Reduction Of Surgical Site Infections Research Articles

Sample sizes for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control including for COVID-19

Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, hand hygiene, and hub disinfection, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of the basic measures to prevent the transmission to patients and clinicians of pathogenic bacteria and viruses, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. We evaluated appropriate sample sizes and strategies for measuring transmission.There was absence of serial correlation among observed counts of transmitted isolates within each of several periods (all P ≥.18). Similarly, observing transmission within or between cases of a pair did not increase the probability that the next sampled pair of cases also had observed transmission (all P ≥.23).Most pairs of cases had no detected transmitted isolates. Also, although transmission (yes/no) was associated with surgical site infection (P =.004), among cases with transmission, there was no detected dose response between counts of transmitted isolates and probability of infection (P =.25).The first of a fixed series of tests is to use the binomial test to compare the proportion of pairs of cases with S. aureus transmission to an acceptable threshold. An appropriate sample size for this screening is N =25 pairs. If significant, more samples are obtained while additional measures are implemented to reduce transmission and infections. Subsequent sampling is done to evaluate effectiveness. The two independent binomial proportions are compared using Boschloo's exact test. The total sample size for the 1st and 2nd stage is N =100 pairs.Because S. aureus transmission is invisible without testing, when choosing what population(s) to screen for surveillance, another endpoint needs to be used (e.g., infections). Only 10/298 combinations of specialty and operating room were relatively common (≥1.0% of cases) and had expected incidence ≥0.20 infections per 8 hours of sampled cases. The 10 combinations encompassed ≅17% of cases, showing the value of targeting surveillance of transmission to a few combinations of specialties and rooms.In conclusion, we created a sampling protocol and appropriate sample sizes for using S. aureus transmission within and between pairs of successive cases in the same operating room, the purpose being to monitor the quality of prevention of intraoperative spread of pathogenic bacteria and viruses.

Post-operative Glycaemic Control Using an Insulin Infusion is Associated with Reduced Surgical Site Infections in Colorectal Surgery.

The incidence of surgical site infection (SSI) in colorectal surgery (CRS) is higher than other forms of general surgery. Post-operative hyperglycaemia causes increased SSI in CRS. Post-operative hyperglycaemia control in cardiac surgery reduces SSI. The aim was to evaluate using a cohort comparison the effect of post-operative glycaemic control using an insulin infusion on SSI in CRS. Collection of data for the ACS-NSQIP was commenced in 2015. The CRS unit added post-operative glycaemic control to the SSI bundle in late 2016. The intervention was an insulin infusion to titrate blood glucose between 135 and 180mg/Dl (7.5 and 10mmol/l). The effect of glycaemic control on SSI was assessed comparing ACS-NSQIP raw data prior and after the intervention was commenced. The NSQIP data from July 2015 to June 2016 revealed the incidence of SSI were 25%. From January 2017 to December 2017, there was a significant reduction in SSI to 6.1% (OR = 517 Cl = 1.92-16.08, p < 0.001). The incidence of organ/space SSI fell significantly from 13% to 1.0% (OR = 11.35, Cl = 1.62-488.7, p < 0.001). There was non-significant reduction in superficial SSI from 11 to 4.0% (OR = 2.93, Cl = 0.68-13.03, p = 0.06). There was no significant difference in other factors associated with SSI in CRS. Post-operative glycaemic control in CRS reduces the rate of SSI. Post-operative glycaemic control should be included in SSI bundles for CRS and may be of benefit in other surgical specialties.

Use of prophylactic closed incision negative pressure therapy is associated with reduced surgical site infections in gynecologic oncology patients undergoing laparotomy

Surgical site infection after surgery for gynecologic cancer increases morbidity. Prophylactic closed incision negative pressure therapy has shown promise in reducing infectious wound complications across many surgical disciplines. This study aimed to determine whether closed incision negative pressure therapy is associated with reduced surgical site infections in gynecologic oncology patients undergoing laparotomy compared with standard dressings. This was a retrospective case-control study of patients undergoing laparotomy for known or suspected gynecologic cancer from Jan. 1, 2017, to Feb. 1, 2020. Patients were matched in a 1:3 ratio (closed incision negative pressure therapy to standard dressing) by body mass index, age, diabetes, bowel surgery, smoking, and steroid use. Surgical site infection was defined according to the Centers for Disease Control and Prevention. Multivariable logistic regression using backward selection was performed. Of the 1223 eligible patients undergoing laparotomy, 64 (5.2%) received closed incision negative pressure therapy dressings and were matched to 192 (15.7%) controls. There were no differences in medical comorbidities (P>.05), site or stage of malignancy (P>.05), duration of surgery (P=.82), or surgical procedures (P>.05). Use of closed incision negative pressure therapy was associated with reduction in all adverse wound outcomes (20.3% vs 40.1%; P<.001). In particular, closed incision negative pressure therapy was associated with a significant reduction in both superficial incisional surgical site infections (9.4% vs 29.7%; P<.001) and deep incisional surgical site infections (0.0% vs 6.8%; P=.04). In multivariable analysis, use of closed incision negative pressure therapy was associated with significant reduction in the incidence of superficial incisional infections alone (odds ratio, 0.29; 95% confidence interval, 0.12-0.73; P=.008) and both superficial and deep incisional infections (odds ratio, 0.29; 95% confidence interval, 0.12-0.71; P=.007). Use of prophylactic closed incision negative pressure therapy after laparotomy in gynecologic oncology patients was found to be associated with reduced superficial incisional and deep incisional infections compared with standard dressings. Furthermore, closed incision negative pressure therapy was associated with reduction in all other adverse wound outcomes. Closed incision negative pressure therapy may be considered for surgical site infection prevention in high-risk gynecologic oncology patients undergoing laparotomy.

A novel prevention bundle to reduce incisional infections after radical cystectomy

PurposeOur institution implemented a novel intervention bundle to reduce incisional surgical site infections (SSIs) for patients undergoing radical cystectomy. The primary objective of this study was to evaluate the efficacy of the bundle in reducing incisional SSIs post-cystectomy. Material and methodsA before-after cohort study was performed on all patients who underwent radical cystectomy by urologic oncologists at The Ottawa Hospital from January 2016 to March 2019. Thirty-day postoperative incisional SSIs were identified from the medical record and were compared to institutionally collected National Surgical Quality Improvement Program data. The SSI reduction strategy was implemented as of March 1st, 2018. Adjusted associations between the SSI intervention with the risk of incisional SSI were determined. Cystectomy incisional SSI rates were compared to all other National Surgical Quality Improvement Program-collected surgeries at The Ottawa Hospital during the same time period. ResultsOne hundred and thirty-two patients were included; 41 following implementation of the SSI reduction bundle. Mean age was 69 years, 104 (79%) were male, and 59 (45%) received neobladders. The risk of incisional SSI decreased from 16.5% preintervention to 2.4% post intervention (risk ratio 0.17; P = 0.004). Intraoperative transfusion and diabetes were independently associated with an increased risk of incisional SSI (P < 0.05). The SSI rate for all other surgical procedures at our institution remained stable during the same time period. ConclusionsThe risk of SSI after radical cystectomy is high. Use of an SSI reduction bundle was associated with a large reduction in incisional SSIs. Further evaluation of this intervention in other centers is warranted

Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis.

In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction. We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space). We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48-0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42-0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46-0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50-0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions. Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.

Reducing abdominal hysterectomy surgical site infections: A multidisciplinary quality initiative

To investigate abdominal hysterectomy surgical site infection (SSI) rates before and after implementation of an SSI care bundle. An SSI bundle for abdominal hysterectomies was introduced in our hospital in April 2014 to reduce the SSI rate. The practices were divided into bundle elements around preoperative, intraoperative, and postoperative care. We conducted a retrospective cohort study around implementation of the SSI care bundle. Women were included if they underwent abdominal hysterectomy between 2012 and 2015. They were then divided into 2 study groups: prebundle and postbundle. The primary study outcome was SSI rate. The superficial SSI rate was the secondary outcome. The overall SSI rate was 6.18% in the prebundle group, with a median monthly SSI rate of 7.03%. After bundle implementation, the overall SSI rate declined to 2.51% (P = .02). The reduction remained significant after multivariate analysis (adjusted odds ratio 0.38; 95% confidence interval 0.15-0.88; P = .03) indicating a 62% reduction in SSI postbundle as compared to prebundle.When comparing rates based on infection classification, superficial SSIs declined significantly from 3.73% in the prebundle group to 0.90% in the postbundle group (P = 0.02). Patient demographics and pre-existing medical conditions were similar pre- and postbundle. Compliance with bundle elements was high. A significant reduction in SSI rate in abdominal hysterectomies was seen following implementation of an infection prevention bundle.

Effects of smoking and different BMI cutoff points on surgical site infection after elective open ventral hernia repair.

BMI > 40kg/m2 and smoking have been identified as risk factors for surgical site infections (SSIs) after ventral hernia repair, however, the relationship with lower BMI values has not been described. The objective of this study was to analyze the relationship between different BMI thresholds, smoking, and SSI after open ventral hernia repair. All patients who underwent an elective non-emergent open ventral hernia repair with mesh were extracted from the 2011 to 2016 NSQIP database. Bivariate, multivariate logistic regression, and Classification and Regression Tree (CART) analyses were used. Of 55,240 patients, 2,620 (4.7%) developed SSIs (superficial: 58.5%, deep:27%, organ-space: 16%). BMI (OR: 1.035; 95% CI:1.03-1.04; p < 0.001) and smoking (OR:1.51; 95% CI:1.37-1.67; p < 0.001) were identified in logistic regression analysis as the two most modifiable risk factors independently associated with SSIs. CART analysis demonstrated that the lowest SSI rate belonged to non-smokers with BMI < 24.2kg/m2 (1.9%), and the highest SSI to smokers with BMI > 42.3kg/m2 (12%). Between these values, there was a stepwise increase in SSI rate as BMI increased, while smoking added additional risk in each group. Following open hernia repair, the association between SSI and being overweight starts at a BMI of 24.2, a threshold lower than previously described. The risk of SSI increases in a stepwise fashion as BMI increases and is augmented by smoking. Future studies are needed to determine if SSI reduction can be achieved with a combination of smoking cessation and weight loss using these BMI thresholds.

Use of iodine-impregnated surgical drapes for prevention of surgical site infection: a systematic review and meta-analysis

Background: Iodine-impregnated surgical drapes aim to protect the wound from bacterial re-colonisation and therefore prevent surgical site infection (SSI). Studies have produced conflicting results regarding the efficacy of this intervention. Methods: Ovid EMBASE, Ovid MEDLINE, Scopus and PubMed were searched for randomised control trials (RCTs) and cohort studies in which iodine-impregnated drapes were used to reduce SSI. The risk of bias was evaluated using the Cochrane Risk of Bias 2.0 tool for RCTs and the ROBINS-I tool for cohort studies. RevMan was used for meta-analysis. Additional sub-group analysis was performed for incision type. Results: Two RCTs and seven cohort studies inclusive of 4119 patients were included. The RCTs demonstrate a risk ratio (RR) for SSI in the intervention group of 0.92 (p=0.70), whereas the RR in the cohort studies is 0.45 (p=0.01). The number needed to prevent SSI in the cohort studies is 19.5. There is also a statistically significant reduction in SSI in the intervention group for clean-contaminated incisions, with SSI occurring in 3.8% of surgeries with an iodophor drape and 9.2% of surgeries without (RR 0.45, p=0.02). Conclusion: Our review suggests that iodine-impregnated drapes are beneficial in reducing postoperative SSI, particularly in clean-contaminated surgeries; however, the grade of evidence is poor.

Introduction of a care bundle effectively and sustainably reduces patient-reported surgical site infection in patients undergoing colorectal surgery

Surgical site infection (SSI) is one of the most common healthcare-associated infections and is particularly prevalent following colorectal surgery. It is associated with an increase in patient morbidity and healthcare costs. SSI is difficult to monitor as it frequently presents after discharge from hospital, especially if enhanced recovery programmes are in place. To develop an effective method for measuring patient-reported 30-day SSI in patients undergoing colorectal resection. To implement a new care bundle capable of delivering a sustainable reduction in SSI. The Public Health England SSI surveillance questionnaire was used. Several data collection methods were tested including postal and telephone-based systems. A new SSI bundle was introduced in our centre incorporating four evidence-based interventions: 2% chlorhexidine skin preparation; repeat-dose antibiotics after 4 h; dual-ring wound protectors; and triclosan-coated sutures for wound closure. System changes were introduced to ensure that the change was sustainable. The most reliable method of measuring patient-reported SSI was found to be postal questionnaire with telephone calls made to non-responders. Response rates to the SSI surveillance questionnaire were consistently >75%. Introduction of the new care bundle produced a significant reduction in SSI from 20% to 10% (P ≤ 0.0001) which has been sustained for six years. This is a reliable method for measuring 30-day patient-reported SSI rates. The introduction of this new care bundle has halved the rate of SSI from 20% to 10%.

Reducing surgical site infections post-caesarean section in an Australian hospital, using a bundled care approach.

The past 20 years have seen increasing Caesarean section (CS) rates in Australia. Increasing antenatal morbidity means that post-CS surgical site infection (SSI) is an issue impacting Australian women, mostly low-socioeconomic and regional communities. Recent trends supporting development of evidence-based bundled approaches to SSI reduction, have not proved efficacy nor supported bundle implementation. This pilot study aimed to develop, implement and assess an evidence-based Caesarean Infection Prevention ("CIP") bundled intervention to reduce post-CS SSI rates in a high risk population. The study was a pre-post-intervention study, including women undergoing CS at one referral hospital between December 1st 2016 and December 31st 2018. A 12 month retrospective pre-intervention review identified women who developed a post-CS SSI. A comprehensive literature review informed the development of the intervention, which was implemented in December 2017. Data was collected for the subsequent 12 months on women undergoing CS. A total of 710 procedures were monitored with 346 and 364 women in the pre and post-intervention groups respectively. Demographic and comorbidity variables remained consistent over time. Post-CS SSI rates significantly reduced post-intervention (5.5% vs. 1.6%, p=0.007), the greatest benefit in class II and III obese patients (12.2% vs. 2.5%, p=0.019). Higher hypertension rates (24% vs. 9%, p=0.01) and lower maternal mean age (27 vs. 30, p=0.01) were seen in patients with SSI. The "CIP" bundle effectively reduced post-CS SSIs in a high risk population. Our findings substantiate the need for development and evaluation of multifaceted, evidenced-based interventions to reduce post-CS SSIs. Retrospectively registered. ACTRN12619001001189, July 2019.

807 Implementation of an Evidence-based Wound Care Process at a Regional Burn Center Reduces Hospital Acquired Infections

Abstract Introduction Central line associated blood stream infection (CLABSI) rates in burn patients exceeds the national average. The purpose of this study was to determine if implementation of an evidence-based process for wound care and central line management reduce infections. Methods A protocol for central line and wound care was developed in conjunction with another burn center with lower CLABSI rates and a care bundle, based on colorectal surgical literature. The new protocol required hand to elbow washing prior to wound care, separating the dirty and clean steps of the wound care process, changing protective gear when going from dirty to clean and performing the Hospital Acquired Infection (HAI) bundle elements separate from wound care. CLABSI and Ventilator Associated Pneumonia (VAP) rates were then compared with the previous year. Results Following implementation of the new wound care guidelines, the number of CLABSIs declined from 10 in 2017 to 2 in 2018 and 1 so far in 2019 (through August 2019). The median number of CLABSIs per 1000 days was 0 (range of 0 to 11) before the bundle and 0 (range of 0 to 4.2) after implementation of the bundle. Using the Wilcox rank sum test, there was no significant difference (p=0.09) between the CLABSI rate per 1000 device days between the time period before the bundle implementation and after the bundle implementation, however this may be due to the small sample size. Although the CLABSI rate did not show a statistically significant decrease, the proportion of positive blood cultures decreased by 50% after implementation of the bundle. The number of VAPs declined from 8 in 2017 to 6 in 2018 and so far in 2019 no VAPs have been reported (through August 2019). There was no difference in device days between groups. Conclusions Creating a wound care process that clearly defines and separates clean and dirty steps, similar to colorectal surgical bundles in the reduction of Surgical Site Infection, reduced CLABSI and HAI rates in a clinically significant, if not statistically significant way in the Burn Intensive Care Unit. Further study is needed to increase the power of this study to possibly detect statistically significant differences. Applicability of Research to Practice Implementation of an evidence-based, standardized practice for wound care improved infection rates at one regional burn center. It would be beneficial for this process to be replicated at other centers to further test correlation with infection reduction.

Gentamicin Containing Collagen Implants and Groin Wound Infections in Vascular Surgery: A Prospective Randomised Controlled Multicentre Trial

The aim of this study was to assess the effectiveness of gentamicin containing collagen implants in the reduction of surgical site infections (SSIs) in patients undergoing an inguinal incision for vascular surgery. Prospective blinded randomised controlled multicentre trial (RCT), performed in four hospitals in The Netherlands and Belgium. This study included 288 patients who underwent an inguinal incision for primary arterial repair (femoral endarterectomy, femorofemoral or femoropopliteal bypass, aortobifemoral bypass, thrombectomy, embolectomy, endovascular aneurysm repair) between October 2012 and December 2015. Patients were randomised to receive a gentamicin implant (study group) or no implant (control group). The calculated sample sizes of 304 patients per group were not reached. Primary outcome was SSI incidence after six weeks. Secondary outcomes were time to onset of infection, length of hospital stay, allergic reactions, treatment with antibiotics, need for re-admission, re-operation and mortality. One hundred fifty-one patients were allocated to the study group (mean age 69±9.2 years) and 137 patients were allocated to the control group (mean age 70±10.4 years). Both groups were homogeneous regarding baseline and intra-operative characteristics. Gentamicin implants did not result in a significant overall reduction of SSIs in the study group (7% vs. 12%, p=.17). In a post hoc analysis comparing two study sites with low (<10%) and two study sites with high (>10%) infection rates in the control group, gentamicin implants significantly reduced SSIs in high risk centres (22% vs. 1%, p<.001), whereas there was no significant effect in low risk centres (13% vs. 7%, p=.30). There were no allergic reactions and all secondary outcomes were comparable between groups. Gentamicin implants did not result in a significant overall reduction of SSIs in this RCT. Gentamicin implants did reduce the incidence of SSIs in high risk centres and may be a valuable adjunct to improve outcomes in such vascular centres with a high incidence of wound infections. However, the limitation of not reaching the calculated sample sizes should be considered.

Abstract P6-14-03: Effectiveness of a breast reconstruction program with early discharge

Abstract Background For the last decade, there has been a significant reduction in hospital length of stay (LOS) after breast cancer surgery, and the last few years there is a tendency of early discharge (ED) rates following mastectomy. We defined same-day surgery (SDS) as admission, surgery and discharge on the same day and ED as hospital length of stay less than 36 hours. Studies show clear benefits with breast cancer patients having SDS such as reduction of hospital and patient costs, faster patient psychological recovery, lower rates of surgical complications and significant reduction of surgical site infection. However, concerns about performing more invasive procedures in an outpatient basis, such as immediate breast reconstruction (BR) is noticeable and few articles addresses this subject. At our institute our goal is to have an early and safely discharge for every patient with low complication rate, independently of the procedure (except for microvascular BR). We sought to describe our early discharge BR program in terms of complication rate and analyze risk factors for one-night hospitalization. Methods IRB approval was obtained for a retrospective review of all BR procedures performed from 2017- 2019 in the National Cancer Institute of Mexico. We selected patients who underwent BR surgeries with or without associated oncologic procedure in a basis of ED mode. Exclusion criteria were microvascular BR and patients who were not admitted the same day of surgery. We analyzed immediate and delayed BR (alloplastic or autologous), oncoplastic procedures and revision surgeries (complications). Demographic, clinical and surgical variables were analyzed in the bivariate analysis. And a logistic regression was used to determine possible risk factors for &amp;gt; 24 hours length of stay (LOS). Results A total of 456 patients were submitted to 692 total breast reconstruction surgeries. We categorized surgical events into 2 groups according to LOS: 419 (61%) in the SDS group with &amp;lt; 24 hours LOS and 273 (39%) in the &amp;gt; 24 hours group. The SDS group had a higher median age (46.7 years versus 44.8; p=0.0265), similar rates of diabetes, systemic hypertension, other comorbidities and ASA class. There is a greater proportion of patients with overweight in the SDS group (47.7% versus 33.7%; p=0.004). SDS group had a median LOS of 9.2 ±2.6 hours versus 33.1± 17.5 hours in the &amp;gt; 24 hours group (p=0.000). In the &amp;gt; 24 hours group the proportion of bilateral surgeries was 29.6% versus 36.8% (p=0.457), MT with alloplastic BR 59.7% versus 24.6% (p=0.000), and axillary lymph node surgery 55% versus 24.5% (p=0.000). Among all surgeries, 131 (18.9%) presented postoperative complications, 14.6% in the SDS group versus 25.6% (p=0.000). The quantity of reconstruction failures was 16 (4.8%). Most common complications were: 10.7% surgical site infection (9.1% in the SDS group versus 13.2%), 9.4 reintervention (7.4% SDS group versus 12.5%),13.6% of emergency room consultation (12.4% SDS group versus 14.3%), 0.6% hematoma. In the multivariate analysis we found significant risk factors for &amp;gt;24 hours LOS were a low educational level, low hemoglobin level, quantity of drains, length of surgery and certain types of surgery such as MT with immediate BR, oncoplastic surgery and autologous BR and presence of axillary lymph node surgery. Conclusions These results demonstrate that an ED breast cancer reconstruction program is safe and effective at our institution. The complication rate for our population is similar to other reported. We also found very positive that although there is no significant difference in complications, reinterventions or readmissions between &amp;gt;24 hours group and patients discharged the same day, there is a slight difference towards less complications in the SDS group which support continue reinforcing our SDS BR program. Citation Format: Juan Enrique Bargallo-Rocha, Daniela Vargas-Salas, Luz M Gutiérrez-Zacarías, Juan A Torres-Domínguez, Judith Acosta-Violante, Erick H Rubio-Arroyo. Effectiveness of a breast reconstruction program with early discharge [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-03.

The use of oral antibiotics and mechanical bowel preparation in elective colorectal resection for the reduction of surgical site infection.

Surgical site infection (SSI) is a major cause of morbidity worldwide following elective colorectal resection, affecting up to 20% of patients 1, 2, 3. Reduction in SSI rates requires a multi‐faceted approach 4 and can be achieved with the use of SSI reduction bundles 5. Such bundles include prophylactic intravenous antibiotics 6 which represent an undisputed standard of care 4. They do not include the use of mechanical bowel preparation (MBP) alone which is not recommended in elective colonic resection to reduce SSI 7, 8, 9, although may offer an advantage in elective rectal resection 10. A long‐standing area of controversy is the use of mechanical bowel preparation and oral antibiotics (MOAB) prior to elective colorectal resection 11, 12. Marked differences exist between clinicians worldwide 13. Recent guidelines from the American Society of Colon and Rectal Surgeons strongly recommend the use of MOAB in elective colorectal resection to reduce SSI 14, 15. Other international bodies have recognized the increasing body of evidence and altered their recommendations in a more conservative manner but stopped short of endorsing this practice because of the lack of Level 1 evidence 16. This paper summarizes the arguments for and against the use of MOAB in elective colorectal resection, highlighting the areas of controversy and evidence gaps, and provides pragmatic suggestions for colorectal practice (Fig. ​(Fig.11). Open in a separate window Figure 1 Arguments for and against the use of mechanical bowel preparation and oral antibiotics in elective colorectal resection. MOAB, mechanical bowel preparation and oral antibiotics; MIS, minimally invasive surgery; ERAS, enhanced recovery after surgery; BMI, body mass index; SSI, surgical site infection; ABx, antibiotics; CDI, Clostridium difficile infection; QI, quality improvement.

Preoperative Risk Factor Optimization Lowers Hospital Length of Stay and Postoperative Emergency Department Visits in Primary Total Hip and Knee Arthroplasty Patients

BackgroundThe evaluation and management of outcomes risk has become an essential element of a modern total joint replacement program. Our multidisciplinary team designed an evidence-based tool to address modifiable risk factors for adverse outcomes after primary hip and knee arthroplasty surgery. MethodsOur protocols were designed to identify, intervene, and mitigate risk through evidence-based patient optimization. Nurse navigators screened patients preoperatively, identified and treated risk factors, and followed patients for 90 days postoperatively. We compared patients participating in our optimization program (N = 104) to both a historical cohort (N = 193) and a contemporary cohort (N = 166). ResultsRisk factor identification and optimization resulted in lower hospital length of stay (LOS) and postoperative emergency department (ED) visits. Patients in the optimization cohort had a statistically significant decrease in mean LOS as compared to both the historical cohort (2.55 vs 1.81 days, P < .001) and contemporary cohort (2.56 vs 1.81 days, P < .001). Patients in the optimization cohort had a statistically significant decrease in 30- and 90-day ED visits compared to the historical cohort (P30-day = .042, P90-day = .003). When compared with the contemporary cohort, the optimization cohort had a statistically significant decrease in 90-day ED visits (21.08% vs 10.58%, P = .025). The optimization cohort had a statistically significant increase in the percentage of patients discharged home. We noted nonsignificant reductions in readmission rate, transfusion rate, and surgical site infections. ConclusionOptimization of patients before elective primary total hip arthroplasty and total knee arthroplasty reduced average LOS, ED visits, and drove telerehabilitation use. Our results add to the limited body of literature supporting this patient-centered approach.

The Clinical and Economic Value of Triclosan-Coated Surgical Sutures in Abdominal Surgery

Surgical site infection (SSI) is a frequent complication of surgical procedures. The aim of this study was to analyze the clinical evidence for SSI prevention with triclosan-coated sutures (TCS) in abdominal surgery and to investigate the economic impact of TCS in this type of procedure compared with conventional absorbable sutures (CS). A literature review was carried out to identify meta-analyses that were published between 1990 and 2019 that assessed the use of TCS in abdominal surgery. A budget impact analysis was performed from an Italian hospital perspective based on the most recently published evidence to simulate the financial impact of TCS in a general surgery unit. Uncertainty was explored through scenario analysis, as well as deterministic and probabilistic sensitivity analyses. Nine meta-analyses and two additional randomized clinical trials were retrieved. All meta-analyses described a reduction (range 19%–44%) in the risk of SSI when TCS were used. The use of TCS was associated with an overall annual net saving for the general surgery unit of €14,785 and a reduction of 3.2 SSIs compared with CS. Sensitivity analyses resulted in a positive annual saving associated with TCS in 98% of scenarios. TCS are a valuable, cost-saving SSI prevention strategy. TCS additional costs would be offset by the reduction in SSIs.

Pre-operative antibiotics and elective colonic resections: Do they reduce surgical site infection and anastomotic leak rates?

Background: Surgical site infections (SSI) and anastomotic leaks (AL) are a significant source of morbidity in patients undergoing elective colorectal surgery. There is evidence for use of pre-operative oral antibiotics (OAB), in combination with mechanical bowel preparation (MBP), to reduce SSI and AL rates in this population. We aimed to determine whether the use of OAB pre-operatively reduced our local SSI rate in elective left-sided colonic resections. Methods: A pre-post intervention study was conducted in a large regional hospital from September 2018 to July 2019. Following approval by the Trust’s Medicines Optimisation Group, patients received oral metronidazole 400mg and oral neomycin 1g at 06:00, 14:00 and 22:00 on the day before surgery. The rates of SSI and AL at 30 days were compared with pre-intervention patients. Standard induction intravenous antibiotics were given to both groups but MBP practices were disparate among the consultant body and were outside the scope of this project. Chi Square and Independent T-tests were used to analyse the data. Results: Data on 100 pre-intervention patients and 47 post-intervention patients showed similar baseline characteristics. SSI rates were 17% (17/100) in the pre-intervention group and 8.5% (4/47) in the post-intervention group (p=0.170). Anastomotic leak rates were 7.0% (7/100) and 2.1% (1/47) respectively (p=0.225). Conclusion: The use of pre-operative OAB was associated with a reduction in SSI and anastomotic leak rates, although these did not reach statistical significance. Possible reasons for this include low patient numbers and inconsistent use of MBP.

Review of antibiotic prophylaxis for the prevention of surgical site infection in low and middle income countries (LMICs)

Background The Scottish Antimicrobial Prescribing Group (SAPG) is supporting two hospitals in Ghana via a Fleming Fund healthcare partnership to develop antimicrobial stewardship. Initial intelligence gathering suggests that antibiotic prophylaxis to prevent surgical site infection (SSI) is suboptimal. To inform a quality improvement programme we have reviewed the evidence for use of surgical prophylaxis in LMICs including staff behaviours and attitudes. Methods MEDLINE, Embase, Cochrane, CINHAL and Google Scholar were searched from inception to 22 July 2019 for trials, audits, guidelines and systematic review in English. Grey literature, websites and reference lists of included studies were searched. The following data were extracted; study characteristics, interventions, outcomes and recommendations. In view of heterogeneity between studies descriptive analysis was conducted. Results Of 185 records screened, 26 studies related to SSI and timing of antibiotic prophylaxis in LMICs were included. The incidence of SSI is significantly higher in LMICs compared with high income countries, recording of infection surveillance data is poor and a lack of local guidelines for antibiotic prophylaxis. Several projects in Africa have reported reduction in SSI with single dose preoperative antibiotic use compared with post-operative prophylaxis and a reduction in cost and nurse time. Despite evidence to the contrary, many surgeons continue to use post-operative antibiotic prophylaxis. Conclusion Education to improve incidence of SSI in LMICs through appropriate antibiotic prophylaxis can be successful. Interventions must include local context and address strongly held beliefs. The establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Measures to reduce end-of-case wound contamination: the impact of intra-wound vancomycin powder and betadine irrigation on surgical site infections in posterior spinal fusion.

Retrospective descriptive, single-center study. To determine the effect of standardized intrawound vancomycin powder and betadine irrigation on surgical site infection (SSI) rates after posterior spinal fusion (PSF) in idiopathic scoliosis. Since 2005, our pediatric spine center has implemented a series of changes to lower the risk of SSI. The most recent interventions-intrawound vancomycin powder and betadine irrigation-are applied just before closure, aiming to reduce the culture-positive bacterial contamination known to occur in many cases. We sought to determine the impact of these end-of-case measures on our center's SSI rate. We retrospectively reviewed patients who underwent PSF for idiopathic scoliosis at our institution from January 1, 2010, to June 30, 2018, identifying all cases that returned to the operating room for surgical debridement within 90days of PSF. Cases were surgeon-audited to ensure inclusion of all infections that met Centers for Disease Control and Prevention (CDC) criteria for acute SSI. Vertical expandable prosthetic titanium ribs, growing rods, staged procedures, and nonidiopathic cases were excluded. Annual rates of SSIs were correlated with the initiation of each SSI prevention measure. Among 740 cases of PSF for idiopathic scoliosis from 2010 to 2018, the overall acute SSI rate by CDC criteria was 0.68%. The idiopathic SSI rate dropped significantly, from 1.70 to 0.20%, after the standardized introduction of intrawound vancomycin powder and betadine irrigation before closure (p < 0.04). The implementation of these end-of-case measures in 2012-2013 was soon followed by an institution best 3.5-year SSI-free period for idiopathic cases. Since intrawound vancomycin powder and betadine irrigation were added to our SSI prevention bundle, we have seen a significantly lower SSI rate after PSFs for idiopathic scoliosis. These findings suggest that anti-SSI interventions to reduce wound contamination at the end of the case may have a particularly positive impact on SSI reduction. Level III, therapeutic.

A systematic review and meta-analysis of randomized controlled trials for the reduction of surgical site infection in closed incision management versus standard of care dressings over closed vascular groin incisions.

ObjectiveSurgical site infection after groin incision is a common complication and a financial burden to patients and healthcare systems. Closed incision negative pressure therapy (ciNPT) has been associated with decreased surgical site infection rates in published literature. This meta-analysis examines the effect of ciNPT (PREVENA™ Incision Management System; KCI, San Antonio, TX) versus traditional postsurgical dressing use in reducing surgical site infection rates over closed groin incisions following vascular surgery.MethodsA systematic literature search using PubMed, OVID, EMBASE, and QUOSA was performed on 3 January 2019, by two independent researchers and focused on publications between 1 January 2005 and 31 December 2018. The review conformed to the statement and reporting check list of the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Inclusion criteria included abstract or manuscript written in English, published studies, conference abstracts, randomized controlled trials (RCTs), ciNPT usage over closed groin incisions in vascular surgery, comparison of ciNPT use and traditional dressings, study endpoint/outcome of surgical site infection, and study population of >10. Characteristics of study participants, surgical procedure, type of dressing used, duration of treatment, incidence of surgical site infection, and length of follow-up were extracted. Weighted odds ratios and 95% confidence intervals were calculated to pool study and control groups in each publication for analysis. Treatment effects were combined using Mantel-Haenszel risk ratios, and the Chi-Square test was used to assess heterogeneity. Overall, high-risk patients, normal-risk patients, and Szilagyi I, II, III outcomes were assessed between ciNPT and control groups. The Cochrane Collaboration tool was utilized to assess the risk of bias for all studies included in the analysis.ResultsA total of 615 articles were identified from the literature search. After removal of excluded studies and duplicates, six RCT studies were available for analysis. In these studies, a total of 362 patients received ciNPT, and 371 patients received traditional dressings (control). Surgical site infection events occurred in 41 ciNPT patients and 107 control patients. The heterogeneity test was nonsignificant (p > 0.05). The overall RCT meta-analysis showed a highly significant effect in favor of ciNPT (OR = 3.06, 95% CI [2.05, 4.58], p < 0.05). High-risk, normal-risk, Szilagyi I, and Szilagyi II meta-analyses were also statistically significant in favor of ciNPT use (p < 0.05). The varying RCT inclusion/exclusion criteria, such as differences in procedure types, and patient populations form the major limitations of this study.ConclusionsA statistically significant reduction in the incidence of surgical site infection was seen following ciNPT usage in patients undergoing vascular surgery with groin incisions.