Surgical Site Infection In Colorectal Surgery Research Articles

Surgical Site Infections in Colorectal Cancer Surgeries: A Systematic Review and Meta-Analysis of the Impact of Surgical Approach and Associated Risk Factors

Background: Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain. Methods: We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor. Results: Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor. Conclusions: The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.

Surgical Site Infections in Colorectal Cancer Surgeries: A Systematic Review and Meta-Analysis of the Impact of Surgical Approach and Associated Risk Factors

Background: Surgical site infections (SSIs) represent a noteworthy contributor to both morbidity and mortality in the context of patients who undergo colorectal surgery. Several risk factors have been identified; however, their relative significance remains uncertain. Methods: We conducted a meta-analysis of observational studies from their inception up until 2023 that investigated risk factors for SSIs in colorectal surgery. A random-effects model was used to pool the data and calculate the odds ratio (OR) and 95% confidence interval (CI) for each risk factor. Results: Our analysis included 26 studies with a total of 61,426 patients. The pooled results showed that male sex (OR = 1.45), body mass index (BMI) ≥ 25 kg/m2 (OR = 1.09), American Society of Anesthesiologists (ASA) score ≥ 3 (OR = 1.69), were all independent risk factors for SSIs in colorectal surgery. Conversely, laparoscopic surgery (OR = 0.70) was found to be a protective factor. Conclusions: The meta-analysis conducted revealed various risk factors, both modifiable and non-modifiable, associated with surgical site infections (SSIs) in colorectal surgery. These findings emphasize the significance of targeted interventions, including optimizing glycemic control, minimizing blood loss, and using laparoscopic techniques whenever feasible in order to decrease the occurrence of surgical site infections in this particular group of patients.

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.

Association of antimicrobial perioperative prophylaxis with cefuroxime plus metronidazole or amoxicillin/clavulanic acid and surgical site infections in colorectal surgery

ObjectiveTo compare intravenous (IV) amoxicillin/clavulanic acid (A/CA) to IV cefuroxime plus metronidazole (C + M) for preventing surgical site infections (SSI) in colorectal surgery.BackgroundGiven their spectra that include most Enterobacterales and anaerobes, C + M is commonly recommended as prophylaxis of SSI in colorectal surgery. A/CA offers good coverage of Enterobacterales and anaerobes as well, but, in contrast to C + M, it also includes Enterococcus faecalis which is also isolated from patients with SSI and could trigger anastomotic leakage.MethodsData from a Swiss SSI surveillance program were used to compare SSI rates after class II (clean contaminated) colorectal surgery between patients who received C + M and those who received A/CA. We employed multivariable logistic regression to adjust for potential confounders, along with propensity score matching to adjust for group imbalance.ResultsFrom 2009 to 2018, 27,922 patients from 127 hospitals were included. SSI was diagnosed in 3132 (11.2%): 278/1835 (15.1%) in those who received A/CA and 2854/26,087 (10.9%) in those who received C + M (p < 0.001). The crude OR for SSI in the A/CA group as compared to C + M was 1.45 [CI 95% 1.21–1.75]. The adjusted OR was 1.49 [1.24–1.78]. This finding persisted in a 1:1 propensity score matched cohort of 1835 patients pairs with an OR of 1.60 [1.28–2.00]. Other factors independently associated with SSI were an ASA score > 2, a longer duration of operation, and a reoperation for a non-infectious complication. Protective factors were female sex, older age, antibiotic prophylaxis received 60 to 30 min before surgery, elective operation, and endoscopic approach.ConclusionsDespite its activity against enterococci, A/CA was less effective than C + M for preventing SSI, suggesting that it should not be a first choice antibiotic prophylaxis for colorectal surgery.

Profilaktička i terapijska primena antibiotika u kolorektalnoj hirurgiji

Complications in colorectal surgery carry a high risk of morbidity and mortality, prolong hospitalization time and increase treatment costs, and the largest number of postoperative complications is related to surgical site infection (SSI). Antibiotic prophylaxis started in the fifties of the last century and changed with each new antibiotic. The following were used in order: aminoglycosides (1943), macrolides (1952), polymyxins (1958), and cephalosporins (1965). With the discovery of metronidazole in 1970, the prophylactic spectrum was extended to include anaerobic bacteria, which are an indispensable part of the flora in this anatomical region. Due to the nature of the gastrointestinal tract, it was believed that oral antibiotic prophylaxis and mechanical bowel preparation (MBP) could achieve intestinal sterilization and thus ensure a safe surgical intervention. However, studies have shown that MBP did not have an overall beneficial effect on postoperative complications and caused significant patient discomfort, so it was almost abandoned. Today, it is known that about 16% of surgical infections are caused by multiresistant bacteria, and only oral antibiotic prophylaxis is not sufficient to prevent these infections. Namely, in the race between bacterial resistance and the development of new antibiotics, antibiotics are increasingly lagging, and the treatment of complications remains a nightmare for surgeons. For this reason, the prevention of SSI in colorectal surgery is a challenge for 21st-century medicine. In modern surgery, both open and laparoscopic, the first and second generations of intravenous cephalosporins are most often used for prophylactic purposes, as antibiotics of a sufficiently broad spectrum, with favorable pharmacokinetics and rare side effects. New research indicates that in colorectal surgery, the combination of standard intravenous prophylaxis with the addition of an oral antimicrobial the day before surgery is superior when it comes to SSI prevention. However, there are still no clear recommendations on the regimen and type of antibiotics and they should be given in institutional guides and protocols, taking into account the bacterial spectrum in the local environment, as well as resistance, and the availability of appropriate drugs. Therapeutic use of antibiotics is reserved for acute conditions in colorectal surgery and its complications. For therapeutic purposes, more potent antibiotics are used against the expected pathogens, usually a combination of several antibiotics, such as third or fourth-generation cephalosporins, metronidazole, fluoroquinolones, or piperacillin/tazobactam and others. When it comes to the therapeutic use of antibiotics in colorectal surgery, research indicates that the most important thing is to recognize the infection in time and immediately start treatment, correct the therapy according to the causative agent, and also to stop the administration of antibiotics in time, to avoid unwanted complications and already advanced bacterial resistance.

Hospital context in surgical site infection following colorectal surgery: a multi-level logistic regression analysis

Surgical site infections (SSI) are associated with poor health outcomes. Their incidence is highest after colorectal surgery, with little improvement in recent years. The role of hospital characteristics is undetermined. Thus, our aim was to investigate whether SSI incidence after colorectal surgery varies between hospitals, and whether such variance may be explained by hospital characteristics. Data were retrieved from the electronic platform of the Directorate General of Health, from 2015 to 2019. Hospital characteristics were retrieved from publicly available data on the Portuguese public administration. Analysis considered a two-level hierarchical data structure, with individuals clustered in hospitals. To avoid overfitting, no models were built with more than one hospital characteristic. Cluster level associations are presented through median odds ratio (MOR) and intraclass cluster coefficient (ICC). Beta coefficients were used to assess the contextual effects. A total of 11 219 procedures from 18 hospitals were included. The incidence of SSI was 16.8%. The ICC for the null model was 0.09. Procedural variables explained 25% of the variance, and hospital dimension explained another 17%. Over 50% of SSI variance remains unaccounted for. After adjustment, heterogeneity between hospitals (MOR: 1.51, ICC: 0.05) was still found. No hospital characteristic was significantly associated with SSI. Procedural variables and hospital dimension explain almost half of SSI variance and should be taken into account when implementing prevention strategies. Future research should focus on compliance with preventive bundles and other process indicators in hospitals with significantly less SSI in colorectal surgery.

A Network Meta-Analysis and GRADE Assessment of the Effect of Preoperative Oral Antibiotics with and Without Mechanical Bowel Preparation on Surgical Site Infection Rate in Colorectal Surgery.

To compare the effect of different methods of bowel preparation on the incidence of surgical site infections (SSI), anastomotic leakage (AL), and mortality in patients undergoing elective colorectal surgery. Recent guidelines advise mechanical bowel preparation with oral antibiotics (MBP-OA) for the prevention of SSI in colorectal surgery. Recent trials suggest oral antibiotics (OA) alone may be sufficient. PubMed, MEDLINE, and Embase were searched from inception until 10-08-2021. We included randomized controlled trials (RCTs) comparing multiple methods of bowel preparation (mechanical bowel preparation [MBP], OA, MBP-OA, or no preparation) with regards to clinical outcomes such as incidence of SSI, AL, and mortality rates. A frequentist random-effects network meta-analysis was conducted to estimate the network effects of the different treatment options. We included 48 studies with 13,611 patients. Compared to no preparation, combined direct and indirect network estimates showed a relative risk (RR) for SSI of 0.57 (95% confidence interval [CI], 0.45-0.72) for MBP-OA, 0.68 (95% CI, 0.49-0.95) for OA, and 1.05 (95% CI, 0.87-1.26) for MBP. The RR for MBP-OA compared to OA was 0.84 (95% CI, 0.60-1.19); in sensitivity analysis of mainly laparoscopic procedures this effect of MBP-OA was more profound (RR, 0.56; 95% CI, 0.31-0.99). This network meta-analysis of RCTs finds that both mechanical bowel preparation with oral antibiotics and oral antibiotics alone are comparably effective in the prevention of SSI. The evidence is uncertain about the relative benefit of MBP-OA compared to OA alone. Therefore, it seems justified to use either of the 2 for the prevention of SSI in colorectal surgery.

Real-World Outcomes of Patients Undergoing Open Colorectal Surgery with Wound Closure Incorporating Triclosan-Coated Barbed Sutures: A Multi-Institution, Retrospective Database Study

PurposeOpen colorectal surgery is associated with a high rate of postoperative wound complications. This is a single-arm study of real-world outcomes of triclosan-coated barbed suture (Ethicon’s STRATAFIXTM Symmetric PDSTM Plus Knotless Tissue Control Device [SSPP]) used in open colorectal surgery.MethodsRetrospective cohort study using the Premier Healthcare Database. The study included patients who underwent an inpatient open colorectal surgery with wound closure using SSPP (size 0 or 1 to increase the likelihood the suture was used in fascia) between October 2015–September 2019 (N=593). Wound complications, hospital length of stay, total hospital costs (2019 US$), and all-cause readmissions post-discharge were measured. Post-hoc multivariable analyses compared wound complications between non-elective admissions and elective.ResultsThe overall incidence of wound complications within 30-days post-procedure was 7.1%, with the majority of those being surgical site infections (SSI) (6.0%). Mean operation time was 190 (standard deviation [SD]=64.4) mins, postoperative length of stay was 8.1 (SD=11.9) days, 30-day readmission rate was 11.8%, and total hospital costs were $31,693 (SD=$40,076). As compared with published literature on the rate of SSI in colorectal surgery, the 30-day rate of SSI in the present study (6.0%) fell within the range of 5.4% to 18.2% for open colorectal surgery and from 4.3% to 21.5% for combined open and minimally invasive procedures. Multivariable-adjusted incidence proportions of wound complications were slightly lower for non-elective admissions and did not differ significantly from those of elective admissions.ConclusionThe rate of wound complications observed in the present study falls within the range of rates previously reported in the literature, suggesting a safe and effective role for SSPP in open colorectal surgery. In post hoc analyses, the adjusted rate of wound complications was similar between non-elective and elective admissions. Head-to-head studies are required to determine comparative advantages or disadvantages for SSPP versus other sutures.

The use of an implemented infection prevention bundle reduces the incidence of surgical site infections after colorectal surgery: a retrospective single center analysis.

Surgical-site infections (SSIs) represent the most common complications after colorectal surgery (CS). Role of preoperative administration of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP), alone or in combination, in the prevention of SSIs after CS is debated. Aim of this study was to assess the effect of the introduction of an Implemented Infection Prevention Bundle (IIPB) in preventing SSIs in CS. A group of 251 patients (Group 1) who underwent CS receiving only preoperative intravenous antibiotic prophylaxis (IAP) was compared to a Group of 107 patients (Group 2) who also received the IIPB. The IIPB consisted of the combination of oral administrations of three doses of Rifaximin 400mg and MBP the day before surgery and in the administration of a cleansing enema the day of the surgical procedure. At the univariate analysis, Group 2 showed significant lower rates of wound infection (WI) (2.8% vs. 9.9%; p = 0.021) and anastomotic leakage (AL) (2.8% vs. 14.7%; p = 0.001) with shorter hospital stay (5 vs. 6days; p < 0.0001). The probability of postoperative AL was lower in Group 2; patients in this Group resulted protected from AL; a statistically significant Odds ratio of 0.16 (CI 0.05-0.55 p = 0.0034) was found. In diabetic patients, that were at higher risk of WI (OR 3.53, CI 1.49-8.35 p = 0.002), despite having any impact on anastomotic dehiscence, the use of IIPB significantly reduced the rate of WI (0% vs 28.1%; p = 0.01). The use of an IIPB significantly reduces rates of SSIs and post-operative hospital stay after CS.

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

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

Effect of Hyperoxygenation During Surgery on Surgical Site Infection in Colorectal Surgery.

PurposeDespite the use of different surgical methods, surgical site infection is still an important cause of mortality and morbidity in patients and imposes a considerable cost on the healthcare system. Administration of supplemental oxygen during surgery has been reported to reduce surgical site infection (SSI); however, that result is still controversial. This study was performed to evaluate the effect of hyperoxygenation during colorectal surgery on the incidence of wound infection.MethodsThis study was a prospective double-blind case-control study. The main aim of the study was to evaluate the effect of hyperoxygenation during colorectal surgery on the incidence of SSI. Also, secondary outcomes, such as atelectasis, pneumonia, respiratory failure, length of hospital stay, and required hospitalization in the intensive care unit were evaluated.ResultsSSI was recorded in 2 patients (2 of 40, 5%) in the hyperoxygenation group (FiO2 80%) and 6 patients (6 of 40, 15%) in the control group (FiO2 30%) (P < 0.05). Time of hospitalization was 6 ± 6.4 days in the hyperoxygenation group and 9.2 ± 2.4 days in the control group (P < 0.05).ConclusionThis study showed a positive effect of hyperoxygenation in reducing SSI in colorectal surgery, especially surgery in an emergency setting. When the low risk, low cost, and effectiveness of this method in patients undergoing a laparotomy are considered, it is recommended for all patients undergoing colorectal surgery.

Impact of a Novel Surgical Wound Protection Device on Observed versus Expected Surgical Site Infection Rates after Colectomy Using the National Surgical Quality Improvement Program Risk Calculator.

Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. A novel surgical device that combines barrier surgical wound protection and continuous surgical wound irrigation was evaluated in a cohort of elective colorectal surgery patients. A retrospective analysis was performed comparing rates of SSI observed in a prospective cohort study with the predicted rate of SSI using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Risk Calculator. A prospective multi-center study of colectomy patients was conducted using a study device for surgical site retraction and protection, as well as irrigation of the incision. Patients were followed for 30 days after the surgical procedure to assess for SSI. After completion of the study, patients' characteristics were inserted into the ACS-NSQIP Risk Calculator to determine the predicted rate of SSI for the given patient population and compared with the observed rate in the study. A total of 108 subjects were enrolled in the study. The observed rate of SSI in the prospective study using the novel device was 3.7% (4/108). The predicted rate of SSI in the same patient population utilizing the ACS-NSQIP Risk Calculator was estimated to be 9.5%. This demonstrated a 61% difference (3.7% vs. 9.5%, p = 0.04) in SSI from the NSQIP predicted rate with the use of the irrigating surgical wound protection and retraction device. These data suggest the use of a novel surgical wound protection device seems to reduce the rate of SSIs in colorectal surgery.

Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery.

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections (SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Surgical site infection after colorectal surgery according to the main anesthetic agent: a retrospective comparison between volatile anesthetics and propofol.

BackgroundAnesthetic agents used for general anesthesia are emerging possible influential factors for surgical site infection (SSI). In this retrospective study, we evaluated the incidence of SSI after colorectal surgery according to the main anesthetic agents: volatile anesthetics vs. propofol.MethodsA total 1,934 adult patients, who underwent elective colorectal surgery under general anesthesia between January 2011 and December 2013, were surveyed to evaluate the incidence of SSI: 1,519 using volatile anesthetics and 415 using propofol for main anesthetic agents. Patient, surgery, and anesthesia-related factors were investigated from all patients. Propensity-score matching was performed to reduce the risk of confounding and produced 390 patients in each group.ResultsWithin the propensity-score matched groups, the incidence of SSI was higher in the volatile group compared with the propofol group (10 [2.6%] vs. 2 [0.5%], OR = 5.0 [95% CI = 1.1-2.8]). C-reactive protein was higher in the volatile group than in the propofol group (8.4 ± 5.6 vs. 7.1 ± 5.3 mg/dl, P = 0.001), and postoperative white blood cells count was higher in the volatile group than in the propofol group (9.2 ± 3.2 × 103/µl vs. 8.6 ± 3.4 × 103/µl, P = 0.041).ConclusionsThe results of this study suggest that intravenous anesthesia may have beneficial effects for reducing SSI in colorectal surgery compared to volatile anesthesia.

Meta-analysis of local gentamicin for prophylaxis of surgical site infections in colorectal surgery.

Surgical site infections (SSIs) following colorectal surgery is common, and local application of gentamicin for SSIs in the surgery remains controversial. To identify whether local application of gentamicin reduces incidence of SSIs in colorectal surgery. PubMed, Embase, the Cochrane Library, and Science Citation Index were searched for relevant randomized controlled trials (RCTs) and reference list up to November 2014. Two independent reviewers screened the records from the electronic databases, selected relevant studies, assessed the methodological quality, and extracted the data from included articles. Stata 12.0 was used to conduct a pooled analysis for main outcomes. Eight relevant randomized controlled trials with a total of 1685 patients were included in the meta-analysis. All included studies were of moderate to high quality by the Cochrane Collaboration's tool for assessing risk of bias. There was no significant difference being found in the total pooled results for wound infection (relative risk (RR) 0.73, 95% confidence interval (CI) 0.47 to 1.12) and organ space infection (RR 0.90, 95% CI 0.51 to 1.59). However, subgroup analysis showed that the significant decrease of wound infection was associated with the population in the Western Europe (RR 0.60, 95% CI 0.42 to 0.87) and follow-up periods of 30 days (RR 0.63, 95% CI 0.42 to 0.94). Local application of gentamicin significantly reduced incidence of wound infection following colorectal surgery in Western Europe, and it was also associated with lower risk of wound infection during follow-up period of 30 days. However, its effectiveness on prophylaxis of perineal wound infection and organ space infection still lacked evidence.

PTU-236 Surgical site infection (SSI) rates in colorectal surgery: room for improvement: Abstract PTU-236 Table 1

<h3>Introduction</h3> SSI in colorectal surgery is a major cause of morbidity and is poorly recorded in clinical practice. We had a high rate of wound infection in our unit and therefore over a four year period we worked as a multidisciplinary group which included colorectal surgeons, infection control / surveillance nurses, microbiologists, theatre nurses and ward nurses to reduce our SSI rate in major elective colorectal surgery. We envisaged that we could reduce our wound infection rate but recognised that deep and organ space infection would remain unchanged, as these are related to anastomotic failure, which would not be altered by this work. Our aim, therefore, was to use quality improvement methodology to change our SSI rates. <h3>Method</h3> We formed a core team –the collaborative who met monthly. Using the model for improvement we set an aim- to reduce colorectal SSI in elective patients by 50% by June 2014. We looked at the evidence to determine changes we would make and we collected data weekly on all elective colorectal patients. Independent to the surgical team, infection surveillance staff monitored colorectal patients’ wounds and identified patients with in hospital and readmission wound infections, within 30 days of surgery (using standard national definitions of SSI). Based on the available evidence we introduced several changes over this quality improvement project: designed dedicated data collection forms written pre-op advice to patients clippers used for immediate hair removal changed to 2% chlorhexedine skin preparation introduced specific closing trays and limited redraping standardised wound dressing and its management, reviewed prophylactic antibiotic cover standardised prophylactic antibiotics and ensured repeat administration in long procedures and where there was excessive blood loss ensured tight glyacemic control in diabetic patients and strove for normothermia Using the model for improvement ensured reliability of all of our processes in the work detailed above and enabled us to maintain success <h3>Results</h3> Three of the four consultant colorectal surgeons were in post for the whole time period and all of their major elective colorectal patients are included. For the calendar years 2012 to 2014 our collective infection rates are shown in the Table 1. We achieved our aim of reducing colorectal SSI by 50%. <h3>Conclusion</h3> By engaging the multidisciplinary team and explaining what we wanted to achieve; we were able to consistently apply the evidence base and substantially lower wound infection rates in elective colorectal surgery. Our next priority in this work is ensure that all of the processes underpinning this reduction are reliable and will continue in perpetuity. <h3>Disclosure of interest</h3> None Declared.

Efforts to Prevent Surgical Site Infection After Colorectal Surgery.

See Article on Page 235-242 A surgical-site infection (SSI) is one of the most interesting issues among surgeons and is the second most frequent nosocomial infection (20%) after urinary tract infection (36%) [1]. The severity of a SSI can vary from trivial to very significant as it can be highly associated with morbidity and mortality. It can also increase the clinical and financial burden because affected patients will need to undergo longer hospitalizations [2]. The causes of SSIs have been considered to be related to three factors: the patient, the contaminating organisms, and the operative procedure [3,4,5]. The patient-related factors, the most important factors in the development of SSIs [6], include old age, immunocompromised condition, and comorbidity such as cirrhosis, diabetes, chronic obstructive pulmonary disease, and cancer [3,5,6,7,8]. The contaminating organisms isolated from SSIs are expected to have originated from the patient's endogenous flora. They will be polymicrobial if the procedure involves opening the colon or rectum [3]. The procedure-related factors consist of inadequate skin preparation, poor preoperative shaving, a long duration of surgery, inadequate ventilation of the operating room, and massive tissue trauma [3,5,7,9,10,11]. In colorectal surgery, surgeons especially give more attention to taking care of the surgical site to avoid infection because wounds of opened viscus organs, such as the colon and the rectum, are considered a clean-contaminated wound, even though the surgery is performed without contamination. A clean wound, in general, is not related with a SSI. Furthermore, fecal contamination and bacterial translocation during the colorectal surgery can cause a postoperative infection and increase the morbidity and mortality. These unpleasant SSIs can be prevented by using several processes, including preoperative skin antisepsis, maintenance of normothermia during surgery, appropriate hair removal, use of a wound protector, and administration of prophylactic antibiotics (PAs). Particularly, in colorectal surgery, the traditional regimens to prevent SSIs are prolonged fasting, bowel preparation, and antibiotic prophylaxis. Because PAs have reduced the incidence of SSIs in colorectal surgery, the colon surgery guidelines recommend that PAs be administered perioperatively [12]. The U.S. Food and Drug Administration approved second-generation cephalosporin monotherapy or a combination of first-generation cephalosporin with metronidazole or ampicillin-sulbactam as PAs for colorectal surgery. However, although previous studies recommended that the duration of prophylaxis be within 24 hours after surgery and showed that long-term prophylaxis was not useful for reducing the wound infection rate [13,14], the current practices in Korea tend to administer different combinations and to use different durations of PAs in different hospitals [15]. The abuse of antibiotics is well known to increase resistance to the antibiotic; in fact, the number of SSIs caused by antibiotic-resistant bacteria and fungi is on the rise [3,11,16,17], which is the reason continuous research for preventing SSIs has been emphasized. For better results, a national consensus for SSI prevention should be reached at the government level in Korea. The American College of Surgeons National Surgical Quality Improvement Program is a national program in the United States to measure surgical outcomes in order to improve surgical care. It has constructed a surgery-related database that has been nationally validated [18]. In Korea, the Korean Nosocomial Infections Surveillance System (KONIS) was established in 2006 [19]. This system uses the KONIS Web-based Reporting and Analysis Program provided by voluntary participation of hospitals for the collection and sharing of SSI data. Recently, KONIS has tried to involve more hospitals and to make a qualified database. This continuous effort is instrumental if the incidence rate of SSIs is to be decreased, which would also decrease the financial burden of health care and increase the quality of surgical outcomes.

Silver-based dressings for the reduction of surgical site infection: Review of current experience and recommendation for future studies

Surgical site infections (SSIs) are the most common hospital acquired infection in surgical patients, occurring in approximately 300,000–500,000 patients a year. SSIs occur across all surgical specialties, but have increased importance in abdominal, colorectal, obstetrical, gynecological, cardiac, vascular, neurological, transplant, and orthopedic procedures where either the inherent risk is elevated or the consequence of an infection would be severe. Current prevention guidelines reduce, but do not completely eliminate, the occurrence of SSIs. We have found the use of silver-nylon wound dressings to significantly reduce the risk SSI associated with colorectal surgery. In this review, we examine the incidence of SSI in high-risk groups, and identify procedures where silver dressings, and other silver products, have been evaluated for the prevention of SSI.Silver-nylon dressings are a useful adjunct in the prevention of SSI in colorectal surgery, neurological surgery, spinal surgery, and certain cardiovascular and orthopedic procedures. Gynecologic, obstetric, breast, transplant, neck, and bariatric procedures, and surgery in obese and diabetic patients, represent other areas where patients are at increased risk of SSI, but in which silver dressings have not been adequately evaluated yet. Recommendation is made for large prospective studies of silver dressings in these populations.

Surveillance of surgical site infections in elective colorectal surgery. Results of the VINCat Program (2007–2010)

The VINCat Program is a standardized surveillance program of healthcare infections in Catalonia, Spain. This program includes monitoring of surgical site infections (SSI) of elective colorectal surgery. The aim of this study was to define SSI rates in colorectal surgery among VINCat hospitals over a period of 4 years.We included consecutive elective colorectal interventions performed in VINCat hospitals from 2007 to 2010. Follow-up visits were performed 30 days after surgery. Prospective monitoring of SSI in colorectal surgery was performed according to standardized VINCat methodology. SSI was defined according to the Centers for Disease Control (CDC) and surgical risk factors according to the National Healthcare Safety Network (NHSN) classification.From 2007 to 2010, 49 centers performed 10,104 surgical procedures. The cumulative incidence of SSI was 20.8% (95% CI: 20.03–21.63). The annual cumulative SSI incidence rate did not vary significantly over the study period; however, there were significant differences among hospital infection rates. The relative frequency of organ-space infection increased from 25% in 2007 to 40% in 2010 (p<0.001). Laparoscopic surgery also increased (28% in 2007 to 42% in 2010, p<0.001). However, no changes were observed in mean surgery duration, ASA score and degree of surgical contamination.The VINCat Program incorporated a large number of Catalan hospitals that participated in standardized monitoring of colorectal surgery. The cumulative incidence rate of SSI for colorectal surgery was 20.8%, although there were large variations between hospitals.

Ring drape do not protect against surgical site infections in colorectal surgery: a randomised controlled study

Surgical site infections (SSIs) remain a major problem in colorectal surgery. In this prospective, randomised study, we compared two kinds of wound protection, namely, "plastic ring drape" versus "standard cloth towels". One hundred one patients were randomised to the control group (wet cloth towels) and 98 to the study cohort (ring drape). SSIs were classified according to Centers for Disease Control and Prevention recommendations. In the control group, 30 patients had an SSI, whereas 20 did so in the study group. This difference was not significant (p = 0.131). Plastic ring drape for wound protection does not guard against SSIs in colorectal surgery.