Overall Rate Of Surgical Site Infections Research Articles

Is barbed better? Evaluation of triclosan-coated barbed suture on wound complications following emergency laparotomy.

Emergent laparotomy is associated with significant wound complications including surgical site infections (SSIs) and fascial dehiscence. Triclosan-coated barbed (TCB) suture for fascial closure has been shown to reduce local complications but primarily in elective settings. We sought to evaluate the effect of TCB emergency laparotomy fascial closure on major wound complications. Adult patients undergoing emergency laparotomy were prospectively evaluated over 1 year. Patients were grouped into TCB versus polydioxanone (PDS) for fascial closure. Subanalysis was performed on patients undergoing single-stage laparotomy. Primary outcomes were SSI and fascial dehiscence. Multivariate analysis identified independent factors associated with SSI and fascial dehiscence. Of the 206 laparotomies, 73 (35%) were closed with TCB, and 133 (65%) were closed with PDS. Trauma was the reason for laparotomy in 73% of cases; damage-control laparotomy was performed in 27% of cases. The overall rate of SSI and fascial dehiscence was 18% and 10%, respectively. Operative strategy was similar between groups, including damage-control laparotomy, wound vac use, skin closure, and blood products. Surgical site infection events trended lower with TCB versus PDS closure (11% vs. 21%, p = 0.07), and fascial dehiscence was significantly lower with TCB versus PDS (4% vs. 14%, p < 0.05). Subanalysis of trauma and nontrauma cases showed no difference in SSI or fascial dehiscence. Multivariable analysis found that TCB decreased the likelihood of fascial dehiscence (odds ratio, 0.07; p < 0.05) following emergency laparotomy. Increased odds of fascial dehiscence were seen in damage-control laparotomy (odds ratio, 3.1; p < 0.05). Emergency laparotomy fascial closure with TCB showed significantly decreased rates of fascial dehiscence compared with closure with PDS and a strong trend toward lower SSI events. Triclosan-coated barbed suture was independently associated with decreased fascial dehiscence rates after emergency laparotomy. Therapeutic/Care Management; Level III.

Effectiveness of Chlorhexidine and Povidone Iodine in Preventing Surgical Site Infections (SSIs) in C-Section Deliveries

Objective: To compare the effectiveness of Chlorhexidine and Povidone iodine in preventing SSIs in C-section deliveries. Methodology: The study was conducted at a medical university and hospital in Karachi, from January 2021 July 2021. A non-probability consecutive sampling technique was used to select 35 participants. The study included women aged 18 to 45 years. The efficacy of Chlorhexidine and Povidone iodine in preventing SSIs was evaluated. Two groups were randomly assigned, with Group 1 receiving Chlorhexidine gluconate and Group 2 receiving Povidone-Iodine for skin preparation. Data on various factors were recorded, and the occurrence of SSIs within ten days of cesarean delivery was assessed. Results: The study included women aged 18 to 45 years. The efficacy of Chlorhexidine and Povidine iodine in preventing SSIs was evaluated. The results showed that Chlorhexidine was effective in preventing SSIs in 94.3% of cases, while Povidone iodine was effective in 91.4% of cases. However, no significant difference was observed between the two groups. The study results were consistent with previous research showing a reduction in SSI rates with the use of Chlorhexidine or Povidone- iodine. The overall rate of SSI was lower in the Chlorhexidine group, but contextual factors and adherence to infection control practices may influence outcomes. Conclusion. This study augments existing knowledge on preventing SSIs in C-section deliveries. While both Chlorhexidine and Povidone-iodine demonstrated comparable efficacy, Chlorhexidine appeared slightly more effective in reducing SSIs. Nonetheless, the study's limitations underscore the necessity for further research in diverse healthcare settings.

Is There an Association between Intra-Operative Detection of Pathogens in Subcutaneous Tissue and Surgical Site Infections? Results from a Prospective Study.

Background: Surgical site infections (SSIs) are a common complication in visceral surgery. Pathogens causing SSIs vary depending on the type of surgery. Patients and Methods: Within the scope of the Reduction of Postoperative Wound Infections by Antiseptica (RECIPE) trial we analyzed the pathogens cultured in intra-operative, subcutaneous swabs and in swabs from SSI in a single-center, prospective, randomized controlled study. Definition of SSI complied with the criteria of the U.S. Centers for Disease Control and Prevention (CDC). Results: The overall rate of SSI was 28.2% in 393 patients. Colorectal surgery was performed in 68.2% of elective laparotomies. Pathogens were more often detected in intra-operative subcutaneous swabs in patients who developed SSIs than in patients who did not develop SSIs (64.4% vs. 38.0%; p < 0.001). Enterococci were found in 29.1% of intra-operative swabs in patients with SSIs, followed by Escherichia coli in 15.5%. A higher rate of Enterococcus faecium was found in patients with anemia versus those without anemia (9.2% vs. 2.3%; p = 0.006) and in patients who smoked versus those who did not (11.8% vs. 3.6%; p = 0.008). A positive subcutaneous swab (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.47-4.29; p = 0.001), pre-operative anemia (OR, 1.84; 95% CI, 1.08-3.13; p = 0.016), and renal insufficiency (OR, 2.15; 95% CI, 1.01-4.59; p = 0.048) were risk factors for SSIs. Conclusions: There is an association between the intra-operative detection of pathogens in subcutaneous tissue and the development of SSIs in visceral surgery. The most prevalent pathogens causing SSIs were enterococci and Escherichia coli. More efforts are justified to reduce subcutaneous colonization with pathogens, for example by using intra-operative wound irrigation with polyhexanide solution. This trial is registered at www.ClinicalTrials.gov (ID: NCT04055233).

EP.TU.870Challenges of Surgical Site Infections (SSIs) and Stoma

Abstract Aims Surgical site infection (SSI) is a costly health burden and is frequently observed in patients who undergo large bowel surgeries with stoma formation. The use of PICO has been associated with reduced rate of SSI and its use is encouraged by NICE. Method We identified patients who underwent elective or emergency large bowel surgeries, between 2014-2018, using the local database collected for national SSI surveillance. PICO order forms were cross-referenced with SSI database. Analysed data is presented as percentages, and variable testing is performed using Chi Square test. Results The overall rate of SSIs was 12.7%. 6.8% of the cohort developed an incisional SSI, while 5.9% developed an organ/space SSI. The presence of stoma had a significant impact in the rate of incisional SSI (10.3% v 4.2%; p = 0.000179). Amongst all patients with PICO dressing applied, stoma formation was associated with a higher rate of incisional SSI (15.2% vs 6.9%, p = 0.042). 28.7% patients with stoma formation had PICO applied. The use of PICO in this group of patients was associated with statistically significant improvement in the rate of incisional SSI (4.4% v 8.4%; p = 0.026) but not in the rate of organ/ space SSI (2.1% v 4.5%; p = 0.18). Similar findings were not observed when considering elective and emergency cases separately. Conclusion The risk of incisional SSIs is high in patients with stoma formation, even in those who had PICO dressing fitted. Tricky fitting of PICO dressing in the presence of stoma could be one hurdle in reducing SSIs.

Reducing surgical site infection rates in colorectal surgery - a quality improvement approach to implementing a comprehensive bundle.

AimSurgical site infections (SSIs) are a preventable cause of morbidity following surgical procedures. Strategies to reduce rates of SSI must address pre‐, peri‐ and postoperative factors and multiple interventions can be combined into ‘bundles’. Adoption of these measures can reduce SSIs, but this is dependent on high levels of compliance. The aim of this work is to assess the change in rates of SSI in elective colorectal surgery after implementing a colorectal SSI bundle.MethodThis is a single‐centre prospective cohort study. All elective colorectal procedures from 2011 until 2018 (inclusive) were included. The primary outcome was inpatient SSI. A multimodal bundle was implemented using quality improvement methodology. The bundle was altered during the timeframe of the study to optimize outcomes. Data were analysed by interrupted time series analysis assessing points at which the bundle was altered.ResultsIn the study period, 1075 elective colorectal procedures were performed. Prior to the introduction of the colorectal SSI bundle, the SSI rate was 16.4%. During the implementation period (2013–2015), the overall rate of SSI fell from 15.9% to 9.4%, with the most significant reduction being in superficial SSI, from 8.6% to 4.7%. In the postimplementation period from 2015–2018, there was a further reduction in the overall rate of SSI (5.1%). In 2018, there were 87 consecutive cases without infection.ConclusionA successful reduction in the rate of SSI following elective colorectal surgery can be achieved by adopting a comprehensive perioperative bundle. This is complemented by a process of continuous measurement and evaluation. The current bundle has achieved a significant reduction in superficial SSI.

A Risk-Stratified Peri-Operative Protocol for Reducing Surgical Site Infection after Cesarean Delivery.

Background: Surgical site infections (SSI) are multifaceted. Pre-operative, intra-operative, and post-operative factors influence the risk of developing an infection. Our objective was to evaluate the effectiveness of an infection risk-stratification checklist, utilizing known SSI risk factors, and a tailored surgical protocol for SSI prevention in women undergoing cesarean delivery. Patients and Methods: A prospective project to reduce SSI was conducted for women undergoing cesarean delivery on the resident staff service at a midwestern, urban tertiary care hospital. Patients were categorized according to an SSI risk-stratification checklist as high risk or low risk. The low-risk group received the local standard of care (single prophylactic dose of pre-operative intravenous antibiotics and a standard pressure dressing). In the high-risk group, prophylactic antibiotic agents were given pre-operatively and continued for the first 24 hours post-operatively. Additionally, patients at high risk received an absorbent dressing (Mepilex Ag®; Mölnlycke Health Care AB, Gothenburg, Sweden) that was applied in the operating room and worn for one week. Results: The overall rate of SSIs decreased from 6.1% (pre-study rate) to 1.4% after initiation of the protocol, a 77% reduction (p < 0.001). The low- and high-risk groups did not differ in infection rate (0% and 1.4%, respectively; p < 0.59). Both deep incisional and organ/space SSIs decreased after initiation of the protocol (91% and 62% decrease, respectively). Conclusion: Stratifying patients into high- and low-risk groups with tailored peri-operative management strategies reduced overall SSIs. The protocol incorporates known risk factors for SSI in a surgical procedure with high rates of SSI. This approach offers a structured method that can be adopted by other hospital systems for SSI prevention in patients undergoing cesarean delivery.

Diabetic Control Predicts Surgical Site Infection Risk in Orthopaedic Trauma Patients.

(1) To determine the incidence of surgical site infections (SSIs) in diabetic orthopaedic trauma patients and (2) to establish a protocol for managing diabetes mellitus (DM) in orthopaedic trauma patients. Retrospective cohort study. Level 1 Trauma Center. All diabetic orthopaedic trauma patients who underwent surgical intervention with at least 1 month follow-up. Patients were classified as poorly controlled or controlled diabetic patients based on admission hemoglobin A1c and blood glucose (BG) levels. Orthopaedic surgical intervention in accordance with fracture type and a standardized diabetes management protocol with internal medicine comanagement. SSI incidence. There were 260 patients during the study period. Two hundred two (77.7%) were included in the final analysis. Seventy-five (37.1%) patients met the criteria for poorly controlled DM. The overall rate of SSI was 20.8%; 32.0% for poorly controlled diabetic patients, and 14.2% for controlled diabetic patients (P < 0.01). The admission blood glucose level (BG, P = 0.05), but not discharge BG, was associated with SSI incidence. Trauma patients with poorly controlled DM have a higher rate of SSIs than patients with controlled DM. Perioperative diabetes control does not seem to decrease infection rates in these patients. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pre-operative skin antisepsis with chlorhexidine gluconate baths and wipes does not prevent postoperative surgical site infection in outpatient pediatric urologic inguinal and scrotal surgery

To reduce surgical site infections (SSI), many institutions utilize pre-operative antisepsis with chlorhexidine gluconate (CHG) baths and/or wipes. CHG reduces bacterial colonization of the skin, but it is unclear whether this reduces SSI, and current guidelines from the American College of Surgeons, the Centers for Disease Control, and the World Health Organization do not support this practice. There are several factors that increase the risk of SSI in adults, but there is limited understanding of these factors in pediatric patients. The primary objectives were to describe the proportion of pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy who develop a postoperative (postop) SSIand to determine whether pre-operative CHG baths/wipes were associated with SSI. The secondary objectives were to identify other factors associated with SSIand to estimate the cost of CHG baths/wipes in this population. Pre-operative antisepsis with CHG baths/wipes was implemented at the authors institution in 2006. The authors performed a retrospective cohort study of patients aged 0-18 yearsundergoing hernia/hydrocele repair and/or orchiopexy by a pediatric urologist at their institution before (2004) and after (2008) the introduction of CHG. The authors compared the proportion of patients with SSI in the no CHG and CHG groups and evaluated for factors associated with SSI. Statistical analysis included Wilcoxon rank-sum test, Chi-squared test, and Fisher's exact test. The cost of CHG baths and wipes was estimated using institutional fees in 2018 US dollars. A total of 543 patients met inclusion criteria,203 in the no CHG group and 340 in the CHG group. The overall rate of SSI was 0.92%. There was no association between use of CHG and SSI. No patient or peri-operative factors were associated with development of SSI. There were no CHG-associated adverse events. The cost of materials was estimated at $3.29/patient ($1118.60 for 340 cases in 2008) in 2018 US dollars. SSI is not common in pediatric patients undergoing hernia/hydrocele repair or orchiopexy. In the present study, pre-operative antisepsis with CHG baths/wipes is not associated with a reduction in SSI and carries additional cost. To the authors knowledge, this is the first study to evaluate the use of pre-operative antisepsis with CHG baths/wipes in an exclusively pediatric population. In the study, CHG baths/wipes add cost with no clear benefit for reducing SSI in pediatric patients undergoing hernia/hydrocele repair and/or orchiopexy.

Infection Rates After Microlaryngeal and Open Phonosurgery: The Role of Postoperative Antibiotics.

Although it is known that the airway has bacterial contamination that seeds the surgical site during microlaryngeal surgery, literature on the use of postoperative antibiotics is lacking. We performed a retrospective analysis of open phonosurgical and phonomicrosurgical cases at a single institution to assess whether use of postoperative antibiotics impacts the incidence of surgical site infections (SSI). In this retrospective cohort study, we reviewed 228 phonomicrosurgery and 53 open phonosurgery cases performed for benign diseases. Surgeries were performed by two laryngologists between February 2016 and August 2018. The surgeons differ in their postoperative antibiotic regimens: no antibiotics versus a 5- to 7-day postoperative course. Data collected include demographics, medical comorbidities, type of benign laryngeal disease, and surgical procedure. The primary outcome measure was postoperative infection, defined as the patient requiring a new prescription for antibiotics, an extended course of antibiotics, or any mention of infection at follow-up/emergency visits within the first month postoperatively. The overall rate of SSI was 3.1% and 0% for phonomicrosurgery and open phonosurgery cases, respectively. For phonomicrosurgery, there was no difference in the rate of SSI for patients who received or did not receive antibiotics perioperatively: 2.9% versus 3.2% (P = 0.99). Similarly, there was no difference in the infection rate for open phonosurgical cases. Infection rates after endoscopic and open phonosurgery are low. In this study, we found no evidence to suggest a protective effect associated with postoperative use of antibiotics. 4 Laryngoscope, 130:1128-1131, 2020.

Prospective Evaluation of Surgical Wound Dressings and the Incidence of Surgical Site Infections in Dogs Undergoing a Tibial Plateau Levelling Osteotomy.

The main aim of this study was to evaluate the efficacy of a topical 2-octyl cyanoacrylate (2OC) tissue adhesive and an adhesive barrier dressing (BD) in minimizing the incidence of surgical site infections (SSI) in dogs undergoing a tibial plateau levelling osteotomy (TPLO). In a prospective clinical study, 437 client-owned dogs undergoing a TPLO as treatment for cranial cruciate ligament disease with or without concurrent patellar luxations from July 2015 to September 2016 were included. In each dog, the type of postoperative wound dressing was randomly selected as either no dressing (ND), a 2OC tissue adhesive or an adhesive BD. Direct examination by a veterinarian was performed at 14, 30, 60 and 90 days postoperatively. If dogs did not return for direct examination, owners were contacted with a questionnaire for the final follow-up of at least 90 days. The overall rate of SSI was 2.3% (10/437). Methicillin-resistant Staphylococcus pseudintermedius was the most common bacteria isolated in 9/10 cases. Infection was confirmed in 2.76% (4/145) of dogs with ND, 2.01% (3/149) of dogs with 2OC and 2.10% (3/143) of dogs with BD. Of the dogs that developed an SSI, type of dressing was not a significant risk factor (p = 0.5305) for infection. Increasing body weight was the only significant risk factor that increased the risk of overall infection (odds ratio = 1.03 [95% confidence interval: 1.02-1.05]). In dogs undergoing a TPLO, there may be no clear benefit in the usage of postoperative wound dressings for the prevention of SSI. Increasing body weight was the only significant factor associated with the development of an SSI.

Incidence, depth, and severity of surgical site infections after neurosurgical interventions.

Today, there are only few reports on the incidence of surgical site infections (SSIs) in neurosurgery. The objective of this work was to determine the rate of SSI at a tertiary neurosurgical department for benchmarking purpose. Data of consecutive patients undergoing neurosurgical treatment between January 2013 and December 2016 were prospectively entered into a registry. SSIs were diagnosed according to the 2017 Centers for Disease Control and Prevention criteria, with severity graded according to the Clavien-Dindo grade (CDG). We analyzed type and length of surgery (LOS), time to SSI, responsible microorganisms, and its association with the functional status (Karnofsky Performance Status = KPS). Of n = 5463 procedures, a SSI occurred in n = 106 (1.94%). The highest rates of SSI occurred after vascular (3.4%) and cerebrospinal fluid (CSF) diversion procedures (3%), as well as after procedures performed to treat a previous complication (2.9%). There was no difference in LOS across procedures with and without SSI. The median time between the index procedure and SSI was 15.5days. SSIs were most frequently diagnosed after hospital discharge (55%). The most common microorganisms were coagulase-negative staphylococci, Staphylococcus aureus, and Escherichia coli. In 62.3% of cases, SSI required invasive treatment (surgical revision). Patients with SSI in the in- and out-patient setting (SSI occurring after hospital discharge) presented both with a median KPS of 80. The current report provides an overview on SSI in a contemporary, unselected, large series of patients undergoing modern neurosurgical care for benchmarking purposes. The overall rate of SSI was about 2%, but subpopulations with higher risks were identified where additional measures could be taken to prevent SSI and monitor patients at risk more closely for SSI.

Wound protectors mitigate superficial surgical site infections after pancreatoduodenectomy

BackgroundWhether the choice of antibiotic prophylaxis, the type of incision, or the use of wound protectors decreases surgical site infections (SSIs) in patients undergoing pancreatoduodenectomy (PD) remains unknown. MethodsPatients undergoing open, elective PD between January 1, 2016 and June 30, 2017 were identified from the American College of Surgeons’ National Surgical Quality Improvement Program registry. Multivariable logistic regression models were constructed to determine the association of antibiotic prophylaxis type, incision type, and wound protector use on the incidence of any, superficial, and organ/space SSIs, and to profile hospitals. ResultsOverall, 5969 patients were included from 140 hospitals. The overall rate of SSI was 20.3% (n = 1213). Superficial SSIs occurred in 432 (7.2%) patients and organ/space SSIs in 841 (14.1%). Wound protector use was associated with 23% lower odds of experiencing any SSIs (OR 0.77, 95% CI 0.60–0.98), reflective of the decreased odds associated with superficial SSIs (OR 0.65, 95% CI 0.44–0.97), but not organ/space SSIs (OR 0.89, 95% CI 0.68–1.17). Highest-performing hospitals frequently utilized broad-spectrum antibiotics, midline incisions, and wound protectors. ConclusionWound protectors reduced superficial, but not organ/space, infections in patients undergoing pancreatoduodenectomy. Routine use of wound protectors in patients undergoing proximal pancreatectomy is recommended.

Impact of Hair Removal on Surgical Site Infection Rates: A Prospective Randomized Noninferiority Trial

Despite substantial prevention efforts, surgical site infections (SSIs) remain the most common health care-associated infection. It is unclear whether the Centers for Disease Control and Prevention recommendation to leave hair intact preoperatively reduces SSIs. A single-center, prospective, randomized, clinical trial was conducted from October 2009 to February 2015 in a 325-bed multispecialty, tertiary care teaching hospital to test the noninferiority of clipping hair to no hair removal in the prevention of SSIs. A total of 4,908 adults scheduled for elective general surgical procedures were screened for study participation. Of these, 600 were approached but refused, and 2,630 were excluded. Patients were randomized 1:1 to either the clipped group (n= 834) or the not-clipped group (n= 844). The clipped group had hair at the surgical site removed using disposable electric clippers. Of the randomized patients, 1,543 (768 in the clipped group and 775 in the not-clipped group) completed follow-up. The primary endpoint was the proportion of patients who could be evaluated and who had no SSI, as defined by CDC criteria. Baseline demographic, clinical, and surgical characteristics were similar between groups. The overall rate of SSI in the per-protocol analysis was 6.12% (47 of 768) in the clipped group and 6.32% (49 of 775) in the not-clipped group (absolute risk difference-0.20%; 95% CI-2.61% to 2.21%), p= 0.037). Because the absolute risk difference confidence interval included the prespecified noninferiority margin of 2%, we were unable to definitively demonstrate noninferiority for clipping hair. Surgical site infection rates were similar whether hair was clipped or not in patients undergoing general surgical procedures.

Decreased Hospital Costs and Surgical Site Infection Incidence With a Universal Decolonization Protocol in Primary Total Joint Arthroplasty

BackgroundStaphylococcus aureus colonization has been identified as a key modifiable risk factor in the reduction of surgical site infections (SSI) related to elective total joint arthroplasty (TJA). We investigated the incidence of SSIs and cost-effectiveness of a universal decolonization protocol without screening consisting of nasal mupirocin and chlorhexidine before elective TJA compared to a program in which all subjects were screened for S aureus and selectively treated if positive. MethodsWe reviewed 4186 primary TJAs from March 2011 through July 2015. Patients were divided into 2 cohorts based on the decolonization regimen used. Before May 2013, 1981 TJA patients were treated under a “screen and treat” program while the subsequent 2205 patients were treated under the universal protocol. We excluded the 3 months around the transition to control for treatment bias. Outcomes of interest included SSI and total hospital costs. ResultsWith a universal decolonization protocol, there was a significant decrease in both the overall SSI rate (5 vs 15 cases; 0.2% vs 0.8%; P = .013) and SSIs caused by S aureus organisms (2 vs 10; 0.09% vs 0.5%; P = .01). A cost analysis accounting for the cost to administer the universal regimen demonstrated an actual savings of $717,205.59. TJA complicated by SSI costs 4.6× more to treat than that of an uncomplicated primary TJA. ConclusionOur universal decolonization paradigm for elective TJA is effective in reducing the overall rate of SSIs and promoting economic gains for the health system related to the downstream savings accrued from limiting future reoperations and hospitalizations.

Antimicrobial Prophylaxis in Instrumented Spinal Fusion Surgery: A Comparative Analysis of 24-Hour and 72-Hour Dosages

Study DesignProspective study.PurposeTo compare the efficacy of 24-hour and 72-hour antibiotic prophylaxis in preventing surgical site infections (SSIs).Overview of LiteratureAntimicrobial prophylaxis in surgical practice has become a universally accepted protocol for minimizing postoperative complications related to infections. Although prophylaxis is an accepted practice, a debate exists with regard to the antibiotic type and its administration duration for various surgical procedures.MethodsOur institute is a tertiary care hospital with more than 100 spinal surgeries per year for various spine disorders in the department of orthopedics. We conducted this prospective study in our department from June 2012 to January 2015. A total of 326 patients were enrolled in this study, with 156 patients in the 72-hour antibiotic prophylaxis group (group A) and 170 patients in the 24-hour group (group B). Cefazolin was the antibiotic used in both groups. Two surgeons were involved in conducting all the spinal procedures. Our study compared SSIs among patients undergoing instrumented spinal fusion.ResultsThe overall rate of SSIs was 1.8% with no statistical difference between the two groups.ConclusionsThe 24-hour antimicrobial prophylaxis is as effective as the 72-hour dosage in instrumented spinal fusion surgery.

Surgical Site Infections in Pediatric Plastic Surgery

INTRODUCTION: Surgical site infections (SSIs) are responsible for significant morbidity and healthcare costs. The US Department of Health and Human Services has identified the reduction of SSIs as a national priority for patient safety and quality improvement. Preventing SSIs is dependent on a clear understanding of modifiable risk factors for targeted intervention. In Pediatric Plastic Surgery, our understanding of risk factors for SSIs has been limited by small sample size, nonstandard definitions, and single-center retrospective data. The objective of this study is to use a large prospective national database to analyze clinical risk factors for SSI in children undergoing plastic surgery operations. METHODS & MATERIALS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Peds) is a quality improvement database that prospectively collects demographic data, perioperative risk factors, and 30-day postoperative morbidity outcomes across 56 participating pediatric institutions. Data for patients less than 18 years old undergoing plastic surgery operations were extracted from the NSQIP-Peds 2012 and 2013 databases using CPT codes. Risk factors for SSI were determined with univariate analyses and multivariate logistic regression. RESULTS: Among 11,656 patients, there were 5520 (47%) craniofacial, 4431 (38%) skin/soft tissue, 747 (6.4%) extremity, 728 (6.2%) transcranial, 211 (1.8%) breast/chest wall, and 19 (0.2%) gastrointestinal/genitourinary operations. Mean age at surgery was 5.5 (± 3.8) years and 52% were male. The overall rate of SSI was 0.7%. There were 57 (0.5%) superficial SSIs, 11 (0.1%) deep SSIs, and 10 (0.1%) organ space SSIs. On univariate analysis, inpatient status (p<0.05), increased total operative time (p<0.01), increased length of hospital stay (p<0.01), and younger age at time of surgery (p<0.05) were risk factors for SSI. Following multivariate logistic regression analyses, increased total operative time (p<0.01) was an independent predictor of SSI. Children undergoing extremity or transcranial operations had a higher proportion of SSI than children undergoing skin/soft tissue, craniofacial, breast/chest wall, and/or gastrointestinal/genitourinary operations (p<0.05). Wound classification and ASA classification were not predictive of SSI. CONCLUSIONS: The overall rate of SSI in children undergoing plastic surgery operations is low. This analysis of a large prospective multicenter database provides a high level of evidence regarding risk factors for SSI in the pediatric plastic surgery population and has implications for quality improvement by identifying modifiable factors for targeted intervention.

Abdominal Hysterectomy: Reduced Risk of Surgical Site Infection Associated with Robotic and Laparoscopic Technique.

Hysterectomy is one of the most common procedures performed in the United States. New techniques utilizing laparoscopic and robotic technology are becoming increasingly common. It is unknown if these minimally invasive surgical techniques alter the risk of surgical site infections (SSI). We performed a retrospective review of all patients undergoing abdominal hysterectomy at our institution between January 2011 and June 2013. International Classification of Diseases, Ninth edition (ICD-9) codes and chart review were used to identify patients undergoing hysterectomy by open, laparoscopic, or robotic approach and to identify patients who developed SSI subsequently. Chi-square and analysis of variance (ANOVA) tests were used to identify univariate risk factors and logistic regression was used to perform multivariable analysis. During this time period, 986 patients were identified who had undergone abdominal hysterectomy, with 433 receiving open technique (44%), 116 laparoscopic (12%), 407 robotic (41%), and 30 cases that were converted from minimally invasive to open (3%). Patients undergoing laparoscopic-assisted hysterectomy were significantly younger and had lower body mass index (BMI) and American Society of Anesthesiologists (ASA) scores than those undergoing open or robotic hysterectomy. There were no significant differences between patients undergoing open versus robotic hysterectomy. The post-operative hospital stay was significantly longer for open procedures compared with those using laparoscopic or robotic techniques (5.1, 1.7, and 1.6 d, respectively; p<0.0001). The overall rate of SSI after all hysterectomy procedures was 4.2%. More SSI occurred in open cases (6.5%) than laparoscopic (0%) or robotic (2.2%) (p<0.0001). Cases converted to open also had an increased rate of SSI (13.3%). In both univariate and multivariable analyses, open technique, wound class of III/IV, age greater than 75 y, and morbid obesity were all associated with increased risk of SSI. Laparoscopic and robotic hysterectomies were associated with a significantly lower risk of SSI and shorter hospital stays. Body mass index, advanced age, and wound class were also independent risk factors for SSI.

Analysis of the Risk Factors Affecting the Surgical Site Infection after Cranioplasty Following Decompressive Craniectomy.

ObjectiveThe risk factors for surgical site infections (SSIs) after cranioplasty following decompressive craniectomy remain unclear. The goal of this study was to analyze the risk factors related to developing SSIs after cranioplasty and to suggest valuable predictors.MethodsA retrospective review was conducted of patients who underwent cranioplasty following decompressive craniectomy at our institution from January 2011 to December 2014, a total of 78 patients who underwent 78 cranioplasties. Univariate and multivariate logistic regression analyses were carried out to determine possible risk factors related to developing SSIs. We analyzed both patient-specific and surgery-specific factors.ResultsThe overall rate of SSIs was 9.0% (7/78). SSIs after cranioplasty were significantly related to being female, having the primary etiology of traumatic brain injury (TBI) and having had a bilateral cranioplasty in the univariate analysis. Multivariate logistic regression analysis showed that being female [odds ratio (OR) 5.98, p=0.000] and having had a bilateral cranioplasty (OR 4.00, p=0.001) significantly increased the risk of SSIs.ConclusionBased on our data, cranioplasty following decompressive craniectomy is associated with a high incidence of SSI. Being female, having a primary etiology of TBI and having had a bilateral cranioplasty may be risk factors for surgical site infections after cranioplasty.

Underweight Body Mass Index as a Predictive Factor for Surgical Site Infections after Laparoscopic Appendectomy

PurposeAnalyses of risk factors associated with surgical site infections (SSIs) after laparoscopic appendectomy (LA) have been limited. Especially, the association of an underweight body mass index (BMI) with SSIs has not been clearly defined. This study aimed to identify the impact of underweight BMI in predicting SSIs after LA.Materials and MethodsThe records of a total of 101 consecutive patients aged ≥16 years who underwent LA by a single surgeon between March 2011 and December 2012 were retrieved from a prospectively collected database. The rate of SSIs was compared among the underweight, normal and overweight and obese groups. Also, univariate and multivariate analyses were performed to identify the factors associated with SSIs.ResultsThe overall rate of SSIs was 12.8%. The superficial incisional SSI rate was highest in the underweight group (44.4% in the underweight group, 11.0% in the normal group, and 0% in the overweight and obese group, p=0.006). In univariate analysis, open conversion and being underweight were determined to be risk factors for SSIs. Underweight BMI was also found to be a significant predictor for SSIs in multivariate analysis (odds ratio, 10.0; 95% confidence interval, 2.0-49.5; p=0.005).ConclusionThis study demonstrated underweight BMI as being associated with SSIs after LA. Surgeons should be more cautious to prevent SSIs in patients that are underweight when performing LA.

Once Is Not Enough

There has been a trend toward limiting perioperative prophylactic antibiotics, based on research not conducted in plastic surgery patients. The authors' university hospital instituted antibiotic prescribing guidelines based on the Surgical Care Improvement Project. An increased rate of surgical-site infections was noted in breast reconstruction patients. The authors sought to determine whether the change in antibiotic prophylaxis regimen affected rates of surgical-site infections. A retrospective study compared patients undergoing breast reconstruction who received preoperative and postoperative prophylactic antibiotics with a group who received only a single dose of preoperative antibiotic. Type of reconstruction and known risk factors for implant infection were noted. Two hundred fifty patients were included: 116 in the pre-Surgical Care Improvement Project group and 134 in the Surgical Care Improvement Project group. The overall rate of surgical-site infections increased from 18.1 percent to 34.3 percent (p = 0.004). Infections requiring reoperation increased from 4.3 percent to 16.4 percent (p = 0.002). Multivariate logistic regression demonstrated that patients in the Surgical Care Improvement group were 4.74 times more likely to develop a surgical-site infection requiring reoperation (95 percent CI, 1.69 to 13.80). Obesity, history of radiation therapy, and reconstruction with tissue expanders were associated with increased rates of surgical-site infection requiring reoperation. Withholding postoperative prophylactic antibiotics in prosthetic breast reconstruction is associated with an increased risk of surgical-site infection, reoperation, and thus reconstructive failure. The optimal duration of postoperative prophylactic antibiotic use is the subject of future study.