSI rate. There were no timely correlations between dexamethasone usage and the occurrence of SSI. In this case-control study we could not detect any evidence for an increased risk for SSI after a single-dose of dexamethasone (4-8 mg) in gynecological patients.

Surgical site infection after preoperative neoadjuvant chemotherapy in patients with locally advanced oral squamous cell carcinoma

We investigated whether preoperative neoadjuvant chemotherapy is associated with increased surgical site infection (SSI) rate in patients with locally advanced oral cancer. In this hospital-based study, we retrospectively reviewed over 2000 chart records of patients with oral cavity cancer from March 1994 to December 2007. Those who received neoadjuvant chemotherapy were identified and matched for age, sex, tumor classification, primary site, and reconstruction methods to hospitalized patients who did not receive chemotherapy. Data were analyzed for the relationship between chemotherapy and SSI. A total of 306 patients were enrolled for final analyses. The overall postoperative SSI rate was 31.0%. The SSI rate in patients after neoadjuvant chemotherapy was similar to that in patients who did not receive the chemotherapy (33.3% vs 29.9%, p = .631). Preoperative neoadjuvant chemotherapy was not associated with increased SSI rate in patients with locally advanced oral cancer.

Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: Problem solution with the bundle approach

Introduction Surgical site infections (SSIs) are the most common nosocomial infections after surgery. However, clinical guidance on how to handle any suspicious clusters of SSI in orthopaedic surgery is missing. We report on problem analysis and solution finding following the observation of an increased rate of SSI in trauma implant surgery. Setting Trauma unit of a university hospital. Methods Over a 2-year observation period, all patients ( n = 370) following surgical stabilisation of proximal femur fractures in a trauma unit of a university hospital were consecutively followed using a standardised case report form. First, a retrospective cohort of 217 patients was collected for whom an increased SSI rate was detected. Based on risk analysis, new standard perioperative procedures were developed and implemented. The impact was evaluated in a prospective cohort of 153 comparable patients. Uni- and multivariable analysis of factors associated with the risk for SSI was undertaken. Results The intervention bundle resulted in a significant reduction of an initially increased SSI incidence of 6.9 (down) to 2.0% ( p = 0.029). Multivariable analysis revealed four risk factors significantly associated with a higher risk of SSI caused by different bacteria: duration of surgery ( p = 0.002), hemiarthroplasty ( p = 0.002), haematoma ( p = 0.004) and the presence of two operating room staff members ( p < 0.001 and 0.035). Conclusions A standardised prospective SSI protocol and detection system offering the simultaneous use of data should guarantee every institution immediate alarm registration to avoid comparable problem situations. Detailed interdisciplinary analysis followed by the implementation of coherent interventions, based on a best-evidence structured bundle approach, may adequately resolve similar critical incidence episodes.

Association between the Pattern of Prophylactic Antibiotic Use and Surgical Site Infection Rate for Major Surgeries in Korea

The purpose of this study was to analyze the association between the pattern of prophylactic antibiotic use (PAU) and the surgical site infection (SSI) rate for major surgeries in Korea. We retrospectively reviewed the medical records of patients who underwent cardiac, colon and gastric surgery, hysterectomies and hip/knee replacements at 20 hospitals, and inclusive of over 500 beds. We randomly sampled 60 cases per surgery type for patients discharged between September and November, 2006. A total fo 2,924 cases were included in our analysis. Cox's proportional hazard analysis was conducted to evaluate the association between the pattern of PAU and SSI rate. The proportion of patients who received their first prophylactic antibiotics (PA) 1 hour before incision was 65.5%, who received inappropriate PAs was 80.8%, and the proportion of patients whose PA was discontinued within 24 hours of surgery was 0.5%. The average duration of PAU after surgery was 9 days. The relative risk (RR) of SSI in patients who received their first PA more than 1 hour before incision was significantly higher than for those who received it within 1 hour prior to incision (RR=8.20, 95% CI=4.81-13.99). Inappropriate PA selection increased SSI rate, albeit with marginal significance (RR=1.97, 95% CI=0.96-4.03). Also, prolonged PAU following surgery had no effect on SSI rate. These results suggest that the pattern of PAU in the surgeries examined was not appropriate. Errors in the timing of PAU and of PA selection increase SSI rate. SSI rate remained unaltered following prolonged PAU after surgery.

Surgical-site infection rates in patients who undergo elective surgery on the same day as their hospital admission.

To follow over time surgical-site infection (SSI) rates in patients admitted to the hospital on the same day as their elective surgery (group I), and to compare these rates with those of other surgical patients who also required postoperative hospitalization but either were hospitalized for 1 or more days immediately prior to surgery or underwent surgery on a nonelective basis (group II). Observation of overall SSI rates over time for group I and II patients and study of risk factors associated with increased SSI rate among group I neurosurgical patients. A 900-bed, tertiary-care community hospital with >10,000 surgical procedures performed each year on patients requiring postoperative hospital stay. A total of 48,464 surgical procedures were performed on consecutive patients from 1990 to 1994, with 18,794 (39%) involving group I patients. In addition, 511 consecutive procedures performed on neurosurgical patients requiring postoperative hospitalization from July 1994 to May 1995 were analyzed. In 1990, the overall SSI rate of group I patients was significantly lower than that of group II patients (0.4% vs 1.3%, relative risk [RR], 3.6; 95% confidence interval [CI95], 2-6.4; P<.0001), but, by 1994, there was no longer any significant difference between the SSI rates of group I and II patients (1.8% and 1.6%, respectively; P=.38). In 1994, the SSI rate in group I neurosurgical patients was significantly greater than that of group II patients (3.4% vs 0.4%; RR, 8.3; CI95, 1.05-66; P=.02). During the period April through September 1994 (warm months), group I neurosurgical patients were associated with a significantly lower American Society of Anesthesiologists score and SSI risk index (based on National Nosocomial Infection Surveillance System data) and a higher likelihood of having "clean-class" wounds, but significantly greater-than-expected SSI rate when adjusted for patient risk index and type of procedure (4.7% vs 1.4%; RR, 3.3; CI95, 1.3-8.6; P=.02). During the same period, the observed and expected SSI rates were not significantly different for group II neurosurgical patients. As a whole, the SSI rates among patients undergoing elective surgery on the same day of their hospital admission is no longer significantly lower than that of other patients who also require postoperative hospitalization. For certain procedures, such as those commonly performed on the neurosurgical service, elimination of preoperative hospital stay may be associated with greater-than-expected risk of SSI.