SSI Rate Research Articles

Prophylactic PICO◊ dressing shortens wound dressing requirements post emergency laparotomy (EL-PICO◊ trial)

BackgroundSurgical site infection (SSI) is a very common complication of emergency laparotomy and causes significant morbidity. The PICO◊ device delivers negative pressure wound therapy (NPWT) to closed incisions, with some studies suggesting a role for prevention of SSI in heterogenous surgical populations. We aimed to compare SSI rates between patients receiving PICO◊ versus conventional dressing post-emergency laparotomy. Secondary objectives were to observe seroma and dehiscence rates, length of stay, days on dressing and patients’ wound experience.MethodsThis double blinded randomized controlled trial was conducted in University Malaya Medical Centre between October 2019 and March 2022. Patients undergoing emergency laparotomy requiring incisions less than 35 cm were included. Statistical analysis was performed using χ2 test for categorical variables, independent T-test or Mann–Whitney U were used for parametric or non-parametric data respectively besides logistic regression. P values of < 0.05 were considered to be significant.ResultsNinety-six patients were analyzed (47 interventions, 49 controls). The duration on dressing was more consistent in the intervention arm (PICO◊) versus control arm [9.78 ± 10.20 vs 17.78 ± 16.46 days, P < 0.001]. There was a trend towards lower SSI [14.3 vs 4.3%, P = 0.09], dehiscence [27.1 vs 10.6%, P = 0.07] and seroma [40.8 vs 23.4%, P = 0.08] rates in the intervention arm but this did not reach statistical significance. Length of stay [9 (IQR: 6–14) vs 11 (IQR: 6–22.5) days, P = 0.18] was fairly similar between the two arms, but more patients were very satisfied with PICO◊ compared to the conventional dressing [80% vs 57.1%, P = 0.03].ConclusionThe use of NPWT in emergency laparotomy improves patients wound care experience, and was associated with trends towards fewer wound related complications. Cost effectiveness needs to be explored in order to further validate its use in the emergency setting, especially for patients with additional risk for SSI.Trial registrationNational Medical Research Registry (NMRR): NMRR-20-1975-55222.

Postoperative continuation of antibiotic prophylaxis beyond 24 h is unnecessary for abdominal surgeries in children and neonates

PurposeDespite recent WHO recommendations, antibiotic prophylaxis is routinely continued for several days after surgery. We conducted a retrospective study to evaluate the safety and efficacy of antibiotic prophylaxis cessation within 24 h after abdominal surgeries MethodsWe retrospectively reviewed the charts of patients who underwent 3 representative gastrointestinal surgeries (1; transumbilical small bowel procedure for intestinal atresia or stenosis, 2; extrahepatic bile duct resection, and hepaticojejunostomy for congenital biliary dilatation, 3; stoma closure for intestinal perforation, anorectal malformation, or inflammatory bowel disease) at our institution between 2011 and 2023. The demographic data collected included age, preoperative hemoglobin level, albumin level, body mass index, and ASA class. Intraoperative and postoperative data were also collected. The patients were divided into 2 groups according to the duration of perioperative antibiotics (‘within 24 h’ and ‘beyond 24 h’), and the incidence of superficial incisional SSI (siSSI) was compared between the 2 groups in each procedure ResultsDuring the study period, 25 cases underwent transumbilical small bowel procedure, 23 cases underwent hepaticojejunostomy, and 45 cases underwent stoma closure. The preoperative care bundle including bowel preparation, cleansing, and operative procedures has not changed during the study period. First- and third-generation cephalosporins were administered to all the patients. All patients received their first single dose of antibiotics within 60 min before the skin incision. In particular, 14 patients who underwent small-bowel procedures received only a single dose. The SSI rates for small bowel procedures, hepaticojejunostomy, and stoma closure were 0%, 4.4%, and 4.4%, respectively. No SSIs were observed in any of the procedures in the 'within 24 h' group ConclusionBased on our study, we conclude that ≤24 h of postoperative continuation of antibiotic prophylaxis is sufficient for siSSI prevention in hepaticojejunostomy and stoma closure. Additionally, single-dose antibiotic prophylaxis is adequate for neonatal small bowel procedures.

The Use of a Novel Surgical Irrigant May Be Associated with Decreased Incidence of Surgical Site Infections

Background Periprosthetic joint infection (PJI) represents a formidable challenge to patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). This investigation evaluated a novel antimicrobial surgical irrigation solution, XPerience (XP) (Next Science LLC, Jacksonville, FL), with proven high &amp; persistent in-vivo efficacy against planktonic bacteria and biofilm. The primary objective of this investigation was to compare the incidence of PJI following TKA performed with use of XP versus a standard control rinse (povidone-iodine). The secondary outcome was an all-cause return to operating room (OR) rate. Methods A retrospective cohort study was conducted from 824 consecutive patients undergoing primary THA/TKA from 12/1/2019 - 11/30/2021 treated using povidone-iodine solution and 471 consecutive patients undergoing primary THA/TKA from 12/1/2021 - 12/30/2022 treated with XP at a single institution by the senior author. All surgeries in both groups followed largely identical preoperative, perioperative, and postoperative protocols. A total of 1,295 cases were analyzed. The groups shared largely analogous background characteristics pertaining to age, sex, BMI, and American Society of Anesthesiologists (ASA) class. Results The overall SSI rate was 0% (0/471) in the XP group and 0.49% (4/824) in the control group (P = 0.3). The overall return to OR rate was 0.21% (1/471) in the XP group and 0.85% (7/824) in the control group (P = 0.3). Control group cases returned to the OR for hematoma debridements, periprosthetic fracture fixation, and PJI revisions. Conclusion This investigation is the first to remark on the clinical efficacy of a novel surgical irrigant. There was no statistically significant difference in rates of PJI or return to OR with the irrigant versus without, though a trend towards lower rates was observed in the context of a low baseline infection rate. Limitations pertaining to a single-center experience and sample size may be addressed by further studies incorporating broader enrollments.

Outcomes of a 3-day transparent film dressing protocol after hypospadias repair

This study aimed to evaluate a 3-day transparent film dressing protocol after hypospadias repair. A retrospective observational study was conducted in boys with hypospadias who were operated in our institution between 2022 and 2023. Postoperatively, the penis was wrapped with a transparent film dressing, which was removed after 3 days. Postoperative complications were observed until postoperative day 14. The associations of age, meatal location, and type of procedure were analyzed using Chi square, Fisher exact, Mann Whitney, and Kruskall Wallis test (p < 0.05 = significant). Sixty-five patients were studied. Median age was five years, the majority had proximal meatus (58.5%), and underwent urethroplasty (76.9%). After dressing removal, positive bacterial culture was found in 43.1%, mild penile edema in 33.8%, bleeding in 10.8%, and SSI in 49.2% of cases, with pus formation (10.8%), dehiscence (9.2%), and urethrocutaneous fistula (10% after urethroplasty procedure). Surgical site infection and positive culture were significantly higher in patients with proximal meatus compared to distal (p = 0.031, p = 0.019; respectively). A 3-day transparent film dressing prevented penile edema and bleeding in most cases. However, the rate of SSI and positive wound culture was high, and was associated with proximal meatal location.

Pediatric obesity and adverse outcomes following deformity correction surgery for adolescent idiopathic scoliosis: A cross-sectional analysis using 2015-2019 NIS data.

Obesity in the pediatric population has been a growing medical concern over the last few decades with a prevalence of 19.7% as of 2017-2020. Obesity is a risk factor for greater scoliotic curves and failure of conservative therapy for adolescent idiopathic scoliosis (AIS). Establishing a correlation between obesity and a wide variety of adverse outcomes following scoliosis surgery can assist in the preoperative consultation with the family and proper optimization of the patient for scoliosis fusion surgery. The National Inpatient Sample (NIS) was used to access inpatient data from 2015 to 2019. Pediatric patients with idiopathic scoliosis admitted for spinal deformity correction via posterior spinal fusion of over 8 levels were identified. Patients were stratified based on the comorbid diagnosis of obesity. Variables that were significantly associated with outcomes (p < 0.05) were used in a multivariable logistic regression to control for confounders. Backwards stepwise p-value removal was used to build the final model and model fit was assessed using the area under the curve. A total of 855 obese and 17,285 non-obese pediatric patients undergoing posterior instrumented fusion for scoliotic deformity correction were identified. The obese group was associated with a higher rate of SSI (0.6% vs 0.1%, p < 0.001), UTI (1.2% vs. 0.3%, p < 0.001), and AKI (0.6% vs 0.1%, p = 0.12) compared to the normal BMI group. Obese patients were also more likely to have a non-routine discharge when compared to non-obese (4.7% vs. 2.3%, p < 0.001). The rate of having more than one complication occurring postoperatively was higher in the obese group, however, this finding was not significant (0.6%, vs 0.4%, p = 0.385). On multivariate regression analysis, obesity was positively associated with SSI (OR = 2.758, CI = 0.999-7.614, p = 0.050), UTI (OR = 2.221, CI = 1.082-4.560, p = 0.030), non-routine discharge (OR = 1.515, CI = 1.070-2.147, p = 0.019), and an extended LOS (OR = 1.869, CI = 1.607-2.174, p < 0.001). Obesity was associated with postoperative blood transfusion, SSI, UTI, increased length of stay, and non-routine discharge after pediatric AIS deformity surgery. In addition to the increased morbidity seen in obese patients, we also identified the significantly increased cost of care for this group when compared to non-obese patients. These data should be used for a robust preoperative risk assessment and evidence for BMI optimization prior to deformity correction for AIS.

Spinal deformity surgery in Scheuermann's kyphosis versus adolescent idiopathic scoliosis: meta-analysis of complications and clinical outcomes.

Surgical management of adolescent idiopathic scoliosis (AIS) and Scheuermann's kyphosis (SK) may be associated with several complications including extended length of stay and unplanned reoperations. Several studies have previously compared postoperative complications and functional outcomes for AIS and SK patients with mixed results. However, a meta-analysis compiling the literature on this topic is lacking. Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored until April 2024. The extracted data consisted of complications (overall and surgical-site infections [SSI]), readmissions, reoperations, and Scoliosis Research Society-22 (SRS-22) score. Mean differences (MD) with 95% CI were used for continuous data and odds ratio (OR) was utilized for dichotomous data were calculated across studies. Seven retrospective articles were included in the meta-analysis, including 4866 patients, with 399 in the SK group and 4467 in the AIS group. SK patients were found to have statistically significantly higher rates of overall complications (OR = 5.41; 95% CI 3.69-7.93, p < .001), SSI (OR = 11.30; 95% CI 6.14-20.82, p < .001), readmissions (OR = 2.81; 95% CI 1.21-6.53, p = 0.02), and reoperations (OR = 7.40; 95% CI 4.76-11.51, p < .001) than AIS patients. However, they had similar SRS-22 scores postoperatively (MD = -0.06; 95% CI -0.16 to 0.04, p = 0.26) despite the SK group having lower SRS-22 scores preoperatively (MD = -0.30; 95% CI -0.42 to -0.18, p < .001). In this meta-analysis of studies comparing spinal deformity surgery outcomes in AIS and SK patients, SK was associated with more complications, readmissions, and reoperations. SK did have equivalent SRS-22 scores postoperatively to AIS patients, highlighting the benefit of surgical treatment despite higher complication rates. This data may help inform healthcare institutions, payors, and quality monitoring organizations who examine outcomes of pediatric and adult spinal deformity surgery.

Staged Management for Distal Femur Fractures: Impacts on Reoperation, Stiffness, and Overall Outcomes.

To evaluate the outcomes of staged management with external fixation (ex-fix) prior to definitive fixation of distal femur fractures. Design: Retrospective cohort. Single Level I Trauma Center. Adults treated operatively between 2004 and 2019 for distal femur fractures (OTA/AO 33A/33C) were identified using Current Procedural Terminology codes. Excluded cases were those with screw only fixation, acute distal femur replacement, 33B fracture pattern, no radiographs available, or did not have 6-months of follow-up. Postoperative complication rates including surgical site infection [SSI], reoperation to promote bone healing, final knee arc of motion <90 degrees, heterotopic ossification formation, and reoperation for stiffness were compared between patients treated with ex-fix prior to definitive fixation and those not requiring ex-fix. A total of 407 patients were included with a mean follow-up of 27 months (median [IQR] of 12 [7,33] months), (range 6-192 months). Most patients were male (52%) with an average age of 48 [Range: 18-92] years. Ex-fix was utilized in 150 (37%) cases and 257 (63%) cases underwent primary definitive fixation. There was no difference in SSI rates (p=0.12), final knee arc of motion <90 degrees (p=0.51), and reoperation for stiffness (p=0.41) between the ex-fix and no ex-fix groups. The 150 patients requiring ex-fix spent an average of 4.2 days (SD 3.3) in the ex-fix before definitive fixation. These patients were further analyzed by comparing the duration of time spent in ex-fix, <4 days (n=82) and ≥4 days (n=68). Despite longer time spent in ex-fix prior to definitive fixation, there was again no significant difference in any of the complication and reoperation rates when comparing the two groups, including final knee arc of motion <90 degrees (p=0.63), reoperation for stiffness (p=1.00), and SSI (p=0.79). Ex-fix of distal femur fractures as a means of temporary stabilization prior to definitive ORIF does not increase the risk of complications such as SSI, final knee arc of motion <90 degrees, or reoperations for bone healing or stiffness when compared to single stage ORIF of distal femur fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of surgical site infection in patients undergoing laparoscopic cholecystectomy with or without prior ERCP.

Objective: To compare the risk of surgical site infections in patients undergoing laparoscopic cholecystectomy with or without prior ERCP. Study Design: Prospective Comparative study. Setting: Surgical Unit-I of Holy Family Hospital, Rawalpindi. Period: December 2021 to May 2022. Methods: Total 140 patients were included. Group A had ERCP before their laparoscopic cholecystectomy. Those, who had laparoscopic cholecystectomy without first undergoing ERCP included in Group B. For this study, we used SPSS to analyze the data we gathered (version 23.0). Two groups were compared for surgical site infection using the Chi-square test. The level of significance was set at P 0.05. Results: Total 140 patients with biliary tract disease (choledocholithiasis, cholangitis and cholelithiasis) were enrolled in this study. In group-A, there were 16(22.9%) males and 54(77.1%) females, while in Group-B, there were 14(20.0%) males and 56(80.0%) females. In patients with prior ERCP group, 28(40.0%) developed surgical site infections, while in patients without ERCP group, 13(18.6%) developed surgical site infections with a p-value of 0.005, which is statistically significant. Conclusion: An increase in the incidence of SSI following laparoscopic cholecystectomy by two- fold is connected with pre-operative (ERCP) so we plan to assess if this technique is linked to a higher risk of wound infection after surgery. we suggest that long term use of antibiotics can reduce the rate of SSI and longer stay of patients in hospital.

Implementation of surgical site infection care bundle in patients undergoing gastrointestinal surgeries

PurposeSurgical site infection (SSI) is one of the frequent healthcare associated infections linked with significant morbidity, prolonged hospitalization, and death. SSI can be reduced by implementation of customized care bundle components as per standard guidelines. Hence this study was undertaken with the objective to implement care bundle in patients undergoing elective gastrointestinal surgeries and assess their impact on SSI rate. MethodsThe study was an interventional study conducted in the department of surgical gastroenterology for 8 months. Sample size was calculated to be 196 and only elective surgeries are included. CDC NHSN 2023 guidelines are used for surveillance of SSI and global guidelines for prevention of SSI was used for preparation of list of pre-operative, intraoperative and post-operative care bundle components and were implemented before the start of the study. ResultsOverall SSI rate and compliance to SSI care bundle in this study are 13.8% and 28.6%, respectively. When compared with the baseline SSI rate of 19.4%, there is reduction of 28.9% in SSI rate after the implementation of care bundle. Escherichia coli (54.2%) is the most commonly isolated organism. Care bundle non-compliant surgeries are associated with 2.3 times (relative risk-2.3) increased risk of SSI. There is fluctuating trend in compliance of care bundle and SSI rates across months. ConclusionThis study shows the importance of implementation of set of care bundle for prevention of SSI which can be customized and adapted for reducing SSI.

Assessing morinidazole for surgical site infection in class III wounds prevention: a multi-centre, randomized, single-blind, parallel-controlled study

Surgical site infections are significant postoperative risks, antibiotic prophylaxis is crucial due to the presence of anaerobic bacteria. This study investigated the efficacy and safety of a novel nitroimidazole, morinidazole, in SSI reduction in class Ⅲ wounds, as there is currently a lack of evidence in the existing literature. A multicenter randomized clinical trial was conducted from December 2020 to October 2022 in the general surgery departments of 12 tertiary hospitals in China. 459 patients in two treatment groups using morinidazole plus ceftriaxone or ceftriaxone alone. Efficacy and safety were evaluated including SSI incidence, adverse events, and compliance. Statistical analysis employed SAS 9.4 software. Data analysis was performed from February to May 2023. A total of 440 participants (median [IQR] age, 63.0 [54.0, 70.0] years; 282 males [64.09%]; 437 patients were of Han race [99.32%]) were randomized. The experimental group exhibited a significantly lower SSI rate compared with the control group (31 [14.49%] vs 52 [23.01%]; risk difference, 1.76%, 95%CI, 1.08% to 2.88%; P=0.0224). The superficial incisional site infections revealed a marked reduction in the experimental group (12 [5.61%] vs 31 [13.37%]; risk difference,2.68%; 95%CI,1.34%to5.36%; P=0.0042). Non-surgical site infections, severe postoperative complications, and total adverse events showed no statistically significant differences between the groups (P>0.05). The significant decrease in SSI rates and superficial incisional infections demonstrates morinidazole as a valuable prophylactic antibiotic. Our findings provided valuable insights for clinical practice, where this new-generation nitroimidazole can play a crucial role in SSI prevention.

A Deeper Look at Proposed Surveillance of Superficial Incision Surgical Site Infections (SSISSIs)

Although the National Healthcare Safety Network (NHSN) recommends the reporting of superficial incisional SSIs, the standardized infection ratio (SIR) models used by the NSHN exclude superficial incisional SSIs cases. Yet, some superficial incisional SSIs may lead to serious adverse patient outcomes. We previously proposed a new category of such infections: serious superficial incisional surgical site infections (SSISSIs), defined as a superficial incisional SSI that (1) required debridement in an operating room and/or (2) led to a hospital readmission within 30 days of surgery. The objective of our study was to determine the prevalence of SSISSIs in a large network of community hospitals and compare hospital rankings of SSI rates of organ/space and deep SSIs (complex SSIs) with and without SSISSIs. We performed a retrospective descriptive analysis of prospectively collected data on 35 NHSN surgical categories in 47 community hospitals within the Duke Infection Control Outreach Network (DICON) from 1/1/2013-12/31/2022. All hospitals used standardized surveillance and data collection strategies throughout the study period. The Wilcoxon rank-sum was used to test for differences in performance rankings of hospitals sorted by rates of complex SSIs alone compared to complex and SSISSI rates. A two-tailed P value of .05 or less was considered significant. Overall, 11,617 SSIs occurred after 1,272,257 surgeries (0.91 SSIs/100 procedures). Out of 3,996 superficial SSIs, 2,038 (17.5% overall, 51.0% of superficial incisional) met criteria for SSISSI. 112 (5.5%) were diagnosed during the current admission and required takeback to the OR for infection; 1,926 (94.5%) were diagnosed during a readmission; and 3841 (33.1%) were diagnosed during readmission and returned to the OR. (Table1) The highest proportion of SSISSIs was diagnosed in patients who underwent gastrointestinal surgery (32.0%) or orthopedic surgery (24.0%). (Table2) Performance ranking of individual hospitals based on rates of complex SSIs, differed significantly when including SSISSIs (p= 0.02). (Table3) Discussion Our findings suggest that SSISSIs make up a moderate but important proportion of SSIs in community hospitals. SSISSIs can be identified through established database surveillance looking at objective measures of returning to the OR for debridement and/or readmission within 30 days. Hospital rankings differed significantly when SSISSIs were added to complex SSIs to calculate SSI rates. As such, including SSISSIs likely provides a more accurate depiction of SSIs with important outcomes and is not as subjective to surveillance bias. Next steps would be specifically to look at outcomes data for complex SSIs compared to SSISSIs to fully evaluate theDisclosure: Jessica Seidelman: UptoDate- Section Editor; BoneSupport- Consultant

Enhanced recovery after non-elective colorectal surgery: Is it time for emergency general surgeons to follow suit?

BackgroundSurgical dogma suggests that enhanced recovery (ERAS) pathways are not feasible in the non-elective setting. This study challenges that dogma with the implementation of ERAS in non-elective colorectal surgery. MethodsSingle center review of all colorectal operations was performed following implementation of ERAS in non-elective colorectal surgery. Compliance and outcomes between elective and non-elective operations were compared. Results142 elective and 116 non-elective operations were performed with a compliance rate of 84 ​% and 46 ​%, respectively. Acceptable compliance was achieved with 7 metrics in the non-elective cohort. Elective operations were associated with an average LOS of 3 days and a 1 ​% SSI rate, compared to 8 days and 15 ​% in the non-elective group. On multivariate analysis, five ERAS metrics were associated with SSI. ConclusionsERAS pathways are often neglected in non-elective surgery. Acute Care Surgeons should recognize the ERAS principles that are appropriate for their patient population and implement these strategies into practice.

Surgical Outcome and Microbial Colonization of Standardized Smear Locations after Pancreatic Head Resection (Pylorus-Preserving Pancreatoduodenectomy, PPPD) for Chronic Pancreatitis and Pancreatic Head Carcinoma.

Introduction: Patients with chronic pancreatitis (CP) as well as with pancreatic head carcinoma (CA) undergo the surgical intervention named "pylorus-preserving pancreatoduodenectomy according to Traverso-Longmire (PPPD)", which allowed a comparative analysis of the postoperative courses. The hypothesis was that patients with CA would have worse general as well as immune status than patients with CP due to the severity of the tumor disease and that this would be reflected in the more disadvantageous early postoperative outcome after PPPD. Methods: With the aim of eliciting the influence of the different diagnoses, the surgical outcome of all consecutive patients who underwent surgery at the Dept. of General, Abdominal, Vascular and Transplant Surgery at the University Hospital at Magdeburg between 2002 and 2015 (inclusion criterion) was recorded and comparatively evaluated. Early postoperative outcome was characterized by general and specific complication rate indicating morbidity, mortality, and microbial colonization rate, in particular surgical site infection (SSI, according to CDC criteria). In addition, microbiological findings of swabs and cultures from all compartments as well as preoperative and perioperative parameters from patient records were retrospectively documented and used for statistical comparison in this systematic retrospective unicenter observational study (design). Results: In total, 192 cases with CA (68.1%) and 90 cases with CP (31.9%) met the inclusion criteria of this study. Surprisingly, there were similar specific complication rates of 45.3% (CA) vs. 45.6% (CP; p = 0.97) and in-hospital mortality, which differed only slightly at 3.65% (CA) vs. 3.3% (CP; p = 0.591); the overall complication rate tended to be higher for CA at 23.4% vs. 14.4% (CP; p = 0.082). Overall, potentially pathogenic germs were detected in 28.9% of all patients in CP compared to 32.8% in CA (p = 0.509), and the rate of SSI was 29.7% (CA) and 24.4% (CP; p = 0.361). In multivariate analysis, CA was found to be a significant risk factor for the development of SSI (OR: 2.025; p = 0.048); the underlying disease had otherwise no significant effect on early postoperative outcome. Significant risk factors in the multivariate analysis were also male sex for SSI and microbial colonization, and intraoperatively transfused red cell packs for mortality, general and specific complications, and surgical revisions. Conclusions: Based on these results, a partly significant, partly trending negative influence of the underlying disease CA, compared to CP, on the early postoperative outcome was found, especially with regard to SSI after PPPD. This influence is corroborated by the international literature.

Metronidazole and cefazolin vs cefazolin alone for surgical site infection prophylaxis in gynecologic surgery at a comprehensive cancer center

BackgroundSurgical site infection (SSI) is one of the most common complications of gynecologic cancer surgery. Current guidelines recommend the administration of cefazolin pre-operatively to reduce SSI rates for patients undergoing clean-contaminated surgeries such as hysterectomy. ObjectiveTo evaluate the impact of a quality improvement project adding metronidazole to cefazolin for antibiotic prophylaxis on SSI rate for women undergoing gynecologic surgery at a comprehensive cancer center. Study DesignThis retrospective, single-center, cohort study included patients who underwent surgery in the Gynecologic Oncology department from 5/2017 to 6/2023. Patients with penicillin allergies and those undergoing concomitant bowel resection(s) and/or joint cases were excluded. The pre-intervention group patients had surgery from 5/2017 to 4/2022, and the post-intervention group patients had surgery from 4/2022 to 6/2023. The primary outcome was 30-day SSI rate. Sensitivity analyses were performed to compare SSI rates based on actual antibiotic(s) received and for those who had a hysterectomy. Factors independently associated with SSI were identified using a multivariable logistic regression model adjusting for confounding variables. ResultsOf 3343 patients, 2572 (76.9%) and 771 (23.1%) were in the pre- and post-intervention groups, respectively. Most patients (74.7%) had a hysterectomy performed. Thirty four percent of cases were for non-oncologic (benign) indications. Pre-intervention patients were more likely to receive appropriate pre-operative antibiotics (95.6% vs 90.7%; p<0.001). The overall SSI rate prior to the intervention was 4.7% compared to 2.6% after the intervention (p=0.010). The SSI rate for all patients who underwent hysterectomy was 4.9% (pre-intervention) vs. 2.8% (post-intervention) (p=0.036); a similar trend was seen for benign cases (4.4% vs 2.4%; p=0.159). On multivariable analysis, the odds ratio for SSI was 0.49 (95% CI 0.38-0.63) for the post- compared to pre-intervention group (p<0.001). In a sensitivity analysis (n=3087), SSI rate was 4.5% for those who received cefazolin alone compared to 2.3% for those who received cefazolin plus metronidazole, with significant decreased odds of SSI for the cefazolin plus metronidazole group (adjusted OR 0.40, 95% CI 0.30-0.53; p<0.001). Among only those who had a hysterectomy performed, the odds of SSI was significantly reduced for those in the post-intervention group (adjusted OR 0.63, 95% CI 0.47-0.86; p=0.003). ConclusionThe addition of metronidazole to cefazolin before gynecologic surgery decreased the SSI rate by half, even after accounting for other known predictors of SSI and differences in practice patterns over time. Providers should consider this combination regimen in women undergoing gynecologic surgery, especially for cases involving hysterectomy.

Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review.

Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.

Addition of vancomycin to cefazolin is often unnecessary for preoperative antibiotic prophylaxis during total joint arthroplasties

PurposeThe gold standard to decrease total joint arthroplasty (TJA) periprosthetic joint infection (PJI) is preoperative antibiotic prophylaxis. Despite substantial prevention efforts, rates of PJIs are increasing. While cefazolin is the drug of choice for preoperative prophylaxis, adjunctive vancomycin therapy has been used in methicillin-resistant Staphylococcus aureus (MRSA) endemic areas. However, studies examining these combinations are lacking. Therefore, we sought to examine complications among vancomycin plus cefazolin and cefazolin-only recipients prior to primary TJA in a single institutional sample and specifically assessed: (1) microbiological aspects, including periprosthetic joint and surgical site infections, microbes cultured from the infection, and frequency of microbes cultured from nasal swab screening; (2) 30-day emergency department (ED) visits and re-admissions; as well as (3) associated risk factors for infection.MethodsA total of 2,907 patients (1,437 receiving both cefazolin and vancomycin and 1,470 given cefazolin only) who underwent primary TJA between 1 January 2014 and 31 May 2021 were identified. SSI and PJI as well as rates of cultured microbes rates were obtained through one year, those with prior nasal swab screening and 30-day re-admission were identified. Subsequently, multiple regression analyses were performed to investigate potential independent risk factors for PJIs.ResultsThere was no significant difference in the rates of SSI (P = 0.089) and PJI (P = 0.279) between the groups at one year after operation. Commonly identified organisms included Staphylococcus and Streptococcus species. The VC cohort did have a greater reduction of MRSA in the previously nasal swab-screened subset of patients. Multiple regression analyses demonstrated emergency as well as inpatient admissions as risk factors for PJI.ConclusionsAdjunctive vancomycin therapy offers increased protection against MRSA in previously screened individuals. However, those negative for MRSA screening do not require vancomycin and have similar protection to infection compared to recipients of cefazolin only in a high-powered single institution analysis in an MRSA endemic area.

Surgical Site Infection in the General Surgery Department of the Commune I Reference Health Center of Bamako

Objective: To study surgical site infections in the general surgery department of the CSRéf in Commune I of the Bamako district. Method: This was a 12-month prospective descriptive and analytical study from 1er June 2021 to 1er May 2022, including all patients operated on and hospitalised in the department. Results: During the study period, we recorded 80 cases of surgical site infection out of 442 patients included in the study, i.e. an overall total of 18.1%. The mean age of the patients was 32.24 years, with extremes ranging from 1 to 82 years. The rate of SSI was influenced by the surgical indication, the type of anaesthesia, the type of surgery according to the Altemeier classification, whether or not antibiotic prophylaxis and drainage were practised, and the length of postoperative hospitalisation. The majority of surgical site infections were diagnosed within the first 5-10 days postoperatively. Superficial infection was the most common (81%). E coli was the most common germ isolated from the site of infection at 49.15%. Most germs were sensitive to the combination of amoxicillin and clavulanic acid, imipenem and gentamicin.

Estimating effectiveness of nasal decolonization in prevention of peri-prosthetic joint infection in nasal carriers of Staphylococcus aureus undergoing arthroplasty in a tertiary care institution

Introduction: Peri-prosthetic joint infection (PJI) is one of the most challenging complications after total joint arthroplasty (TJA) surgeries. This study aims to (i) compare overall PJI rates with and without pre-operative nasal screening and decolonization for Staphylococcus aureus; (ii) estimate the difference in SSI rates between carriers and non-carriers undergoing TJA; and (iii) determine the efficacy of decolonization in reducing PJI rate in nasal carriers. Methods: A total of 760 patients were included in the study; with 399 patients in the study group, who underwent pre-operative screening and decolonization for nasal colonization with S. aureus; and 361 patients in the control group, who did not undergo pre-operative screening for nasal colonization. Patients were followed for 90 days post-surgery, and PJI rates were recorded following the Centers for Disease Control SSI criteria. Results: Twenty-one (5.26%) out of 399 patients in the study group developed PJI as opposed to 38 (10.53%) out of 361 patients in the control group. PJI rate due to either MSSA or MRSA was 2.5% in the study group (10/399) as opposed to 7.75% in the control group (28/361), with “P value” of 0.002 (&lt;0.05). Discussion: The overall SSI incidence was reduced by 51% after implementing the decolonization protocol. Regarding specific S. aureus SSI, 7.5% of the SSIs in the control group were caused by S. aureus, while only 2.5% were caused by this microorganism after implementing the screening and decolonization protocol. Conclusion: Implementing a screening and decolonization protocol for S. aureus before TJA can lead to a significant reduction in S. aureus surgical site infections.

Is weight trajectory a better marker of wound complication risk than BMI in hernia patients with obesity?

Complex ventral hernias are frequently repaired via an open transversus abdominis release (TAR). Obesity, particularly a BMI > 40, is a strong predictor of wound morbidity following this procedure. We aimed to determine if preoperative weight loss may still be beneficial in patients with persistently elevated BMIs. A retrospective chart review of patients with obesity (BMI ≥ 30) who underwent open TAR at a tertiary academic medical center from January 2018 to December 2021 was completed. Demographics, medical history, operative details, and postoperative data were analyzed. Weight and BMI were recorded at three time points: > 6months prior to initial surgical consultation, surgical consultation, and day of surgery. In total, 182 patients with obesity underwent an open TAR. Twenty-seven patients (14.8%) underwent surgery with a BMI > 40; they did not have any significant differences in surgical site occurrences (SSO, 48.1% vs 32.9%, p = 0.13) or surgical site infections (SSI, 25.9% vs 23.2%, p = 0.76) compared to those with a BMI ≤ 40.The average timeframe analyzed for preoperative weight loss was 592days. Patients who had at least a 3% weight loss (n = 49, 26.9%) had decreased rates of SSI compared to those who did not have this weight loss (12.2% vs 27.8%, p = 0.03), despite the groups having similar BMIs at the time of surgery (36.4 vs 36.0, p = 0.50). Patients who only had a 1% weight loss did not see a decrease in SSI rate compared to those who did not (20.6% vs 25.4%, p = 0.45). Weight loss may be a better indicator of a patient's risk for wound morbidity following TAR than BMI alone, as weight loss of at least 3% resulted in fewer SSIs despite similar BMIs at time of surgery. Further research into optimal timing and amount of weight loss, as well as effects on long-term outcomes, is needed to confirm these findings.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study

BackgroundSurgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure. MethodsWe conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition. ResultsWe included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 ​% vs. 11.9 ​%; p ​= ​0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 ​% vs. 4.4 ​%; p ​= ​0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group. ConclusionThe rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.