Reduction Of Surgical Site Infections Research Articles

Topical antimicrobial treatment of mesh for the reduction of surgical site infections after hernia repair: a systematic review and meta-analysis.

Use of mesh is essential in hernia repair. A common complication after hernia repair is surgical site infection (SSI), which poses a risk in spreading to the mesh, possibly causing mesh infection. Topical antimicrobial pretreatment of mesh may potentially reduce SSI risk in hernia repair and has shown promising results in in vitro and in vivo studies. Clinical evidence, however, is more important. This systematic review aims to provide an overview of available clinical evidence for antimicrobial pretreated mesh in hernia repair surgery to reduce SSI. We report in accordance with PRISMA guidelines. CENTRAL, EMBASE, CINAHL and PubMed were searched up to October 2023 for studies that investigated the use of antimicrobial pretreated mesh on SSI incidence in adults undergoing hernia repair. The primary outcome was SSI incidence. We also collected data on pathogen involvement, hernia recurrence, and mesh infection. A meta-analysis on SSI risk and GRADE-assessment was performed of eligible studies. We identified 11 eligible studies (n = 2660 patients); 5 randomized trials and 6 cohort studies. Investigated interventions included pre-coated mesh, antibiotic carriers, mesh soaked or irrigated with antibiotic or antiseptic solution. Meta-analysis showed no significant reduction in SSI for antibiotic pretreated polypropylene mesh (RR 0.76 [95% CI 0.27; 2.09]; I2 50%). Data on topical mesh pretreatment to reduce SSI risk after hernia repair is limited. Very low certainty evidence from randomized trials in hernia repair surgery shows no significant benefit for antibiotic mesh pretreatment for SSI reduction, but data are imprecise due to optimal information size not being met.

From basic research to clinical practice: The impact of laminar airflow filters on surgical site infection in vascular surgery

BackgroundLaminar airflow filters have been suggested as a potential preventive factor for surgical site infections, given their ability to reduce the airborne microbiological load. However, their role is still unclear, and evidence regarding vascular surgery patients is scarce. Our aim was to assess the impact of laminar-airflow filters on surgical site infections. MethodsThis single-centre retrospective cohort study was conducted with vascular surgery patients who underwent arterial vascular intervention through a groin incision between July 2018 and July 2019 (turbulent airflow cohort) and July 2020 and July 2021 (laminar airflow cohort). Data were prospectively collected from electronic medical files. We estimated the cumulative incidence of surgical site infections and its 95% confident interval (95%CI). A propensity score matching analysis was performed. ResultsWe included 200 patients, 78 in the turbulent airflow cohort and 122 in the laminar airflow cohort. The cumulative incidence was 15.4% (12/78; 95%CI: 9.0–25.0%) in the turbulent-airflow cohort and 14.8% (18/122; 95%CI: 9.5 –22.1%) in the laminar-airflow cohort (p-value: 1.00). The propensity score matching yielded a cumulative incidence of surgical site infection of 13.9% (10/72) with turbulent airflow and 12.5% (9/72) with laminar airflow (p-value: 1.00). Risk factors associated with infection were chronic kidney disease (OR 2.70; 95%CI: 1.14–6.21) and a greater body mass index (OR 1.47; 95%CI: 1.01–2.14). ConclusionLaminar airflow filters were associated with a non-significant reduction of surgical site infections. Further research is needed to determine its usefulness and cost-effectiveness. Surgical site infection incidence was associated with chronic kidney disease and a greater body mass index. Hence, efforts should be made to optimize the body mass index before surgery and prevent chronic kidney disease in patients with known arterial disease.

Incisional Wound Irrigation for the Prevention of Surgical Site Infection

Surgical site infections (SSIs) are common postoperative complications and associated with significant morbidity, mortality, and costs. Prophylactic intraoperative incisional wound irrigation is used to reduce the risk of SSIs, and there is great variation in the type of irrigation solutions and their use. To compare the outcomes of different types of incisional prophylactic intraoperative incisional wound irrigation for the prevention of SSIs in all types of surgery. PubMed, Embase, CENTRAL, and CINAHL databases were searched up to June 12, 2023. Included in this study were randomized clinical trials (RCTs) comparing incisional prophylactic intraoperative incisional wound irrigation with no irrigation or comparing irrigation using different types of solutions, with SSI as a reported outcome. Studies investigating intracavity lavage were excluded. This systematic review and network meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two reviewers independently extracted the data and assessed the risk of bias within individual RCTs using the Cochrane Risk of Bias 2 tool and the certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation framework. A frequentist network meta-analysis was conducted, and relative risks (RRs) with corresponding 95% CIs were reported. The primary study outcome was SSI. A total of 1587 articles were identified, of which 41 RCTs were included in the systematic review, with 17 188 patients reporting 1328 SSIs, resulting in an overall incidence of 7.7%. Compared with no irrigation, antiseptic solutions (RR, 0.60; 95% CI, 0.44-0.81; high level of certainty) and antibiotic solutions (RR, 0.46; 95% CI, 0.29-0.73; low level of certainty) were associated with a beneficial reduction in SSIs. Saline irrigation showed no statistically significant difference compared with no irrigation (RR, 0.83; 95% CI, 0.63-1.09; moderate level of certainty). This systematic review and network meta-analysis found high-certainty evidence that prophylactic intraoperative incisional wound irrigation with antiseptic solutions was associated with a reduction in SSIs. It is suggested that the use of antibiotic wound irrigation be avoided due to the inferior certainty of evidence for its outcome and global antimicrobial resistance concerns.

Plastic Wound Protector vs Surgical Gauze for Surgical Site Infection Reduction in Open GI Surgery

Surgical site infections (SSIs) are prevalent hospital-acquired infections with significant patient impacts and global health care burdens. The World Health Organization recommends using wound protector devices in abdominal surgery as a preventive measure to lower the risk of SSIs despite limited evidence. To examine the efficacy of a dual-ring, plastic wound protector in lowering the SSI rate in open gastrointestinal (GI) surgery irrespective of intra-abdominal contamination levels. This multicenter, patient-blinded, parallel-arm randomized clinical trial was conducted from August 2017 to October 2022 at 13 hospitals in an academic setting. Patients undergoing open abdominal bowel surgery (eg, for bowel perforation) were eligible for inclusion. Patients were randomized 1:1 to a dual-ring, plastic wound protector to protect the incision site of the abdominal wall (experimental group) or a conventional surgical gauze (control group). The primary end point was the rate of SSI within 30 days of open GI surgery. A total of 458 patients were randomized; after 1 was excluded from the control group, 457 were included in the intention-to-treat analysis (mean [SD] age, 58.4 [12.1] years; 256 [56.0%] male; 341 [74.6%] with a clean-contaminated wound): 229 in the wound protector group and 228 in the surgical gauze group. The overall SSI rate in the intention-to-treat analysis was 15.7% (72 of 458 patients). The SSI rate for the wound protector was 10.9% (25 of 229 patients) compared with 20.5% (47 of 229 patients) with surgical gauze. The wound protector significantly reduced the risk of SSI, with a relative risk reduction (RRR) of 46.81% (95% CI, 16.64%-66.06%). The wound protector significantly decreased the SSI rate for clean-contaminated wounds (RRR, 43.75%; 95% CI, 3.75%-67.13%), particularly for superficial SSIs (RRR, 42.50%; 95% CI, 7.16%-64.39%). Length of hospital stay was similar in both groups (mean [SD], 15.2 [10.5] vs 15.3 [10.2] days), as were the overall postoperative complication rates (20.1% vs 18.8%). This randomized clinical trial found a significant reduction in SSI rates when a plastic wound protector was used during open GI surgery compared with surgical gaze, supporting the World Health Organization recommendation for use of wound protector devices in abdominal surgery. ClinicalTrials.gov Identifier: NCT03170843.

Hospital based interventional study implementation of supervised quality improvement protocol in reducing surgical site infections in obstetrics and gynaecological major surgeries: A study protocol

Background Surgical site infections (SSIs) pose a significant challenge in obstetric and gynaecological surgeries, with incidence rates ranging from 0.5% to 15%. These infections not only impact patient outcomes but also contribute to extended hospital stays and increased healthcare costs. To address this issue, a hospital-based interventional study is proposed, focusing on the implementation of a comprehensive quality improvement protocol within the Department of Obstetrics and Gynecology at Acharya Vinoba Bhave Rural Hospital (AVBRH), Wardha. Methods The study will include approximately 800 obstetric and gynaecological surgeries per year. Ethical approval has been obtained and written informed consent will be obtained from all enrolled women. The intervention involves the implementation of a surgical site infection prevention quality improvement protocol, encompassing elements such as standardized pre-operative antiseptic agents, proper cleaning procedures, and the use of injectable cefazolin. A structured proforma will be developed for data collection, covering demographic details, surgical parameters, surgeon characteristics, and post-operative outcomes. Expected outcome This study aims to assess the efficacy of the quality improvement protocol in reducing the incidence of surgical site infections. We anticipate that the implementation of this protocol will lead to a significant reduction in SSIs, improving patient outcomes and safety in obstetric and gynaecological surgeries. The study's findings will not only contribute to the body of knowledge on infection prevention but will also serve as a valuable framework for enhancing surgical safety in similar healthcare settings. Continuous evaluation and refinement of the protocol will be crucial for sustained success in reducing SSIs and improving overall patient care.

Effect of weight-adjusted antimicrobial antibiotic prophylaxis on postoperative dosage and surgical site infection incidence in total joint arthroplasty

Surgical site infections (SSI) following total joint arthroplasty pose a significant concern for both providers and patients across the globe. Currently, administration of antimicrobial antibiotic prophylaxis is used throughout the world to reduce the incidence of SSI. However, the correct dosage and frequency of administration remains debatable. In this editorial, we emphasized the determination of the effect of administration of weight-adjusted antimicrobial antibiotic prophylaxis regime on the incidence of SSI and postoperative dosage reduction compared to the conventionally used regime during total joint arthroplasty. The results demonstrated similar efficacy between both regimes with respect to the incidence of SSI. In addition, weight-adjustment led to reduced postoperative dosage and has the potential to reduce chances of achieving lower therapeutic concentration, drug resistance, drug toxicity, and costs.

Antimicrobial prophylaxis in companion animal surgery: A scoping review for European Network for Optimization of Antimicrobial Therapy (ENOVAT) guidelines

Surgical antimicrobial prophylaxis (SAP) is widely used to reduce the risk of surgical site infections (SSI), but there is uncertainty as to what the proportion of SSI reduction is. Therefore, it is difficult for surgeons to properly weigh the costs, risks and benefits for individual patients when deciding on the use of SAP, making it challenging to promote antimicrobial stewardship in primary practice settings. The objective of this study was to map the veterinary evidence focused on assessing the effect of SAP on SSI development and in order to identify surgical procedures with some research evidence and possible knowledge gaps. In October 2021 and December 2022, Scopus, CAB Abstracts, Web of Science Core Collection, Embase and MEDLINE were systematically searched. Double blinded screening of records was performed to identify studies in companion animals that reported on the use of SAP and SSI rates. Comparative data were available from 34 out of 39123 records screened including: eight randomised controlled trials (RCT), 23 cohort studies (seven prospective and 16 retrospective) and three retrospective case series representing 12476 dogs and cats in total. Extracted data described peri- or post-operative SAP in nine, and 25 studies, respectively. In the eight RCTs evaluating SAP in companion animals, surgical procedure coverage was skewed towards orthopaedic stifle surgeries in referral settings and there was large variation in SAP protocols, SSI definitions and follow-up periods. More standardized data collection and agreement of SSI definitions is needed to build stronger evidence for optimized patient care.

Care Bundles in Surgical Site Infection Prevention: A Narrative Review

Abstract Purpose of Review Surgical site infections are healthcare-associated infections that cause significant morbidity and mortality. Best practices in prevention of these infections are combined in care bundles for consistent implementation. Recent Findings Care bundles have been used in nearly all surgical specialties. While the composition and size of bundles vary, the effect of a bundle depends on the number of evidence-based interventions included and the consistency of implementation. Bundles work because of the cooperation and collaboration among members of a team. Bundles for prevention of surgical site infections should address the multiple risk factors for infection before, during, and after the surgery. Summary Bundles increase standardization of processes and decrease operative variance that both lead to reductions in surgical site infections.

Identifying Risk Factors for Surgical Site Infection After Stoma Closure in Infants for Targeted Implementation of Surgical Site Infection Reduction Bundle.

Background: To determine risk factors for surgical site infection (SSI) in infants after stoma closure, to identify at-risk patients, plan timing of surgery, and implement SSI-reduction strategies. Patients and Methods: A single center retrospective comparison study of all children less than one year of age who underwent enterostomy closure (2018-2020) with SSI diagnosed through a prospective surveillance program, using criteria from Public Health England (PHE). Demographics and risk factors, types of SSI, systemic sepsis, mortality and length of stay were compared between SSI and non-SSI. Significant factors associated with SSI were analyzed in a multivariate binomial logistic regression model. Results: Eighty-nine stoma closures were performed, most commonly for necrotizing enterocolitis (NEC) and anorectal malformation. Fourteen had SSI (16%): 12 superficial and two deep; three developed systemic sepsis, but no 30-day mortality. Surgical site infection was associated with NEC (12/14 vs. 32/75; p = 0.003), younger age (median 76 vs. 89 days; p = 0.014), lower corrected gestation (cutoff: 39 weeks gestation; 11/14 vs. 27/75; p = 0.004) and lower weight (cutoff: 2.2 kg; 7/14 vs. 16/75; p = 0.032), compared with non-SSI. After correcting for age, gestation, and weight, logistic regression showed NEC was an independent predictor for SSI (odds ratio [OR], 12; 95% confidence interval [CI],1.2-125). The at-risk cohort (n = 56; 63%) had seven-fold increased risk of SSI and four-fold longer hospital stay, which may be the target for SSI-reduction strategies. Conclusions: Necrotizing enterocolitis-related stoma closure is at increased risk for SSI. Considerations for delaying stoma closure until achieving 39 weeks gestation or 2.2 kg in weight may further reduce SSI. Targeting SSI-reduction strategies using these criteria may improve resource-rationalization.

Innovative device for surgical wound irrigation: a preclinical testing and pilot clinical validation study

Introduction Surgical site infection (SSI) poses a substantial postoperative challenge, affecting patient recovery and healthcare costs. While surgical wound irrigation is pivotal in SSI reduction, consensus on the optimal method remains elusive. We developed a novel device for surgical wound irrigation and conducted preclinical and clinical evaluations to evaluate its efficacy and safety. Methods Two preclinical experiments using swine were performed. In the washability test, two contaminated wound model were established, and the cleansing rate between the device and the conventional method were compared. In the contamination test, the irrigation procedure with a fluorescent solution assessed the surrounding contamination of drapes. Subsequently, a clinical trial involving patients undergoing abdominal surgery was conducted. Results The washability test demonstrated significantly higher cleansing rates with the device method (86.4% and 82.5%) compared to the conventional method (65.2% and 65.1%) in two contamination models. The contamination test revealed a smaller contaminated region with the device method than the conventional method. In the clinical trial involving 17 abdominal surgery cases, no superficial SSIs or adverse events related to device use were observed. Conclusions Our newly developed device exhibits potential for achieving more effective and safe SSI control compared to conventional wound irrigation.

Does Intrawound Vancomycin Decrease Postoperative Surgical Site Infection in Spine Surgery: A Retrospective Case-control Study.

Retrospective Case-Control series. The objective of this study is to define the overall postoperative rate of surgical site infection (SSI) in patients undergoing spine surgery and examine the effects of intrawound Vancomycin on postoperative infection rates. Surgical site infections (SSI) account for 22% of all health care-associated infections. The use of intrawound Vancomycin in an attempt to reduce the incidence of postoperative SSI has not been sufficiently evaluated in the existing literature. All spine surgeries (n=19,081) from our institution were reviewed from 2003 to 2013. All cases of verified SSI were identified from the database. Cases were then matched to controls in a 1:1 fashion based on age, gender, and date of surgery (+/-30d). Patient demographics, comorbidities, estimated blood loss, duration of surgery, intrawound administration of Vancomycin, and smoking status were evaluated. At total of 316 cases of SSI after spine surgery were identified, representing an infection rate of 1.7%. The mean follow-up for cases and controls was 31.5 and 41.6 months, respectively. OR for intrawound Vancomycin was 0.44 (95% CI 0.23-0.88, P=0.019). OR for BMI greater than 30 was 1.63 (95% CI 1.04-2.56, P=0.03). In this large cohort of spine surgery patients, administration of intrawound Vancomycin was associated with a significant reduction in postoperative surgical site infections. Further studies are needed to determine appropriate dosing and application as well as long-term safety in spine surgery.

Decreasing post hysterectomy surgical site infections with the implementation of a hysterectomy-specific bundle

Surgical site infections (SSI) are a common complication of hysterectomy. Surgical bundles have been shown to reduce SSIs. Here we describe a bundle that was used to combat an abnormal rise in SSI events that resulted in a greater than 75% reduction at our institution. A hysterectomy-specific bundle was developed based on prior success of SSI prevention bundles. Development involved longitudinal education and training to ensure accuracy and compliance. All inpatient abdominal, laparoscopic, and vaginal hysterectomies performed at a tertiary referral center were included. The pre-intervention, intervention, and post-intervention periods were each one year in length. SSI rates were peer-reviewed monthly and overall trends were tracked, including compliance to bundle guidelines. Pre-intervention, an abnormal rise in SSI was identified at 3.76%. During the intervention, 309 inpatient hysterectomies were completed. In this period, six post-hysterectomy SSI events occurred (3.76% vs 1.94%, p=0.21). Four SSIs followed laparotomy and two followed laparoscopy. Compliance during the intervention period ranged from 79-89% with a mean of 85%. In the post-intervention period, there were six SSI following 689 hysterectomies (3.76% vs 0.87%, p=0.004). The majority of SSI occurred after abdominal hysterectomy. Implementation of a hysterectomy-specific surgical bundle allowed for a significant reduction in post-hysterectomy SSI during a yearlong intervention period and a sustained, further reduction in the post-intervention period.

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study)

BackgroundNegative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life. MethodThis is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life. ConclusionPatients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Surgical Site Infection Prevention Using "Strike Teams": The Experience of an Academic Colorectal Surgical Department.

Surgical site infections (SSIs) are healthcare-acquired infections with substantial morbidity. Surgical site infection persist because of low adherence to prevention bundles comprising multiple infection control elements. We propose the "Strike Team" as an implementation strategy to improve adherence and reduce SSI in colorectal surgery. At an academic medical center, a multidisciplinary Strike Team met monthly to review colorectal SSI cases, audit and discuss barriers to adherence to SSI prevention bundle, and propose actionable feedback. The latter was shared with frontline clinicians by the Strike Team's surgical leaders in everyday practice. Colorectal SSI rates and bundle adherence data were disseminated quarterly via the hospital intranet and reviewed with surgeons at departmental meetings. Trends in adherence and SSI rates were analyzed by regression analysis using a time series model. While the Strike Team was active, adherence to antibiotic prophylaxis, maintenance of normoglycemia, and standardized intraoperative skin preparation significantly increased (p < .05). There was a trend toward statistically significant reduction in SSI (p = .07), although it was not maintained once the Strike Team activity was disrupted by the COVID-19 pandemic. Colorectal SSI prevention requires a resource-intensive, multidisciplinary approach with numerous strategies to improve adherence to infection control bundles, as illustrated by our SSI Strike Team experience.

Topical Antibiotic Prophylaxis for Preventing Surgical Site Infections of Clean Wounds: A Systematic Review and Meta-Analysis.

Background: Topical antibiotic agents are not generally indicated for preventing of surgical site infections (SSIs) in clean incisions, and the drug concentrations that should be delivered to local incision sites remain uncertain. The aim of this study was to critically assess the efficacy of topical antibiotic agents in comparison with non-antibiotic agents for preventing SSIs in clean incisions by performing a systematic review and meta-analysis. Methods: We conducted a search of literature in PubMed, Embase, and Cochrane Databases and included randomized controlled trials (RCTs) on topical antibiotic use for patients with clean post-surgical incisions. The primary outcome was the incidence of SSI, presented as the event rate. Eleven RCTs were included. Results: Using random-effects modeling, the pooled risk ratio (RR) of developing a post-surgical incisions infection was 0.83 (95% confidence interval [CI], 0.61-1.16; I2, 0%). In subgroup analyses, no reductions in SSI were observed when topical antibiotic agents were used to treat incisions due to spinal (RR, 0.75; 95% CI, 0.40-1.38; I2, 0%), orthopedic (RR, 0.69; 95% CI, 0.37-1.29; I2, 0%), dermatologic (RR, 0.77; 95% CI, 0.39-1.55; I2, 65%), or cardiothoracic surgeries (RR, 1.31; 95% CI, 0.83-2.06; I2: 0%). The incidence of SSI across different operative phases did not differ for the application of topical antibiotic agents compared with non-antibiotic agents (RR, 0.80; 95% CI, 0.56-1.14; I2, 0%). Conclusions: The results of this meta-analysis show that topical antibiotic agents provide no clinical benefit for preventing SSI in clean incisions.

Antimicrobial Prophylaxis With Ampicillin-sulbactam Compared With Cefazolin for Esophagectomy: Nationwide Inpatient Database Study in Japan.

To assess the effect of antimicrobial prophylaxis with ampicillin-sulbactam (ABPC/SBT) compared with cefazolin (CEZ) on the short-term outcomes after esophagectomy. CEZ is widely used for antimicrobial prophylaxis in esophagectomy without procedure-specific evidence, whereas ABPC/SBT is preferred in some hospitals to target both aerobic and anaerobic oral bacteria. Data of patients who underwent esophagectomy for cancer between July 2010 and March 2019 were extracted from a nationwide Japanese inpatient database. Overlap propensity score weighting was conducted to compare the short-term outcomes [including surgical site infection (SSI), anastomotic leakage, and respiratory failure] between antimicrobial prophylaxis with CEZ and ABPC/SBT after adjusting for potential confounders. Sensitivity analyses were also performed using propensity score matching and instrumental variable analyses. Among 17,772 eligible patients, 16,077 (90.5%) and 1695 (9.5%) patients were administered CEZ and ABPC/SBT, respectively. SSI, anastomotic leakage, and respiratory failure occurred in 2971 (16.7%), 2604 (14.7%), and 2754 patients (15.5%), respectively. After overlap weighting, ABPC/SBT was significantly associated with a reduction in SSI [odds ratio 0.51 (95% CI: 0.43-0.60)], anastomotic leakage [0.51 (0.43-0.61)], and respiratory failure [0.66 (0.57-0.77)]. ABPC/SBT was also associated with reduced respiratory complications, postoperative length of stay, and total hospitalization costs. The proportion of Clostridioides difficile colitis and noninfectious complications did not differ between the groups. Propensity score matching and instrumental variable analyses demonstrated equivalent results. The administration of ABPC/SBT as antimicrobial prophylaxis for esophagectomy was associated with better short-term postoperative outcomes compared with CEZ.

Surgical Site Infection After Stoma Reversal: A Comparison Between Linear and Purse-String Closure.

Intestinal stomas are utilized for both benign and malignant conditions of the intestine to mitigate the risk of anastomotic leakage and re-exploration. However, stomas are associated with various complications, such as stoma necrosis, peri-stomal irritation, parastomal hernia, bleeding, bowel obstruction, and electrolyte abnormalities. Surgical site infection (SSI) is a significant source of morbidity following stoma reversal, leading to increased patient morbidity. The conventional method of stoma reversal involves closing the skin with non-absorbable sutures in a linear fashion, which is known as linear skin closure (LSC). Recently, a new method of skin closure using purse-string approximation (PSA) has been advocated, which allows healing by secondary intention. The rationale for this study is to compare the SSI associated with LSC and PSA after stoma reversal. This study aims to compare the frequency of SSI between LSC and PSA in stoma reversal. The study was conducted at the Department of General Surgery, Shifa International Hospitals Ltd. (SIH), Islamabad, Pakistan. The study is a randomized controlled clinical trial carried out between the 14th of March 2021 and the 22nd of November 2022. The sampling technique was non-probability consecutive random sampling. The sample size was calculated using the WHO sample size calculator by using the hypothesis test for two population proportions. The minimum sample size in each group was 40 patients. The total sample size was 80 patients. The overall frequency of SSIin all the patients was 18/80 (22.5%). The frequency of SSI in Group 1 (LSC) was 6/40 (15.0%), and in Group 2 (PSA), it was 12/40 (30.0%). The frequency of SSI in Group 2 (PSA) was twice as high as in Group 1 (LSC); however, the p-value was calculated to be 0.108. Therefore, this difference was statistically insignificant. While PSA has exhibited promise in reducing SSI rates and enhancing aesthetic outcomes and patient satisfaction, there is still enough data favoring LSC. Moreover, insufficient data is available for our population to make a definitive statement. Consequently, further research on this topic is warranted, preferably involving larger sample sizes and multicenter randomized controlled trials, to establish which technique is superior in SSI reduction.

Scalability and Sustainability of a Surgical Infection Prevention Program in Low-Income Environments

Surgical infections are a major cause of perioperative morbidity and mortality, particularly in low-resource settings. Clean Cut, a 6-month quality improvement program developed by the global nonprofit organization Lifebox, has demonstrated improvements in postoperative infectious complications. However, the pilot program required intense external programmatic and resource support. To examine the improvement in adherence to infection prevention and control standards and rates of postoperative infections in hospitals in the Clean Cut program after implementation strategies were updated and program execution was refined. This cohort study evaluated and refined the Clean Cut implementation strategy to enhance scalability based on a qualitative study of its pilot phase, including formalizing programmatic and educational materials, building an automated data entry and analysis platform, and reorganizing hospital-based team composition. Clean Cut was introduced from January 1, 2019, to February 28, 2022, in 7 Ethiopian hospitals that had not previously participated in the program. Prospective data initiated on arrival in the operating room were collected, and patients were followed up through hospital discharge and with 30-day follow-up telephone calls. Implementation of the refined Clean Cut program. The primary outcome was surgical site infection (SSI); secondary outcomes were adherence to 6 infection prevention standards, mortality, hospital length of stay, and other infectious complications. A total of 3364 patients (mean [SD] age, 26.5 [38.0] years; 2196 [65.3%] female) from 7 Ethiopian hospitals were studied (1575 at baseline and 1789 after intervention). After controlling for confounders, the relative risk of SSIs was reduced by 34.0% after program implementation (relative risk, 0.66; 95% CI, 0.54-0.81; P < .001). Appropriate Surgical Safety Checklist use increased from 16.3% to 43.0% (P < .001), surgeon hand and patient skin antisepsis improved from 46.0% to 66.0% (P < .001), and timely antibiotic administration improved from 17.8% to 39.0% (P < .001). Surgical instrument (38.7% vs 10.2%), linen sterility (35.5% vs 12.8%), and gauze counting (89.2% vs 82.5%; P < .001 for all comparisons) also improved significantly. A modified implementation strategy for the Clean Cut program focusing on reduced external resource and programmatic input from Lifebox, structured education and training materials, and wider hospital engagement resulted in outcomes that matched our pilot study, with improved adherence to recognized infection prevention standards resulting in a reduction in SSIs. The demonstration of scalability reinforces the value of this SSI prevention program.

1466. Povidone-Iodine Irrigation versus Saline Irrigation for Reduction of Surgical Site Infections in Patients Undergoing Total Knee and Total Hip Arthroplasty: a large retrospective, propensity matched cohort study

Abstract Background Surgical site infection (SSI) after total hip and total knee arthroplasty (THA/TKA) is a serious surgical complication. Perioperative irrigation with antiseptic compounds such as povidone-iodine have been used and are recommended by the World Health Organization and the Centers for Disease Control to reduce this risk. However, evidence supporting its superiority relative to non-antiseptic substances such as saline has been inconsistent. Therefore, we aim to identify if irrigation with povidone-iodine in THA/TKA reduces incidence of SSI in patients compared to saline irrigation. Methods In this retrospective, cohort study of 21,482 patients who underwent TKA or THA, we compared SSI rates between patients who received povidone-iodine irrigation and saline irrigation. Univariate and multivariable analyses were performed to identify risk factors for SSI. We also performed a propensity matched analysis. Each patient’s propensity for receiving povidone-iodine irrigation was calculated using select patient and surgical variables. Standardized mean differences were calculated to confirm reduction of potential confounding between the matched groups. Results There were 8,486 patients given saline irrigation and 12,996 patients given povidone-iodine irrigation (Table 1). In the univariate analysis, we did not identify a difference between povidone-iodine and saline (p = 0.76). Multivariate analysis showed diabetes, general anesthesia, and a procedure time of 2-3 hours increased risk of SSI, but povidone-iodine irrigation was not significantly different from saline (OR 1.1; CI 0.6-1.9) (Table 2). After propensity score matching there were 21 (0.25%) SSI in the povidone-iodine group and 19 (0.23%) in the saline group. Standardized mean differences were below 0.2 for all selected variables (Table 3). Odds of SSI were no different between the two matched groups (OR 1.1; CI 0.6-2.1).Table 1.Overview of patient and surgical variables by irrigation solution.Table 2.Multivariable analysis adjusted for age, sex, diabetes mellitus, anesthesia type, and procedure time. Showing odds of developing a surgical site infection.Table 3.Graph of standardized mean differences before and after matching. Blue dots represent unmatched cohort. Orange dots represent matched cohort. Table shows odds of developing a surgical site infection for the matched cohort. Conclusion Our analysis indicates no difference between povidone-iodine and saline irrigation in reducing SSI after THA/TKA. In situations where financial cost may be a factor in determining whether to use saline or povidone-iodine, we conclude that saline irrigation is equally efficacious and therefore a reasonable choice. Disclosures Eric Smith, MD, Conformis: Advisor/Consultant|Depuy: Advisor/Consultant

The Role of Patient Engagement in Surgical Site Infection Reduction: A Process Improvement Project.

Surgical site infections (SSIs) are the second most common healthcare-associated infection, with prevention being a high-priority goal for all healthcare organizations. Although routine surveillance and standardized prevention protocols have long been used, patient engagement is an additional intervention that should be considered and may be beneficial in SSI prevention. To determine if the development of a standardized patient education discharge plan for management of a surgical site and/or surgical drain would contribute to a reduction in SSI rates in inpatients undergoing colorectal, plastic, or general surgery. A preintervention/postintervention design was used. Before intervention, patients and surgeons were surveyed regarding various discharge practices related to surgical incision/drain care. The intervention consisted of implementing a standardized discharge plan including standardized education and patient discharge kits. After implementation, patients were surveyed regarding discharge practices. Patient survey responses and SSI rates were compared between the preintervention and postintervention time frames. Rates of SSIs decreased across all three surgical specialties during the project period: colorectal SSIs decreased from 3.2% to 2.7%, plastics from 1.2% to 0.5%, and general from 0.86% to 0.33%. Improvements were also realized in patient survey responses to various aspects of surgical incision/drain care. Patient engagement may be an important strategy to integrate with SSI evidence-based care bundles. Active engagement of surgical patients perioperatively has the potential to improve the patient experience, which ultimately can result in improved healthcare outcomes for this population.