Infection Prevention Bundle Research Articles

Assessing antibiotic stewardship using the surgical site infection prevention bundle.

Antibiotic prophylaxis is crucial in head and neck surgery to prevent infection from clean contaminated wounds. Scottish Intercollegiate Guidelines Network (SIGN) guidance, the gold standard of practice, recommends that administration of broad spectrum antibiotics is discontinued after 24 hours post-operation. A three-audit cycle quality improvement project was conducted to assess clinical practice against SIGN guidance at a large London teaching hospital. Three change initiatives were implemented to improve antibiotic stewardship. First, an update of Trust guidelines with an associated poster campaign to educate staff and improve awareness. Second, introduction of a specific 'prophylactic antibiotics in head and neck surgery' bundle on the electronic hospital-wide prescribing system. Third, an update to an antibiotic prescribing guide (Microguide). Over a 3-year study period the number of patients receiving antibiotics beyond 24 hours declined significantly (88% in 2015, 76% in 2016, 25% in 2018), demonstrating improved compliance with SIGN guidelines overall. Despite this, staff documentation of indications for extended antibiotic use remains suboptimal (58% in 2016 and 44% in 2018) as does the number of specimens sent for microbiological analysis (52% in 2016 and 0% in 2018). Appropriate prophylactic antibiotic prescribing can improve morbidity and mortality rates in head and neck cancer patients. Three change initiatives have been demonstrated which can help to improve prescribing compliance in line with SIGN guidance. Ongoing auditing is required to maintain the longevity of improvements made and encourage staff documentation of indications for extended antibiotic use and microbiology specimen analysis.

The implementation of an infection prevention bundle reduces surgical site infections following cranial surgery.

The benefit of an infection prevention bundle made up of five basic procedures to avoid surgical site infections (SSIs) following cranial surgery was evaluated. Data from all patients with first time elective brain surgery from March 2014 till May 2016 were analyzed. In April 2015, an infection prevention bundle was implemented. The rate of SSIs after first time elective cranial surgery of patients operated 1year before and 1year after the implementation was compared. Of the 321 cases operated before the implementation of the infection prevention bundle, 13 cases (4%) developed a SSI. After the implementation, only 6 patients out of 288 were re-operated due to a SSI (2%). The most frequent etiological germ cultivated was Staphylococcus aureus. The implementation of a bundle of 5basic infection prevention steps leads to a clinical relevant reduction of SSIs.

Creating a Surgical Site Infection Prevention Bundle for Patients Undergoing Cesarean Delivery: 1.6 www.aornjournal.org/content/cme.

We formed an interdisciplinary team to create a standardized, evidence-based protocol that would reduce cesarean delivery surgical site infection rates at our tertiary teaching facility. The Joint Commission's current implementation guide for surgical site infections, although comprehensive, does not specifically address strategies associated with the obstetric patient population. The team's approach included developing and providing patient education and preparation, standardizing prophylactic antibiotic administration, developing consistent evidence-based abdominal and vaginal preparation processes, standardizing postoperative incision care, and engaging clinical team members in process improvement. This collaboration resulted in a decrease in surgical site infection rates from 4.1% in 2014 and 5.9% in 2015 to 0.8% by the end of 2016 and 0.6% in the first two quarters of 2017. Systemizing processes initiated by the interdisciplinary team improved patient outcomes, limited readmissions, and reduced costs to the institution.

Sepsis prevention in neonates in Zambia study: Impact of an infection prevention bundle on neonatal sepsis and mortality

Background: Sepsis is a major cause of mortality in neonates in sub-Saharan Africa. Bloodstream infections (BSIs), the most common hospital-associated infections in neonates, occur more frequently in resource-limited countries than in industrialized countries and contribute to many in-hospital neonatal deaths. We assessed the efficacy of a novel bundle of low-cost infection prevention and control (IPC) measures targeted to known and suspected risk factors for neonatal hospital-associated BSI. We studied the impact of this intervention bundle on BSI and mortality in a neonatal intensive care unit (NICU) at the University Teaching Hospital (UTH) in Lusaka, Zambia. Methods & Materials: This prospective observational cohort study of neonates who survived > 3 days after NICU admission consisted of a six-month baseline period (“baseline”), two months during which interventions were introduced (“implementation”), and 10 months of intervention assessment (“intervention”). The intervention bundle consisted of IPC training, introduction of alcohol-based hand wash, weekly bathing of neonates > 1.5 kg with 2% chlorhexidine, targeted environmental cleaning, and SMS reminders of IPC messages. The outcomes were all-cause neonatal mortality (primary) and suspected sepsis and laboratory-confirmed BSIs (secondary). Results: From September 2015 through March 2017, we enrolled 2669 eligible neonates. Median maternal age, maternal HIV status, and newborn characteristics were similar in the baseline, implementation, and intervention periods (with the exception of birth weight). Half of neonates had one or more episodes of sepsis, including 549 (41%) who had a positive blood culture. Klebsiella pneumoniae, predominantly ESBL-producing, was most common (n = 289, 70%); possible contaminants were isolated in most other positive cultures (n = 140, 25.5%). All-cause neonatal mortality was lower during the intervention (18.0%) than the baseline period (23.6%), and similar reductions in mortality were seen in all birthweight categories. The incidence density rates for suspected sepsis and BSI with a pathogen were significantly lower in the intervention relative to baseline periods for all birth weight categories, except babies weighing < 1 kg. Conclusion: This bundle of infection prevention measures resulted in reductions in all-cause neonatal mortality, suspected sepsis, and BSI with pathogens. This combination of low-cost measures has potential to be applied in other contexts where hospital-associated sepsis is a major contributor to neonatal mortality.

Infection control bundles in intensive care: an international cross-sectional survey in low- and middle-income countries

In low- and middle-income countries (LMICs), the burden of healthcare-associated infections (HCAIs) is not known due to a lack of national surveillance systems, standardized infection definitions, and paucity of infection prevention and control (IPC) organizations and legal infrastructure. To determine the status of IPC bundle practice and the most frequent interventional variables in LMICs. A questionnaire was emailed to Infectious Diseases International Research Initiative (ID-IRI) Group Members and dedicated IPC doctors working in LMICs to examine self-reported practices/policies regarding IPC bundles. Responding country incomes were classified by World Bank definitions into low, middle, and high. Comparison of LMIC results was then made to a control group of high-income countries (HICs). This survey reports practices from one low-income country (LIC), 16 middle-income countries (MICs) (13 European), compared to eight high-income countries (HICs). Eighteen (95%) MICs had an IPC committee in their hospital, 12 (63.2%) had an annual agreed programme and produced an HCAI report. Annual agreed programmes (87.5% vs 63.2%, respectively) and an annual HCAI report (75.0% vs 63.2%, respectively) were more common in HICs than MICs. All HICs had at least one invasive device-related surveillance programme. Seven (37%) MICs had no invasive device-related surveillance programme, six (32%) had no ventilator-associated pneumonia prevention bundles, seven (37%) had no catheter-associated urinary tract infection prevention bundles, and five (27%) had no central line-associated bloodstream infection prevention bundles. LMICs need to develop their own bundles with low-cost and high-level-of-evidence variables adapted to the limited resources, with further validation in reducing infection rates.

Outbreak report: a nosocomial outbreak of vancomycin resistant enterococci in a solid organ transplant unit

BackgroundVancomycin resistant enterococci (VRE) are an emerging problem in health care settings. The purpose of the investigation was to assess the extent of the outbreak including environmental contamination and to limit further transmission.MethodsWe used retrospective patient and laboratory data including pulse field gel electrophoresis (PFGE) typing and virulence and resistance gene analysis. For comparison of medians the Mann-Whitney and for comparison of proportions the Fisher exact tests were used.ResultsPFGE typing of VRE strains of an outbreak of 15 VRE cases in a solid transplant unit revealed that nine of the cases belonged to one identical pattern (A), which was only found twice in the environment. Eleven further positive environmental samples showed a different, but identical PFGE pattern E. Only one patient was infected with this environmental strain.Two of nine (22.2%) PFGE A, but nine of eleven (81.2%) PFGE E samples were positive for gelatinase E (p = 0.01), which is described as enhancing biofilm production, suggesting a survival benefit for this strain on inanimate surfaces.ConclusionRoutine disinfection was not able to stop the cluster, but after repeated enforcement of the infection prevention and control (IPC) bundle such as training, strict adherence to hand hygiene and surface disinfection no further cases were observed. We conclude that certain VRE strains predominate in the environment whereas others predominate in humans. Enforcement of the IPC bundle is essential for controlling VRE outbreaks and reducing further transmission.

"The Invisible Staff": A Qualitative Analysis of Environmental Service Workers' Perceptions of the VA Clostridium difficile Prevention Bundle Using a Human Factors Engineering Approach.

Using a novel human factors engineering approach, the Systems Engineering Initiative for Patient Safety model, we evaluated environmental service workers' (ESWs) perceptions of barriers and facilitators influencing adherence to the nationally mandated Department of Veterans Affairs Clostridium difficile infection (CDI) prevention bundle. A focus group of ESWs was conducted. Qualitative analysis was performed employing a visual matrix display to identify barrier/facilitator themes related to Department of Veterans Affairs CDI bundle adherence using the Systems Engineering Initiative for Patient Safety work system as a framework. Environmental service workers reported adequate cleaning supplies/equipment and displayed excellent knowledge of CDI hand hygiene requirements. Environmental service workers described current supervisory practices as providing an acceptable amount of time to clean CDI rooms, although other healthcare workers often pressured ESWs to clean rooms more quickly. Environmental service workers reported significant concern for CDI patients' family members as well as suggesting uncertainty regarding the need for family members to follow infection prevention practices. Small and cluttered patient rooms made cleaning tasks more difficult, and ESW cleaning tasks were often interrupted by other healthcare workers. Environmental service workers did not feel comfortable asking physicians for more time to finish cleaning a room nor did ESWs feel comfortable pointing out lapses in physician hand hygiene. Multiple work system components serve as barriers to and facilitators of ESW adherence to the nationally mandated Department of Veterans Affairs CDI bundle. Environmental service workers may represent an underappreciated resource for hospital infection prevention, and further efforts should be made to engage ESWs as members of the health care team.

Decreased Surgical Site Infection Rate in Hysterectomy: Effect of a Gynecology-Specific Bundle.

We implemented a hysterectomy-specific surgical site infection prevention bundle after a higher-than-expected surgical site infection rate was identified at our institution. We evaluate how this bundle affected the surgical site infection rate, length of hospital stay, and 30-day postoperative readmission rate. This is a quality improvement study featuring retrospective analysis of a prospectively implemented, multidisciplinary team-designed surgical site infection prevention bundle that consisted of chlorhexidine-impregnated preoperative wipes, standardized aseptic surgical preparation, standardized antibiotic dosing, perioperative normothermia, surgical dressing maintenance, and direct feedback to clinicians when the protocol was breached. There were 2,099 hysterectomies completed during the 33-month study period. There were 61 surgical site infections (4.51%) in the pre-full bundle implementation period and 14 (1.87%) in the post-full bundle implementation period; we found a sustained reduction in the proportion of patients experiencing surgical site infection during the last 8 months of the study period. After adjusting for clinical characteristics, patients who underwent surgery after full implementation were less likely to develop a surgical site infection (adjusted odds ratio [OR] 0.46, P=.01) than those undergoing surgery before full implementation. Multivariable regression analysis showed no statistically significant difference in postoperative days of hospital stay (adjusted mean ratio 0.95, P=.09) or rate of readmission for surgical site infection-specific indication (adjusted OR 2.65, P=.08) between the before and after full-bundle implementation periods. The multidisciplinary implementation of a gynecologic perioperative surgical site infection prevention bundle was associated with a significant reduction in surgical site infection rate in patients undergoing hysterectomy.

Success of a Colorectal Surgical Site Infection Prevention Bundle in a Multihospital System.

Surgical site infections, readmissions, and extended hospital stays are risks for patients undergoing colon surgeries. These procedures are often urgent, and patients may have multiple comorbidities. Preoperative and postoperative steps to reduce the number of complications provide substantial benefits clinically, economically, and psychologically. We used a multidisciplinary, collaborative approach to identify best practices when developing and implementing a standardized approach to the management of patients undergoing elective colon surgery. Interventions included nutrition supplements and preoperative and postoperative protocols. Our management project showed a 74.6% reduction in readmissions, a 22.73% reduction in length of stay, an 85% reduction in colon surgical site infections measured by incidence (84.5% reduction) and standard infection ratio (54.55% reduction), and 95% compliance with the use of both order sets during an 18-month period. Applying standardized order sets for assessing and addressing patient comorbidities before colorectal surgery can result in a substantial and sustainable reduction in complications.

Implementation of an infection prevention bundle and increased physician awareness improves surgical outcomes and reduces costs associated with spine surgery.

OBJECTIVE Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. This study investigated the effects of the development and implementation of an infection prevention protocol that was augmented by increased physician awareness of spinal fusion surgical site infection (SSI) rates and resultant cost savings. METHODS A cohort clinical investigation over a 10-year period was performed at a single tertiary spine care academic institution. Preoperative infection control measures (chlorohexidine gluconate bathing, Staphylococcus aureus nasal screening and decolonization) followed by postoperative infection control measures (surgical dressing care) were implemented. After the implementation of these infection control measures, an awareness intervention was instituted in which all attending and resident neurosurgeons were informed of their individual, independently adjudicated spinal fusion surgery infection rates and rankings among their peers. During the course of these interventions, the overall infection rate was tracked as well as the rates for those neurosurgeons who complied with the preoperative and postoperative infection control measures (protocol group) and those who did not (control group). RESULTS With the implementation of postoperative surgical dressing infection control measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% (risk ratio 0.55; 95% CI 0.32-0.93; p = 0.03) for those in the protocol cohort, resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for neurosurgeons in the control group, although the overall infection rate among all neurosurgeons decreased by 54% from 3.3% to 1.5% (risk ratio 0.46; 95% CI 0.28-0.73; p = 0.0013). CONCLUSIONS A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased SSI rates and an associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures result in improvements in surgical outcomes and costs.

03: Surgical site infection prevention bundle for hysterectomy: Effect on costs of surgical admission and 30-day readmissions

Although surgical site infection (SSI) prevention bundles for hysterectomy are becoming standard at many institutions to improve patient care and experience, there are scant data available about how SSI prevention bundles affect cost of care. This study aimed to evaluate the effect of an SSI prevention bundle initiated at our institution on costs of initial surgical admission and subsequent re-admission for SSI-related causes. Data on hysterectomies performed from April 1, 2013, to December 31, 2015, were prospectively collected. There were 1303 cases in the 20-month period prior to full bundle implementation (April 1, 2013 to November 30, 2014) and 703 cases in the 13-month post-full bundle implementation period (December 1, 2014 to December 31, 2015). We used ICD-9/10 diagnosis codes to determine causes of readmissions within 30 days of hysterectomy, and focused on readmissions related to SSI. Total costs of care during hysterectomy hospitalization and SSI-related readmissions were obtained from our institution’s financial database, and included hospital facility costs of operating room supplies, laboratory fees, imaging, medications, room and board, and nursing care. All costs are reported in inflation adjusted 2015 US dollars. Patients’ clinical characteristics were collected via medical record review. Wilcoxon rank-sum tests and generalized linear regression analysis were used to compare costs in the pre- and post-full bundle implementation periods. Costs of hysterectomy hospitalization were significantly higher in the post-full bundle implementation period than in the pre-full bundle implementation period ($5,513 vs. $4,919, p < 0.001). When stratified by route of hysterectomy and presence or absence of gynecologic cancer, there was a statistically significant increase in cost of hysterectomy between the pre-full bundle and post-full bundle intervention periods for all routes except straight-stick laparoscopies for benign indications. The costs of hysterectomy admissions in pre-full bundle compared to post-full bundle implementation periods were, for benign disease: total abdominal hysterectomy (TAH): $4,801 versus $5,173 (p = 0.005), total laparoscopic hysterectomy (TLH): $4,186 versus $4,314 (p = 0.61), and robot-assisted total laparoscopic hysterectomy (raTLH): $4,666 versus $5,027 (p = 0.02). For malignancy: TAH: $6,602 versus $9,407 (p < 0.001), TLH: $4,408 versus $6,671 (p = 0.002), and raTLH: $4,469 versus $6,107 (p < 0.001). Multivariable regression analysis adjusting for patient age, comorbid conditions, BMI, and surgical route also suggested higher cost of hysterectomy hospitalizations during the period after full bundle implementation (adjusted cost ratio = 1.11, p < 0.001). The median cost of SSI-related hospital re-admissions were $3,527 pre-full bundle and $3,797 post-full bundle implementation (p = 0.65). The mean cost of all SSI related re-admissions was $5,795 ± 1,903. In our institution’s experience, SSI prevention bundles did not reduce hospital costs of surgical admissions over time, despite a significant decrease in SSI rate during the study period. Although there are cost savings in preventing readmission, there may be increasing hospital costs, particularly for open and robot-assisted laparoscopic cases, that warrant further assessment.

A standardized protocol to reduce pediatric baclofen pump infections: a quality improvement initiative.

OBJECTIVE Intrathecal baclofen pumps are generally placed in children for the treatment of spasticity and dystonia. Use of implants in this pediatric population with comorbidities is reported to have a high risk of complications and infections. With the aim of reducing baclofen pump-related infections, a quality improvement project was instituted at the authors' institution. METHODS A workflow paradigm unique to baclofen pump implantation aimed at decreasing implant-related infections was implemented. All baclofen pump operations performed at the authors' institution between August 2012 and June 2016 were reviewed. An infection prevention protocol was created and implemented in August 2014 based on a literature review and the consensus opinion of the pediatric neurosurgeons in the group. Compliance with the prevention bundle was tracked. Case outcomes before and after implementation of the protocol with a minimum of 3 months of follow-up were retrospectively reviewed. Univariate and multivariate analyses were performed to assess the association of the steps in the prevention bundle with infection and complication outcomes. RESULTS A total of 128 baclofen pump surgeries were performed (64 preprotocol and 64 postprotocol). The patient age range was 3 to 27 years. The overall compliance rate with the infection prevention bundle was 82%. The pre- and postimplementation infection rates were 12.5% and 6.3%, respectively (p = 0.225). The total pre- and postimplementation complication rates were 23.4% and 9.4%, respectively (p = 0.032). The absolute and relative risk reductions for infections were 6.3% (95% CI 3.8%-16.3%) and 50%, respectively; for complications, the absolute and relative risk reductions were 14.1% (95% CI 1.5%-26.7%) and 60%, respectively. CONCLUSIONS The total complication rate following intrathecal baclofen pump surgery was significantly lower after implementation of the quality improvement protocol. This study is an example of using checklist standardization to diminish special cause variability.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery.

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery. A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded. A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028). The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

An Effective Bundled Approach Reduces Surgical Site Infections in a High-Outlier Colorectal Unit.

Surgical site infections are the most common hospital-acquired infection after colorectal surgery, increasing morbidity, mortality, and hospital costs. The purpose of this study was to investigate the impact of preventive measures on colorectal surgical site infection rates in a high-volume institution that performs inherent high-risk procedures. This was a prospective cohort study. The study was conducted at a high-volume, specialized colorectal surgery department. The Prospective Surgical Site Infection Prevention Bundle Project included 14 preoperative, intraoperative, and postoperative measures to reduce surgical site infection occurrence after colorectal surgery. Surgical site infections within 30 days of the index operation were examined for patients during the 1-year period after the surgical site infection prevention bundle was implemented. The data collection and outcomes for this period were compared with the year immediately before the implementation of bundle elements. All of the patients who underwent elective colorectal surgery by a total of 17 surgeons were included. The following procedures were excluded from the analysis to obtain a homogeneous patient population: ileostomy closure and anorectal and enterocutaneous fistula repair. Surgical site infection occurring within 30 days of the index operation was measured. Surgical site infection-related outcomes after implementation of the bundle (bundle February 2014 to February 2015) were compared with same period a year before the implementation of bundle elements (prebundle February 2013 to February 2014). Between 2013 and 2015, 2250 abdominal colorectal surgical procedures were performed, including 986 (43.8%) during the prebundle period and 1264 (56.2%) after the bundle project. Patient characteristics and comorbidities were similar in both periods. Compliance with preventive measures ranged between 75% and 99% during the bundle period. The overall surgical site infection rate decreased from 11.8% prebundle to 6.6% at the bundle period (P < 0.001). Although a decrease for all types of surgical site infections was observed after the bundle implementation, a significant reduction was achieved in the organ-space subgroup (5.5%-1.7%; P < 0.001). We were unable to predict the specific contributions the constituent bundle interventions made to the surgical site infection reduction. The prospective Surgical Site Infection Prevention Bundle Project resulted in a substantial decline in surgical site infection rates in our department. Collaborative and enduring efforts among multiple providers are critical to achieve a sustained reduction See Video Abstract at http://links.lww.com/DCR/A438.

Simple Operating Room Bundle Reduces Superficial Surgical Site Infections After Major Urologic Surgery

To reduce our superficial surgical site infection rate following major urologic surgery by implementing a simple operating room bundle. A simple operating room bundle was applied to all major urologic cases (cystectomy, nephrectomy, and prostatectomy) at a single tertiary referral center. The bundle included allowing skin prep to dry appropriately, changing gloves before skin closure, irrigating the wound before skin closure, and using a new separate sterile closing instrument set for skin closure. Alcohol-based preps were also introduced hospital-wide 3 months into the study period. The SSI rate was obtained from the National Surgical Quality Improvement Program (NSQIP) database. The surgical site infection (SSI) rate was assessed after a 14-month study period for a total of 510 cases. Before instituting the alcohol-based prep, but after the bundle was implemented, 138 cases were analyzed over a 3-month period with an SSI rate of 0%. For the remaining 11 months with both the alcohol-based prep and the infection prevention bundle in place, the infection rate was 1.37% (7/510) as compared with 3.57% (22/615) for the 12-month period before bundle introduction, a statistically significant reduction (P = .023). The SSI rate after major urologic surgery at 1 center was reduced after the introduction of a simple, fast, low-cost, and easily reproducible bundle into the operating room. The use of this bundle reduces SSI, which is critical for the patient and the physician in this era of public reporting and reimbursement based on outcomes.

Implementation of central line-associated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring

BackgroundCentral line-associated bloodstream infections (CLABSIs) can be prevented through well-coordinated, multifaceted programs. However, implementation of CLABSI prevention programs requires individualized strategies for different institutional situations, and the best strategy in resource-limited settings is uncertain. Peer tutoring may be an efficient and effective method that is applicable in such settings.MethodsA prospective intervention was performed to reduce CLABSIs in a surgical intensive care unit (SICU) at a tertiary hospital. The core interventions consisted of implementation of insertion and maintenance bundles for CLABSI prevention. The overall interventions were guided and coordinated by active educational programs using peer tutoring. The CLABSI rates were compared for 9 months pre-intervention, 6 months during the intervention and 9 months post-intervention. The CLABSI rate was further observed for three years after the intervention.ResultsThe rate of CLABSIs per 1000 catheter-days decreased from 6.9 infections in the pre-intervention period to 2.4 and 1.8 in the intervention (6 m; P = 0.102) and post-intervention (9 m; P = 0.036) periods, respectively. A regression model showed a significantly decreasing trend in the infection rate from the pre-intervention period (P < 0.001), with incidence-rate ratios of 0.348 (95% confidence interval [CI], 0.98–1.23) in the intervention period and 0.257 (95% CI, 0.07–0.91) in the post-intervention period. However, after the 9-month post-intervention period, the yearly CLABSI rates reverted to 3.0–5.4 infections per 1000 catheter-days over 3 years.ConclusionsImplementation of CLABSI prevention bundles using peer tutoring in a resource-limited setting was useful and effectively reduced CLABSIs. However, maintaining the reduced CLABSI rate will require further strategies.

Evidence-Based Bundles and Cesarean Delivery Surgical Site Infections

To estimate the association of implementation of evidence-based bundles with surgical site infection rates after cesarean delivery. We searched MEDLINE through PubMed, EMBASE, Scopus, the Cochrane Database of Systematic Reviews, Google Scholar, and ClinicalTrials.gov. We searched electronic databases for randomized controlled trials and observational studies comparing evidence-based infection prevention bundles for cesarean delivery, defined as implementation of three or more processes proven to prevent surgical site infection such as chlorhexidine skin preparation, antibiotic prophylaxis, and hair clipping, with usual care. The primary outcome was overall surgical site infection, defined using Centers for Disease Control and Prevention's National Healthcare Safety Network criteria. Secondary outcomes were superficial or deep surgical site infection and endometritis. Quality of studies and heterogeneity were assessed using validated measures. Pooled relative risks (RRs) with 95% CIs were calculated using random-effects models. Numbers needed to treat were estimated for outcomes with significant reduction. We found no randomized controlled trials. Fourteen preintervention and postintervention studies met inclusion criteria. Eight were full-text articles, and six were published abstracts. Quality of most of the primary studies was adequate with regard to the intervention, but modest in terms of implementation. The rate of surgical site infection was significantly lower after implementing an evidence-based bundle (14 studies: pooled rates 6.2% baseline compared with 2.0% intervention, pooled RR 0.33, 95% CI 0.25-0.43, number needed to treat=24). Evidence-based bundles were also associated with a lower rate of superficial or deep surgical site infection (six studies: pooled rate 5.9% baseline compared with 1.1% intervention, pooled RR 0.19, 95% CI 0.12-0.32, number needed to treat=21). The rate of endometritis was low at baseline and not significantly different after intervention (six studies: pooled rate 1.3% baseline compared with 0.9% intervention, pooled RR 0.57, 95% CI 0.31-1.06). Evidence-based bundles are associated with a significant reduction in surgical site infection after cesarean delivery.

A Multidisciplinary Infection Control Bundle to Reduce the Number of Spinal Cord Stimulator Infections

To investigate the effect of a quality improvement project that resulted in an infection control bundle to reduce the number of spinal cord stimulator (SCS) infections. The study was performed in a single center for neuromodulation from January 1, 2014, through May31, 2016. In response to a high number of surgical site infections (SSIs) after SCS surgery, a multidisciplinary team analyzed the surgical process and developed an infection prevention bundle consisting of five items: 1) showering and decolonization for five days prior to surgery and showering in the hospital on the morning of surgery; 2) performing the SCS implantation as the first in the daily operating room (OR) program; 3) maintaining a minimal number of people in the OR; 4) providing home care nurses with a folder with SCS wound care instructions including pictures; 5) giving oral specific wound care instructions to patients. The number of infections was calculated for the baseline, implementation, and sustainability phases. A total of 410 SCS surgeries were performed during the study period. In the preintervention phase, 26/249 (10.4%) SCS surgeries were infected. During the implementation and sustainability phase, 2/59 (3.4%) and 1/102 (1.0%) SCS surgeries were infected, respectively. The reduction in the number of infections in pre and postintervention phase was statistically significant (p = 0.003). Multidisciplinary measures to reduce SSIs reduced the number of SCS associated infections in our study setting.

Combination of Oral Antibiotics and Mechanical Bowel Preparation Reduces Surgical Site Infection in Colorectal Surgery

Surgical site infections (SSI) are a common complication after colorectal surgery. An infection prevention bundle (IPB) was implemented to improve outcomes. A standardized IPB that included the administration of oral antibiotics with a mechanical bowel preparation, preoperative shower with chlorhexidine, hair removal and skin preparation in holding, antibiotic wound irrigation, and a "clean-closure" protocol was implemented in January 2013. Data from the American College of Surgeons NSQIP were analyzed at a single academic institution to compare pre-IPB and post-IPB SSI rates. In January 2014, a prospective database was implemented to determine compliance with individual IPB elements and their effect on outcomes. For the 24 months pre-IPB, the overall SSI rate was 19.7%. During the 30 months after IPB implementation, the SSI rate decreased to 8.2% (p < 0.0001). A subset of 307 patients was identified in both NSQIP and our prospective compliance databases. Elements of IPB associated with decreased SSI rates included preoperative shower with chlorhexidine (4.6% vs 16.2%; p= 0.005), oral antibiotics (3.4% vs 15.4%; p < 0.001), and mechanical bowel preparation (4.4% vs 14.3%; p= 0.008). Patients who received a full bowel preparation of both oral antibiotics and a mechanical bowel preparation had a 2.7% SSI rate compared with 15.8% for all others (p < 0.001). On multivariate analysis, full bowel preparation was independently associated with significantly fewer SSI (adjusted odds ratio 0.2; 95% CI 0.1 to 0.9; p= 0.006). Implementation of an IPB was successful in decreasing SSI rates in colorectal surgery patients. The combination of oral antibiotics with a mechanical bowel preparation was the strongest predictor of decreased SSI.

Implementation of a Central Line-associated Bloodstream Infection (CLABSI) Prevention Bundle for Adult Hematologic Malignancy and Bone Marrow Transplant Patients

Implementation of a Central Line-associated Bloodstream Infection (CLABSI) Prevention Bundle for Adult Hematologic Malignancy and Bone Marrow Transplant Patients