Subsequent Surgical Site Infection Research Articles

Prevalence and antimicrobial susceptibility patterns of bacteria colonizing the external ocular surfaces of patients undergoing ocular surgeries at Bugando Medical Center in Mwanza, Tanzania

ObjectiveUnderstanding microbiota colonizing ocular surfaces is key to expedite antibiotic prophylactic options for ocular surgeries, and therefore, prevent subsequent surgical site infections (SSIs). To fill this critical gap, we aimed at determining the prevalence and antibiotic susceptibility patterns of bacteria colonizing the external ocular surfaces of 224 patients undergoing ocular surgeries at Bugando Medical Centre (BMC) in Mwanza, Tanzania between May and August 2023.ResultsThe study participants had a median age of 62.5 (interquartile range: 39.5–75.0) years. A total of 78.1% (175/224) ocular swabs were culture positive yielding 196 bacterial isolates. Staphylococcus epidermidis [43.4% (n = 85)], Staphylococcus aureus [21.9% (n = 43)] and Pseudomonas aeruginosa [14.3% (n = 28)] were the most common bacteria. There were low proportions of resistance among predominant Gram-positive and Gram-negative bacteria to gentamicin (≤ 25.0%), and similarly, low resistance among Gram negative bacteria was observed against 3rd generation cephalosporins (≤ 25.0%) and piperacillin-tazobactam (0.0%). Variable resistance profiles were notable to the most commonly used antibiotics (ciprofloxacin and tetracycline: 0.0–66.7%). Our findings underscore an urgent need to revisit antibiotic prophylactic guidelines for ocular surgeries in this tertiary hospital, and calls for prospective evaluation of incident SSIs post-ocular surgeries to guide specific management.

Preclinical safety evaluation of continuous UV-A lighting in an operative setting.

Germicidal ultraviolet (UV-C) light has been shown as an effective modality for disinfection in laboratory settings and in the operative room. Traditionally, short-wavelength UV-C devices, which have previously been shown to cause DNA damage, are utilized only for disinfection in pre- and post-operative settings and are not continuously active during operations. Continuous use of intraoperative UV light has potential to decrease pathogens and subsequent surgical site infections (SSIs), which arise in approximately 5-15% of operative cases. SSIs are a significant determinant of patient morbidity, readmission rates, and overall cost. Therefore, a method of UV light disinfection with a low risk of DNA damage is needed so that greater antimicrobial protection can be afforded to patients during the entirety of their surgical procedures. A new disinfection device that harnesses longer-wavelength UV-A light to disinfect the surgical field throughout the entirety of the procedure, including pre- and post-operation has been developed. This study aimed to determine if UV-A light administered intraoperatively was safe, as defined by the minimal presence of DNA damage and safe amounts of reflection upon medical personnel. Using in vitro models, we examined the differential impacts of UV-C and UV-A light on DNA damage and repair pathways. In a murine model, we looked at the production of DNA damage photoproduction in relation to UV-A versus UV-C exposure. Our results show UV-A light does not induce a significant amount of DNA damage at the cellular or tissue level. Furthermore, a preclinical porcine study showed that surgical personnel were exposed to safe levels of UV-A irradiance from an overhead UV-A light used during an operation. The amount of UV-A transmitted through surgical personal protective equipment (PPE) also remained within safe levels. In conclusion, we found that UV-A may be safe for intraoperative use.

A retrospective exploratory analysis on surgical site infections in a tertiary care hospital in Karnataka

Background: Surgical site infections (SSIs) are the highest reported complications of surgery and serious postoperative nosocomial infections associated with patient morbidity, prolonged hospitalization, and economic burden. This study was conducted to estimate the prevalence of SSIs, bacterial profile, and their antimicrobial susceptibility among patients who underwent surgery and subsequent SSIs at a tertiary care hospital in a coastal district of Karnataka, India. Methods: A retrospective study was conducted by collecting the data of patients diagnosed with SSIs at tertiary care hospital during the period of four years from 2018 January to 2021 December. Data analysis was performed to estimate the prevalence of SSI, determine the bacterial profile and their antibiotic susceptibility using Jamovi software. Results: Among 95611 patients who underwent surgery, a total of 443 (0.46%) patients were clinically diagnosed with SSI. Maximum SSI cases were obtained from the Department of Orthopaedics (42.2%), followed by General Surgery (22.3%) and Neurosurgery (6.5%). Staphylococcus aureus (39.0%) was the most predominant bacteria among the isolates, followed by Escherichia coli (19.04%) and Klebsiella pneumoniae (10%). A total of 55.6% of Staphylococcus aureus exhibited methicillin resistance. Most of the bacterial isolates were susceptible to Trimethoprim sulphamethazole, Gentamycin and Amikacin. Conclusions: Though the prevalence of SSI is less it requires due attention to prevent the SSIs in the hospitals. Identification of risk factors help in planning the preventive strategies. Consistent Infection control practices are implemented in hospital for preventing the transmission of diseases, strengthening the antimicrobial stewardship program and regular antimicrobial surveillance.

No Link Between Inadvertent Surgical Glove Contamination and Surgical Site Infection in Patients Undergoing Elective Neurosurgical Operations

Controllable factors associated with surgical site infections (SSIs) have focused on reducing contamination of the surgical field with potential pathogens. The aim of this prospective study is to determine the incidence of glove contamination in a series of elective neurosurgical operations and determine the relationship of such glove contamination to subsequent SSI. We hypothesize that contamination of surgical gloves is associated with subsequent SSI. In this prospective quality improvement study, gloves of the surgical team were swabbed for standard culture just prior to wound closure of elective neurosurgical operations. Patient characteristics, surgical details, and occurrence of subsequent SSIs were collected retrospectively from the electronic medical records. Data were analyzed with χ2 with Fisher's exact test and Student's t test. Surgical glove contamination occurred in 10 of 96 elective neurosurgical cases (10.4%). SSIs occurred in 6 cases (6.2%), but no SSI occurred in a case in which surgical glove contamination occurred (P=1). SSI was associated with younger patient age (P=0.0448), and surgical glove contamination was associated with less resident experience (P=0.0354). Surgical glove contamination identified at the time of wound closure does not correlate with the development of subsequent SSI in elective neurosurgical operations.

2150. Surgical Prophylaxis in Pediatric Liver Transplant Recipients: Variations in Protocol and Impact on 30-Day Surgical Site Infections

Abstract Background Children undergoing liver transplantation are at risk for surgical site infections (SSI). IDSA/ASHP/SIS/SHEA guidelines recommend surgical prophylaxis with a third-generation cephalosporin plus ampicillin or piperacillin-tazobactam alone. The study objectives were to describe the surgical prophylaxis used at our institution, obtain data on whether prophylactic antimicrobials are adjusted for multidrug resistant organisms and to determine whether adjustments correlate with SSI. Methods Pediatric liver transplant procedures, with associated peri-operative and intra-operative antimicrobials, were extracted from our institutions’ Anesthesia Record Keeping System (ARKS) between 2005-2022. Medical records were reviewed for demographics, microbiological data (e.g., colonization), protocol deviations and 30-day CDC/NHSN SSIs. Results Seventy-one procedures were performed in 69 patients, median age 3 years (range, 5 months- 17 years), where 89% had a pre-transplant infectious disease consultation. Variations from protocol occurred in 39% (n=28), of which 3 were consult-directed. Sixteen were colonized with an organism prior to transplant (3 MDRO and 1 Candida spp.), of which 10 had a protocol adjustment (p< 0.001). The most common additional antimicrobials were vancomycin (n=17) and fluconazole (n=8). Reasons for fluconazole were fulminant liver failure (n=2), surgeon concern (n=3), colonization or prolonged antimicrobials prior to transplant (n=2) and continuation of prophylaxis (n=1). Ten procedures were complicated by an SSI (14%). SSI rates did not differ in those with and without protocol adjustments (p=0.50). Conclusion Adjustments to guideline concordant surgical prophylaxis recommendations occurred in 39% of pediatric liver transplant procedures, with the most common being addition of vancomycin or fluconazole. Adjustments were based on a pre-transplant infectious disease consult recommendations in 11% of cases. Protocol adjustment correlated with any pretransplant microbiology culture result, but not with either MDRO colonization or subsequent SSI. Antimicrobial stewardship efforts may be indicated to address variations in antimicrobial prophylaxis in pediatric liver transplant patients. Disclosures All Authors: No reported disclosures.

Effectiveness of early exercise on reducing skeletal muscle loss during preoperative neoadjuvant chemotherapy for esophageal cancer.

To investigate if early exercise can help prevent skeletal muscle loss and improve the clinical outcomes of esophageal cancer patients receiving preoperative neoadjuvant chemotherapy (NAC). This was a single-center, retrospective observational cohort study of 110 patients with advanced esophageal cancer. We analyzed the effect of early exercise on the risk of skeletal muscle loss (defined as > 2.98%) during NAC and the subsequent clinical outcomes. Patients in the early exercise group (n = 71) started exercise therapy 8days earlier than those the late exercise group (n = 39). The median age of the patients was 65.4years, the mean BMI was 21.1kg/m2, and 92 (84%) of the 110 patients were men. Skeletal muscle loss occurred in 34% and 67% of the early and late exercise groups, respectively (p < 0.001). There was a lower risk of surgical site infection in the early exercise group (1% vs 16%, p = 0.021). Multivariate analysis revealed that early exercise reduced the risk of skeletal muscle loss (OR = 0.25, 95% CI 0.09-0.65, p = 0.006). Our results suggest that early exercise reduces the risk of both skeletal muscle loss during NAC and subsequent surgical site infection in patients with esophageal cancer.

Staphylococcal decolonization to prevent surgical site infection: Is there a role in colorectal surgery?

We implemented a preoperative staphylococcal decolonization protocol for colorectal surgeries if efforts to further reduce surgical site infections (SSIs). Retrospective observational study. Tertiary-care, academic medical center. Adult patients who underwent colorectal surgery, as defined by National Healthcare Safety Network (NHSN), between July 2015 and June 2020. Emergent cases were excluded. Simple and multivariable logistic regression were performed to evaluate the relationship between decolonization and subsequent SSI. Other predictive variables included age, sex, body mass index, procedure duration, American Society of Anesthesiology (ASA) score, diabetes, smoking, and surgical oncology service. In total, 1,683 patients underwent nonemergent NHSN-defined colorectal surgery, and 33.7% underwent the staphylococcal decolonization protocol. SSI occurred in 92 (5.5%); 53 were organ-space infections and 39 were superficial wound infections. We detected no difference in overall SSIs between those decolonized and not decolonized (P = .17). However, superficial wound infections were reduced in the group that received decolonization versus those that did not: 7 (1.2%) of 568 versus 32 (2.9%) of 1,115 (P = .04). Staphylococcal decolonization may prevent a subset of SSIs in patients undergoing colorectal surgery.

Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital.

With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution. A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery. A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA. Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda.

The World Health Organization (WHO) recommends adherence to its surgical safety checklist (SSC) to optimize patient safety and reduce cesarean surgical site infection (SSI). Educational interventions combined with audit and feedback mechanisms on the checklist use by clinicians have the potential to improve adherence and clinical outcomes. Despite the increase in cesarean delivery rates, there is a paucity of data on how such interventions can improve adherence in resource-limited settings. We performed a quality improvement project to measure the impact of an educational intervention with daily audit and feedback procedures on rates of WHO SSC adherence, including pre-operative antibiotic administration and SSI at Mbarara Regional Referral Hospital maternity ward in Uganda. The study involved chart abstraction of WHO SSC and pre-operative antibiotic use during cesarean deliveries and signs of subsequent SSI in three phases. First, we conducted a retrospective review of all charts from May to June 2018 (pre-intervention phase). Second, we instituted an educational intervention on the WHO SSC and pre-operative antibiotics use, followed by a daily audit of charts and feedback to clinicians from July to August 2018 (the intervention phase). Third, we reviewed charts from September to October 2018 (the post-intervention phase). The WHO SSC adherence, pre-operative antibiotic administration and SSI rates were measured as the proportion of the total cesarean deliveries per study phase and then compared across the three phases. We reviewed 678 patients' charts (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). The mean patient age was 25 years. The use of the WHO SSC was 7% in the pre-intervention phase compared to 92% in the intervention phase (P < 0.001), and 77% in the post-intervention phase (P < 0.001). Pre-intervention antibiotic receipt was 18% compared to 90% in the intervention phase (P < 0.001) and 84% in the post-intervention phase (P < 0.001). The documented SSI rate in the pre-intervention phase was 15% compared to 7% in the intervention phase (P = 0.02) and 11% in the post-intervention phase (P = 0.20). An educational intervention, daily audit and feedback to clinicians increased the use of the WHO SSC and prophylactic antibiotics for cesarean delivery-although the rates waned with time. Research to understand factors influencing the checklist use and antibiotic prophylaxis including prescriber knowledge, motivation and clinical process is required. Implementation interventions to sustain usage and impact on clinical outcomes need to be explored.

Low rate of subsequent surgery and serious complications following intra-articular steroid injection for base of thumb osteoarthritis: national cohort analysis.

ObjectivesIntra-articular steroid injection is commonly used to treat base of thumb osteoarthritis (BTOA), despite a lack of large-scale data on safety and effectiveness. We estimate the incidence of serious complications and further procedures following BTOA injection, including the risk of post-operative serious surgical site infection for subsequent operative intervention.MethodsHospital Episode Statistics data linked to mortality records from 1 April 1998 to 31 March 2017 were used to identify all BTOA injections undertaken in adults in the National Health Service secondary care in England. Patients were followed up longitudinally until death or 31 March 2017. A multivariable regression with a Fine and Gray model adjusting for the competing risk of mortality in addition to age, sex and socioeconomic deprivation was used to identify factors associated with progression to further procedure. Secondary outcomes included serious complications after injection and subsequent surgical site infection.ResultsA total of 19 120 primary injections were performed during the 19-year period in 18 356 patients. Of these 76.5% were female; mean age 62 years (s.d. 10.6); 50.48% underwent further procedure; 22.40% underwent surgery. Median time to further intervention was 412 days (IQR 110–1945). Female sex was associated with increased risk of proceeding to surgery. Serious complication rate following injection was 0.04% (0.01–0.08) within 90 days. Of those proceeding to surgery 0.16% (0.06–0.34) presented with a wound infection within 30 days and 90 days, compared with an overall post-operative wound infection rate of 0.03% (0.02–0.05).ConclusionsVery low rates of serious complications were identified following BTOA injections performed in secondary care; only one in five patients proceeded to subsequent surgery.Clinical trial registrationclinicaltrials.gov, https://www.clinicaltrials.gov, NCT03573765

890. Incidence and Microbiology of Surgical Site Infection (SSI) after Breast Surgery

BackgroundSurgical site infection (SSI) after breast surgery is much more common than expected after a clean surgical procedure. Although breast SSIs are primarily Gram-positive; recent literature shows an increase in Gram-negative infections. We assessed the risk factors and microbiology of SSI following breast surgery at our institution.MethodsWe conducted a historical cohort study of all (³ 18 y) females who had surgery from 1/1/2014-3/31/2019 and subsequent SSI within 90 days of the procedure. Two controls, matched for surgery type, were selected per case. Data were collected on demographic and clinical characteristics, surgery type, microbiology and antibiotics. Data were analyzed using the χ 2 test, Student’s t-test and multivariable logistic regression with a forward likelihood ratio algorithm.ResultsAfter excluding patients with limited data, we reviewed 284 charts: 95 of 132 cases and 189 controls. The 90-day incidence of SSI was 3.5 % (132/3755). Cases were younger than controls: 53.9 ± 12.4 years vs. 58.3± 13.7 years, respectively, p=0.02. Controls had more comorbidities: 1.8 ± 1.3 vs. 1.4 ± 0.7,respectively, p=0.001. Tissue expanders were placed in 65 (70%) cases versus 11 (5.8%) controls (p < 0.0001). After controlling for age, BMI, comorbidities and post-operative antibiotics, only tissue expanders were associated with infection (OR=35.1, p< 0.0001, 95% CI: 16.6, 74.0).Microbiological data were available for 84 cases. Gram-positive organisms accounted for 45 (53.6%) infections and Gram-negative organisms accounted for 39 (46.4%) infections. Over 72% of African Americans (p= 0.014), 76.5% of patients with diabetes (p=0.005) and 57.1 % with tissue expanders (p= 0.02) had Gram-negative infections. The table shows the multivariable predictors of Gram-negative infection. Tissue expander removal was required in 61.5% of patients with Gram-negative infections compared to 39% with Gram-positive infections.Predictors of Gram-negative SSI after breast surgery ConclusionPatients with tissue expanders had a higher incidence of SSI after breast surgery; removal was often required in Gram-negative infections. Diabetes and post-operative antibiotics were significant predictors of Gram-negative infection. Knowledge of local epidemiology is a key factor in deciding empiric therapy for SSI.Disclosures All Authors: No reported disclosures

886. Impact of Type of Surgical Management on the Incidence of Recurrent Surgical Site Infections Following Hip and Knee replacements in Calgary, Alberta

BackgroundRecurrent surgical site infections (SSIs) are associated with decreased quality of life for patients and increased economic burden to healthcare systems. Positive cultures at reimplantation and patient co-morbidities have been shown to increase the risk of recurrent SSI in hip and knee surgical site infections. Two-stage exchange has been considered for the most appropriate surgical management for these SSI’s, however, it is unclear whether the type of revision arthroplasty and pathogen of the first SSI impacts recurrence rates.MethodsA retrospective review of prospectively collected data on all complex SSIs following primary hip and knee arthroplasties between April 1 2012 and March 31, 2019, in Calgary, Alberta was performed. Patients were followed for two years post-index arthroplasty to determine initial management of first complex SSI (Debridement, antibiotics and implant retention (DAIR) vs DAIR+liner exchange vs one-stage vs two-stage), rate of recurrent complex SSI, and microbiological data for first and subsequent SSI’s.ResultsOf the 142 complex SSIs, 95 (66.9%) were managed with DAIR and liner exchange, 25 (17.6%) were managed with DAIR, 13 (9.1%) with one-stage and 8 (5.6%) with two-stage procedures. The recurrence rate was 19/95 (20%) for DAIR and liner, 8/25 (32%) for DAIR alone, 2/13 (15%) with one stage, and 3/8 (37.5%) with two-stage. There was no significant difference in recurrence rates of complex SSI when stratified by surgical management. Of the pathogens, Staphylococcus aureus (S.aureus) (including methicillin-resistant S. aureus (MRSA)) accounted for 35.2% of total first SSI and 50% of recurrences. A significantly higher proportion of S.aureus infections (including MRSA) ended up with a recurrent infection compared to all other pathogens (p=0.045). Of the 32 recurrences, 28.1% were due to the same pathogen as the initial SSI.ConclusionS.aureus was the most common pathogen causing initial and recurrent SSIs. This reinforces that S.aureus complex SSIs would likely benefit from early recognition and aggressive treatment. Recurrence of SSI was not impacted by type of revision arthroplasty. This study is limited by a small sample size. These findings contribute to the paucity of literature in this area and suggest a need for expansion to larger populations.Disclosures All Authors: No reported disclosures

A Descriptive Analysis of Infection Present at Time of Surgery (PATOS) in NHSN Surgical Site Infection (SSI) Data, 2015–2018

Background: In 2015, the CDC NHSN introduced infection present at time of surgery (PATOS) as a required data element for reporting surgical site infections (SSIs). PATOS is the documented observation that infection was visualized during the operative procedure and at the same tissue level of subsequent SSI. PATOS SSIs are excluded from CDC calculations of SSI summary measures, the standardized infection ratios (SIRs), including the SSI SIRs used by CMS public reporting and payment programs. The characteristics of PATOS SSIs have not been assessed since its introduction, prompting interest in the review of these SSIs. This study describes PATOS SSI surveillance for 2015–2018, with specific focus on infections following colon surgery (COLO), the NHSN operative procedure category with highest reported incidence of PATOS. Methods: We analyzed all procedures and SSIs reported to the NHSN. Using measures of frequency, we quantified the proportion of SSI and PATOS SSI attributed to all procedures and to COLO specifically. The mid-p method was used for proportion comparison. Procedure and SSI data were described by year and characteristics. Results: Between 2015 and 2018, 12,046,033 procedures and 188,770 SSIs (2%) were reported. Of these SSIs, 22,096 (12%) were PATOS SSIs (Fig. 1). COLO accounted for 11% of all procedures reported, for a total of 1,328,852 procedures with 72,891 (5%) resulting in SSI. COLO accounted for 64% of PATOS SSIs. The proportion of SSIs reported as PATOS SSIs resulting from COLO increased from 18% in 2015 to 22% by 2018 (Fig. 2). The proportion of COLO PATOS SSIs was statistically different from the proportion of PATOS SSIs for all other procedures each year (P &lt; .0001). Organ-space (OS) SSIs accounted for 76% of COLO PATOS SSIs (10,558 of 13,911), and most of these SSIs were SSI intra-abdominal infections (IABs) (91%). The proportion of COLO PATOS SSI superficial incisional primary (SIP) was statistically different from non-COLO PATOS SSI SIP (P = .0105) (Fig. 2). Of COLOs linked to PATOS SSIs, 53% were assigned dirty or infected wound classification. Conclusions: The increase in PATOS SSIs linked to COLO procedures underscores the importance of monitoring PATOS SSIs at the facility level. Focused validation of PATOS data is needed to identify reasons for this increase, which may include misapplication or misunderstanding of PATOS determinations. Validation may highlight the potential need for prevention strategies or interventions related to PATOS.Funding: NoneDisclosures: None

Closed-incision negative-pressure wound management in surgery—literature review and recommendations

Summary Background Wound healing deficits and subsequent surgical site infections are potential complications after surgical procedures, resulting in increased morbidity and treatment costs. Closed-incision negative-pressure wound therapy (ciNPWT) systems seem to reduce postoperative wound complications by sealing the wound and reducing tensile forces. Materials and methods We conducted a collaborative English literature review in the PubMed database including publications from 2009 to 2020 on ciNPWT use in five surgical subspecialities (orthopaedics and trauma, general surgery, plastic surgery, cardiac surgery and vascular surgery). With literature reviews, case reports and expert opinions excluded, the remaining 59 studies were critically summarized and evaluated with regard to their level of evidence. Results Of nine studies analysed in orthopaedics and trauma, positive results of ciNPWT were reported in 55.6%. In 11 of 13 (84.6%), 13 of 15 (86.7%) and 10 of 10 (100%) of studies analysed in plastic, vascular and general surgery, respectively, a positive effect of ciNPWT was observed. On the contrary, only 4 of 12 studies from cardiac surgery discovered positive effects of ciNPWT (33.3%). Conclusion ciNPWT is a promising treatment modality to improve postoperative wound healing, notably when facing increased tensile forces. To optimise ciNPWT benefits, indications for its use should be based on patient- and procedure-related risk factors.

Correlation of intraoperative donor duodenal-segment swab cultures with the subsequent occurrence of surgical site infections in kidney and pancreas transplant recipients.

Pancreas transplantation is employed for the treatment of type I diabetes mellitus. It is postulated that surgical site infection (SSI), particularly organ-space infections, after pancreas transplantation may arise from microbial contamination arising from the donor duodenal segment. Therefore, some centers have adopted the practice of culturing the donor duodenal segment and subsequently administering antimicrobial therapy to the recipient directed at the microorganisms isolated to prevent SSI. In this retrospective cohort study, we evaluated the correlation between positive donor duodenal-segment cultures and SSIs in the recipients. Data were recorded and analyzed to assess the correlation of the organisms isolated in the donor duodenal cultures with those producing SSI in the recipients. We evaluated 379 consecutive pancreas transplant recipients from January 2000 to December 2015. Donor duodenal swab cultures were performed at the time of pancreas transplantation, and 206 (54.3%) were positive. SSIs occurred in 51 of the 206 recipients (24.8%) with positive duodenal-segment cultures and in 41 of 173 individuals (23.7%) with negative cultures (P = .81; r = 0.00). Notably, deep and organ-space SSIs were observed in 27 of 206 of the positive duodenal culture groups (13.1%) versus 29 of 173 of the negative duodenal culture groups (16.8%; P = 0.31; r = -0.059). No differences were detected in the pathogens producing SSIs between the group with a positive duodenal swab versus the group with a negative swab. Microorganisms producing SSIs matched those found in the positive donor duodenal cultures in only 15 patients (7.8%). Although positive cultures from the donor duodenal segment prompted the administration of antimicrobial therapy in the recipient directed against the pathogen isolated, this practice did not reduce SSIs compared with those transplant recipients with culture-negative duodenal swabs. In addition, the organisms isolated from the donor duodenal segment were not predictive of subsequent SSI.

Reflections on the Complexity of Surgical Site Infection Prevention and Detection from an Organizational Lens.

Background: Within the United States, surgical site infections (SSIs) have now become the most common hospital-acquired infection and impact 2%-5% of all surgical patients. It is estimated that approximately 60% of SSIs could be prevented through improved adherence to pre-existing practice guidelines. Methods: The myriad of contributing factors leading to SSIs highlights the need for a multi-faceted approach. Although collaboration and coordination among providers and patients represents a requirement of any sustainable solution, it also creates a space and possible role for innovative technologies and mobile applications utilizing patient-generated health data (PGHD). Results: Upon analysis of hospital practice, we have identified substantial variability in documentation, peri-operative care, and post-discharge instruction with regard to SSI prevention and incision care techniques. This variability is further exacerbated by a loss of information within each transition of patient care. As a result, a patient's risk of SSI often becomes dictated by their provider's preferred (and sometimes arbitrary) peri-operative practices and their own initiative in following poorly explained pre-operative instructions. The quality and efficiency of any subsequent SSI treatment similarly rests on a seemingly inconsistent approach with poor patient instruction for the post-discharge setting. Conclusions: Surgical site infection risk can be mitigated successfully through reliable performance of several evidence-based process measures within the operating room, which are now at the guideline level. However, optimal performance only happens when teams and patients are aligned and truly believe both that the evidence is correct, and that SSIs are preventable. The journey toward this goal will be an iterative process that may take months to years. Although technology can be complementary, it cannot replace human passion for harm prevention.

The role of patients and healthcare workers Staphylococcus aureus nasal colonization in occurrence of surgical site infection among patients admitted in two centers in Tanzania

BackgroundColonization with Staphylococcus aureus has been identified as a risk for subsequent occurrence of infection. This study investigated the relationship between S. aureus colonization of patients and healthcare workers (HCWs), and subsequent surgical site infections (SSI).MethodsBetween December 2014 and September 2015, a total of 930 patients and 143 HCWs were enrolled from the Bugando Medical Centre and Sekou Toure hospital in Mwanza, Tanzania. On admission and discharge nasal swabs, with an additional of wound swab for those who developed SSI were collected from patients whereas HCWs were swabbed once. Identification and antimicrobial susceptibility testing were done by VITEK-MS and VITEK-2, respectively. Detection of Panton Valentine leukocidin (PVL) and mecA genes was done by PCR. S. aureus isolates were further characterized by spa typing and Multi-Locus Sequence Typing (MLST).ResultsAmong 930 patients screened for S. aureus on admission, 129 (13.9%) were positive of which 5.4% (7/129) were methicillin-resistant S. aureus (MRSA). Amongst 363 patients rescreened on discharge, 301 patients had been tested negative on admission of whom 29 (9.6%) turned positive after their hospital stay. Three (10.3%) of the 29 acquired S. aureus were MRSA. Inducible Clindamycin resistance occurred more often among acquired S. aureus isolates than among isolates from admission [34.5% (10/29) vs. 17.1% (22/129), P = 0.018]. S. aureus contributed to 21.1% (n = 12) of the 57 cases of investigated SSIs among 536 patients followed. Seven out of eight S. aureus carriage/infection pairs had the same spa and sequence types. The previously reported dominant PVL-positive ST88 MRSA strain with spa type t690 was detected in patients and HCW.ConclusionA significant proportion of patients acquired S. aureus during hospitalization. The finding of more than 90% of S. aureus SSI to be of endogenous source underscores the need of improving infection prevention and control measures including screening and decolonization of high risk patients.

Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

The 2017 U.S. Centers for Disease Control and Prevention (CDC) guidelines for the prevention of surgical site infection (SSI) recommended against continuation of antibiotics postoperatively after total joint arthroplasty. This is disconcerting, as the revised guidelines are based on only 6 orthopaedic studies, of which 83% (5 of 6) were published from 1987 to 1991. The purpose of the current study was to conduct a systematic review and meta-analysis of the literature regarding the efficacy and duration of surgical antibiotic prophylaxis (SAP) in total joint arthroplasty. PubMed, Ovid MEDLINE, and Ovid Embase were screened for "surgical antimicrobial prophylaxis orthopedic," in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, without a specified time frame with respect to publication date. A total of 693 studies were screened, and 32 studies were evaluated. Data were extracted regarding antibiotic type, number of doses, and duration. Prospective and retrospective studies examining perioperative antibiotics with subsequent SSI and periprosthetic joint infection (PJI) rates in total joint arthroplasty were included. Twenty-three randomized controlled trials (RCTs) and 2 prospective cohort, 3 retrospective cohort, and 4 case-control studies with a total of 51,627 patients were included in this review. The overall pooled effect for the comparison between a single preoperative dose of antibiotic and continued (preoperative plus postoperative) administration was 0.96 (95% confidence interval [CI], 0.73 to 1.26), suggesting no difference in effect. However, the 95% CI for the relative risk would include a reduction of approximately 27% in either group. The overall pooled effect from the comparison between SAP of ≤24 and >24 hours postoperatively demonstrated no difference in effect. All included studies were underpowered and heterogenous regarding type of antibiotic used and duration. Our review confirms the benefit of SAP utilization in total joint arthroplasty. The available evidence does not show added benefit of postoperative SAP or continuation beyond 24 hours. However, the overall GRADE (Grading of Recommendations Assessment, Development and Evaluation) of evidence of the available literature was low (high risk of bias, high risk of publication bias, and low precision). The findings of this study demonstrate the need for Level-I studies with adequate power to evaluate the safety of shortened SAP duration after total joint arthroplasty and its effect on SSI/PJI prior to widespread implementation. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Longer Operative Time Results in a Higher Rate of Subsequent Periprosthetic Joint Infection in Patients Undergoing Primary Joint Arthroplasty

BackgroundWhether prolonged operative time is an independent risk factor for subsequent surgical site infection (SSI) and periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) remains a clinically significant and underexplored issue. The aim of this study is to investigate the association between operative time and the risk of subsequent SSI and PJI in patients undergoing primary TJA. MethodsWe retrospectively reviewed 17,342 primary unilateral total knee arthroplasty and total hip arthroplasty performed at a single institution between 2005 and 2016, with a minimum follow-up of 1 year. A multivariate logistic regression model was conducted to identify the association between operative time and the development of SSI within 90 days and PJI within 1 year. ResultsOverall, the incidence of 90-day SSI and 1-year PJI was 1.2% and 0.8%, respectively. Patients with an operative time of >90 minutes had a significantly higher incidence of SSI and PJI (2.1% and 1.4%, respectively) compared to cases lasting between 60 and 90 minutes (1.1% and 0.7%), and those lasting ≤60 minutes (0.9% and 0.7%, P < .01). In the multivariate model, the risk for infection increased by an odds ratio of 1.346 (95% confidential interval 1.114-1.627) for 90-day SSI and 1.253 (95% confidential interval 1.060-1.481) for 1-year PJI for each 20-minute increase in operative time. ConclusionIn patients undergoing primary TJA, each 20-minute increase in operative time was associated with nearly a 25% increased risk of subsequent PJI. We advocate that surgeons pay close attention to this underappreciated risk factor while maintaining safe operative practices, which minimize unnecessary steps and wasted time in the operating room.

Operating Room Foot Traffic: A Risk Factor for Surgical Site Infections

Extensive studies on foot traffic in the operating room (OR) have shown little correlation between surgical site infections (SSIs) and traffic of OR personnel in and out of the OR. While evidence supports the relation between foot traffic in the OR, airborne bacteria, and subsequent SSIs in orthopedic surgical procedures, the studies were conducted over four years and in more than 8,000 patients. The direct relation this finding has to general surgery patients has yet to be proven; however, protocols to reduce foot traffic may have a beneficial effect for the OR team.