Surgical Site Infection Prevention Measures Research Articles

SP1.5 - PRESS survey: PREvention of surgical site infection—a global pan-specialty survey of practice

Abstract Aims This survey aimed to establish current global practice across surgical subspecialties in the prevention of surgical site infection (SSI). Methodology A cross-sectional survey was formulated following a published protocol, aligning with established global guidelines for SSI prevention. A panel of experts provided guidance during iterative rounds of internal validation, incorporating consensus-based modifications. Prior to online dissemination via QualtricsXM link and QR code through international surgical societies, the survey underwent final external validation. Recruitment strategies were through international societies, snowballing and social media. Findings There were 1232 responses from 97 countries, with 698(56.7%) participants completing all inquiries. Responses were primarily provided by consultants or equivalent (766,75.2%), spanning all ten Royal College of Surgeons-recognised subspecialties. A significant majority (786/889,88.4%) routinely employs clinical examination for SSI diagnosis, while one-third (305/889,34.3%) never use the CDC criteria. Regarding surgical field preparation, less than half regularly use alcoholic povidone-iodine (339/778,43.6%) or chlorhexidine gluconate (370/778,47.6%). However, approximately one-third often or always use aqueous (478/1556,30.7%) or alcoholic (454/1556,29.2%) solutions for hand scrub. Surgeons exhibit a higher likelihood of changing gloves (614/734,83.7%) than instruments (513/734,69.9%) to facilitate clean skin closure. Most UK surgeons (181/206,87.9%) express equipoise in randomising patients for interventions in a potential platform trial evaluating SSI prevention. Conclusions Significant diversity characterizes global and subspecialty-specific practices in various SSI prevention measures, attributable to conflicting guidance and limited evidentiary support for recommendations. Encouragingly, a substantial number of surgeons express readiness to contribute to a robust evidence base through participation in potential platform trials for SSI prevention.

PRESS survey: PREvention of surgical site infection-a global pan-specialty survey of practice protocol.

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices. This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses. Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Compliance with surgical site infection prevention measures in hospitals

Objective: To assess compliance with actions for surgical site infection prevention and control, adopted in clinical practice in accordance with the recommendations proposed by the World Health Organization: auditing the moment of antibiotic administration, trichotomy with an electric clipper/disposable blade, material sterility confirmation, and surveillance and dissemination of surgical site infection rates. Methods: This is a cross-sectional observational study, carried out in 30 hospitals in the state of Minas Gerais, from February 2018 to April 2019, based on an audit of a surgical procedure, situational diagnosis and interview with Hospital Infection Control Services. Results In 93.3% of Hospital Infection Control Services, protocols for prophylactic antibiotic use and compliance audits were reported, 69% reported trichotomy with an electric clipper. All carried out surgical site infection surveillance, however, only 63.3% carried out rate disclosure. In the situational diagnosis, trichotomy was performed in 76.7% inside the operating room with an electric clipper (56.7%). In the audit of the moment of antimicrobial administration between 30-60 minutes before surgical incision, compliance was identified in 63.3%; 93.3% of services confirmed material sterility through process indicators. Conclusion: Differences were found between recommendations from the Hospital Infection Control Service and compliance with good practices during situational diagnosis and auditing of surgical procedures, reinforcing the need for training and audits aimed at effectively complying with professionals’ practices regarding such measures.

Prospective compliance assessment of surgical site infection prevention measures in colorectal surgery

Prospective compliance assessment of surgical site infection prevention measures in colorectal surgery

Age as a risk factor for surgical site infections: German surveillance data on total hip replacement and total knee replacement procedures 2009 to 2018.

BackgroundOlder age is frequently cited as a risk factor for healthcare-associated infections in general, and surgical site infections (SSIs) specifically.AimWe aimed to investigate the correlation between age and SSI occurrence.MethodsData on total hip replacement (THR) and total knee replacement (TKR) surgeries and resulting SSIs documented in the German national surveillance network from a 10-year period from 2009 to 2018 were selected for analysis. SSI rates and adjusted odds ratios (AOR) were calculated and a multivariable analysis to determine risk factors for SSI occurrence was conducted.ResultsA total of 418,312 THR procedures resulting in 3,231 SSIs, and 286,074 TKR procedures with 1,288 SSIs were included in the analyses. For THR, SSI rates were higher in older age groups when compared with the reference age group of 61-65 years. A significantly higher risk was observed in the 76-80 years age group (AOR: 1.21, 95% CI: 1.05-1.4). An age of ≤ 50 years was associated with a significantly lower SSI risk (AOR: 0.64, 95% CI: 0.52-0.8). For TKR, a similar correlation was observed, with the exception of the youngest age group (≤ 52 years), which was shown to have an SSI risk equal to that of the knee prosthesis reference age group (78-82 years).ConclusionA strong correlation between increasing age and SSI occurrence was observed for both procedure types. The results of our analyses provide a basis to consider future targeted SSI prevention measures for different age groups.

A Simple Infection Prevention 'Bundle' Including Preoperative Bath With Hair-Wash to Reduce Surgical Site Infection (SSI) Following Elective Caesarean and Gynaecological Surgery in India.

ABSTRACTBackground:Surgical site infections (SSIs) may be reduced by following SSI prevention measures. We assessed the SSI rate following caesarean section (CS) and gynaecologic surgery after implementing a simple SSI prevention bundle including preoperative bath and hair washMethods:The study was carried out in two hospitals in North India (Post Graduate Institute of Medical Education and Research [PGIMER] and Civil Hospital CH) from August 2018 to July 2019. The SSI rate during intervention period (9 months) was compared with baseline rate (3 months). Womens’ knowledge about SSI was assessed preoperatively and after counselling, postoperativelyResults:The baseline SSI rate after CS (n = 165) was 11.1% at PGIMER and 8.5% at CH. After gynae surgery (n = 172), it was 13% at PGIMER and 11.5% at CH. During intervention, (CS = 585, gynae surgery = 503), SSI rate was reduced significantly at PGIMER (CS: 11.1% to 3.7%, P = 0.048; gynae surgery: 13% to 7.1%, P = 0.027), but not at CH (CS: 8.5% to 8.2%, P = 0.903; gynae surgery: 11.5% to 11.4%, P = 0.984). Three measures were followed more often at PGIMER than at CH: before CS, bath with hair-wash: 99.3% vs 78.5%, P = 0.00, hair-clipper vs razor: 100% vs 5.1%, P = 0.00 and antibiotic prophylaxis ≤120 min: 100% vs 92.4%, P = 0.00; and before gynae surgery, bath with hair-wash: 93.2% vs 71%, P = 0.00, hair-clipper vs razor: 93.6% vs 1.9%, P = 0.00 and antibiotic prophylaxis ≤120 min: 100% vs 80.8%, P = 0.00. Postoperatively, womens’ knowledge about SSI prevention improved significantly at the two sitesConclusion:The reduction in SSI at PGIMER was attributed to better compliance to SSI prevention measures listed above. Counselling women about simple SSI prevention method like preoperative bath with scalp hair wash increased their knowledge about these significantly.

Incidence and risk factors associated with surgical site infection following cesarian section at Kibungo Referral Hospital, Rwanda – A prospective cohort study

Introduction: Cesarian section (CS) is lifesaving both for the mother and the baby. Worldwide, there has been an increase in the incidence of CS. However, complications may arise postoperatively for both mother and newborn. Our aim was to determine the incidence rate of post-CS surgical site infection (SSI), identify factors associated with SSI, and identify the most frequent microorganisms associated with the presence of post-CS SSI.Methods: This is a prospective cohort study conducted at KRH, including all CS, performed from February to April 2020. Patient’s demographics, operative management, and outcomes were analyzed. Results: A total of 201 patients aged between 15 to 47 years were operated on and 3.48% developed SSI. 90% were from Ngoma district, 47% had secondary education followed by 36% with primary education. The majority (97%) had no comorbidities. Povidone and chlorhexidine combined was the most commonly used disinfectant. 53% were emergencies and 92% of CS were performed by general practitioners. The average duration of operation was between 30 to 45minutes. Showering prior to operation (RR=0.39) at 95% CI [0.005-0.29], not shaving 30 minutes prior to incision (RR: 25.5) at 95% CI [3.5-18.7] and use of both povidone and chlorhexidine for skin preparation (RR= 0.15) at 95% CI [0.1-1.6] are associated with reduced risk of developing SSI. Obstructed labor/dystocia ((RR=4.55) at 95%, CI [1.6-45.4]) increases the infection risk. Staphylococcus aureus was the most frequently isolated microorganism in post-CS SSI patients.Conclusion: Active hospital infection services and adherence to evidence-based guidelines for SSI prevention measures would reduce the post-CS SSI incidence rate and improve patient care.

Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital

Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures. We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital. We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners. A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease. With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.

How Do Safety Climate Ratings Relate to Attitudes Towards and Knowledge About Surgical Site Infection Prevention Measures?

Group Name: Watussi Study GroupBackground: A positive safety climate is an important precursor of safe care outcomes. However, only limited evidence supports the association of low surgical-site infection (SSI) rates and positive safety climate. We investigated the role that perceptions of SSI prevention measures play for both safety climate level and strength as a subjective norm, that is, the social pressure perceived to perform the prevention measures, commitment to observe SSI prevention measures despite other situational pressures, and the level of knowledge about the prevention measures. Methods: The safety climate scale of the Safety Attitudes Questionnaire and 3 scales assessing subjective norm, commitment, and knowledge were used. All items were translated and retranslated from German to French and to Italian. All translated scales were pretested for understandability. Operating room (OR) personnel in 54 Swiss acute-care hospitals were surveyed, resulting in 2,769 analyzed responses with data aggregated on the hospital level. Two regression analyses were conducted: one using the percentage of positive responses per hospital as a safety climate level indicator, and another using the standard deviation of the safety climate ratings per hospital as a safety climate strength indicator. As independent variables, the hospital means of subjective norm, commitment, and knowledge were investigated and appropriately adjusted for number of respondents and sample composition. Results: The sample consisted of 1,495 nurses (54%) and 1,101 physicians (40%). Commitment and subjective norm were significant predictors (p < 0.001 and p < .05, respectively) of safety climate level, in the expected positive direction, but KNOW was not (R2, adjusted: 0.48); for safety climate strength, only COM was significant p < 0.001 (R2, adjusted: 0.27). Conclusions: The extent to which OR personnel were committed to perform the measures, such as timely administration of antibiotics, was associated with their safety climate rating level and strength. Thus, the rather general safety climate assessments are related to more specific safety behaviors necessary to achieve good outcomes such as low infection rates. Subjective norm was related to safety climate level only, indicating that in work environments with a good safety climate, the perceived social pressure to adhere to infection prevention measures may be higher. Knowledge about SSI prevention had no significant impact on safety climate, pointing to future research regarding the role of education in implementing prevention measures. Investigating how attitudes and knowledge about measures to prevent specific patient safety outcomes furthers our understanding of the role of safety climate in patient safety improvement.Funding: NoDisclosures: None

Current practices and evaluation of barriers and facilitators to surgical site infection prevention measures in Jimma, Ethiopia.

Surgical site infections (SSIs) greatly burden healthcare systems around the world, particularly in low- and middle-income countries. We sought to employ the Systems Engineering Initiative for Patient Safety (SEIPS) model to better characterize SSI prevention practices and factors affecting adherence to prevention guidelines at Jimma University Medical Center (JUMC). Our cross-sectional study consisted of semistructured interviews designed to elicit perceptions of and barriers and facilitators to SSI prevention among surgical staff and observations of current preoperative, perioperative, and postoperative SSI prevention practices in surgical cases. Interviews were recorded, manually transcribed, and thematically coded within the SEIPS framework. Trained observers recorded compliance with the World Health Organization's SSI prevention recommendations. A tertiary-care hospital in Jimma, Ethiopia. Surgical nurses, surgeons, and anesthetists at JUMC. Within 16 individual and group interviews, participants cited multiple barriers to SSI prevention including shortages of water and antiseptic materials, lack of clear SSI guidelines and training, minimal Infection Prevention Control (IPC) interaction with surgical staff, and poor SSI tracking. Observations from nineteen surgical cases revealed high compliance with antibiotic prophylaxis (94.7%), hand scrubbing (100%), sterile gloves and instrument use (100%), incision site sterilization (100%), and use of surgical safety checklist (94.7%) but lower compliance with preoperative bathing (26.3%), MRSA screening (0%), and pre- and postoperative glucose (0%, 10.5%) and temperature (57.9%, 47.3%) monitoring. Utilizing the SEIPS model helped identify institution-specific barriers and facilitators that can inform targeted interventions to increase compliance with currently underperformed SSI prevention practices at JUMC.

Increase in surgical site infections caused by gram-negative bacteria in warmer temperatures: Results from a retrospective observational study.

Surgical site infections (SSIs) occur more frequently during periods of warmer temperatures. We aimed to investigate for which pathogens this association is particularly strong. A retrospective observational study was conducted. Data from the SSI-module of the German nosocomial infection surveillance system between 2000 and 2016 were linked with data from the German Meteorological Service. Patient- and procedure-related data were associated with monthly aggregated meteorological data. Due to high correlation with other meteorological parameters, we focused on the outside temperature. Adjusted odds ratios were calculated for SSI rates relating to temperature. SSIs were stratified by pathogen. A P value of <.05 was considered significant. Altogether, 2,004,793 procedures resulting in 32,118 SSIs were included. Generally, warmer temperatures were associated with a higher SSI risk, especially for SSIs with gram-negative pathogens. This association was particularly prominent for Acinetobacter spp, Pseudomonas aeruginosa, and certain Enterobacteriaceae. Per additional 1°C, we observed a 6% increase in the SSI risk for Acinetobacter spp and a 4% increase for Enterobacter spp. Superficial SSIs with Acinetobacter spp were 10 times more likely to occur when comparing surgeries in months with mean temperatures of ≥20°C to mean temperatures of <5°C. Higher temperatures were associated with increased SSI rates caused by gram-negative bacteria. Future SSI prevention measures should consider this aspect. Underlying shifts in microbiome composition due to climate factors should be included in further analyses. Given the expected rise of global temperatures until the end of the century, this topic has relevance from multiple perspectives.

Operating Room Nurses’ Knowledge of Surgical Site Infection Prevention Measures

Background: Surgical site infection (SSI) stands out among healthcare-related infections as one of the most important globally due to its associated morbidity and mortality. However, it is well known that the transoperative period is recognized as one of the most critical moments for the prevention of SSI. Objective: We evaluated the knowledge of the operating room (OR) nurse coordinators regarding SSI prevention measures. Methods: We conducted a cross-sectional study in 30 large hospitals in the state of Minas Gerais, Brazil, from February 2018 to April 2019. Data were collected through interviews with OR nurse coordinators. Results: Administration time of prophylactic antibiotic administered between 30 and 60 minutes prior to surgery was reported by 84% of the professionals and the suspension of this agent in the first 24 hours was reported by 47.8%. Preoperative hair removal within the operating room was mentioned by 60% of respondents and 36.7% mentioned using a razor. The Safe Surgery program of the WHO was unknown to 6.7% of nurses. Among those who knew about it, 20.8% stated that there was no surgical site demarcation. Presentation of the surgical team occurred before the beginning of the procedure in only 53.3% of the institutions. Patient surveillance for SSI was reported by 93.3% of respondents, but the criteria adopted for the diagnosis of SSI were unknown, even though SSI rates were given for 90% of services, predominantly via meetings (53.5%). Conclusions: The knowledge of nurses related to the prevention of SSI was not satisfactory, pointing to the need for immediate efforts in education and awareness programs. Such programs may facilitate changes in practice through the recognition of surgical patient risk by these professionals, thus leading to better planning and practice during the trans-operative period.Funding: NoneDisclosures: None

Surgical Site Infection Prevention: An Analysis of Compliance With Good Practice in Large Hospitals

Background: Surgical site infection (SSI) is considered one of the most frequent adverse events globally. One of the strategies to mitigate its occurrence was proposed by the WHO in 2008 as part of the Safe Surgery Saves Lives program to reduce the rate of SSI by 25% by 2020. Objectives: To evaluate adherence to SSI prevention and control actions in large hospitals using a score. Methods: This cross-sectional study was conducted in 30 hospitals in Minas Gerais, Brazil, from February 2018 to April 2019. Data collection was performed through interviews with the coordinator of the hospital infection control service (HICS), situational diagnoses, and observation of a surgical procedures at the time of the visit. Data were analyzed using SPSS software. The variables were described using descriptive statistics. The project was approved by the Research Ethics Committee of the Federal University of Minas Gerais (COEP/UFMG) (CAAE: 30782614.3.00005149). A score was determined to identify the degree of compliance of institutions to SSI prevention practices. Results: In 93.3% of the HICSs, routines or protocols for the use of prophylactic antibiotic in surgery and compliance audits were mentioned, 69% reported hair removal with a clipper. SSI surveillance occurred in all institutions; however, only 63.3% disclosed SSI rates. In the situational observations, 60% of the professionals performed hand antisepsis within 3–5 minutes. Most frequently, hair removal was performed inside the operating room in 76.7% of the observed procedures and an electric clipper was used 56.7% of the time. In the surgery audit, prophylactic antimicrobial administration occurred between 30 and 60 minutes before surgical incision in only 63.3% of the observed procedures. The traffic in the operation room was limited to the necessary minimum in only 53.3% of observed procedures and unnecessary opening of the doors occurred in 76.7% of the observations. Patient temperature was not monitored in 70% of the audited procedures. Conclusions: According to the proposed score, 1 of the institutions (3.3%) complied with SSI prevention and control measures sufficiently; 25 complied partially (83.3%); and 4 (13.3%) demonstrated poor compliance.Funding: NoneDisclosures: None

Clinicians perception and assessment of risk factors for surgical site infections in small animal practice in South-West, Nigeria

This study evaluated the prevalence of Surgical Site Infections (SSIs), the enhancing risk factors in small animal hospitals and clinics, and clinicians’ perception of SSIs in South-west, Nigeria. Ten years (2007-2017) surgical patients’ case records from four government veterinary hospitals were initially studied. Fifty-seven copies of structured pre-tested questionnaires were further administered to practice representatives in government and private small animal facilities in 6 states of South-West, Nigeria. Data were analyzed with descriptive statistics and Pearson Chi-square at 95% confidence intervals. One hundred and twenty-six out of 584 small animal surgical patients satisfied the inclusion criteria. Eight (6.3%) cases from the case records had SSIs. Fifty out of 57 retrieved questionnaires satisfied the inclusion criteria for analysis. Sixty-four percent of respondents had the Doctor of Veterinary Medicine (DVM) degree while 36% had additional degrees. The majority (64%) of respondents had 1 to 3 years practice experience with the rest having above 3 years. Most of the respondents (96%) had good knowledge of SSI, 78.7% usually manage SSI cases and 18% had lost patients due to SSIs. Only 48% of the practices perform surgery in designated operating rooms. The environment (94%), hands of clinicians/caregiver (80%) and patients’ skin (62%) were the main sources of SSIs in respondents’ practice. Few respondents (19.1%) administer prophylactic antibiotics for all surgeries, 6.1% discontinue within 24 h post-surgery, while 75.5% continue antibiotic therapy for 3 to 7 days post-surgery. Lack of facilities (40%) and funds (54%) prevented some clinicians from keeping up with SSIs prevention measures. There was an association between the risk factors of post-operative wound dehiscence (P=0.006), classification of the surgical procedures (P=0.032) and SSI occurrence. Although many small animal practitioners are aware of SSIs risk factors, only few adhere to prevention protocols. Key words: Surgical site infection (SSI), risk factors, small animal clinicians, perception.

Is virtual reality effective to teach prevention of surgical site infections in the operating room? study protocol for a randomised controlled multicentre trial entitled VIP Room study

IntroductionSome surgical site infections (SSI) could be prevented by following adequate infection prevention and control (IPC) measures. Poor compliance with IPC measures often occurs due to knowledge gaps and insufficient...

Surgical Site Infection Prevention Measures in General Surgery: Position Statement by the Surgical Infections Division of the Spanish Association of Surgery

Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30–60min before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.

Caracterização das infecções de sítio cirúrgico em um hospital público de ensino na cidade de Cascavel, Paraná

Introduction: Surgical Site Infection (SSI) is one of the major Health Care-Related Infections (HAI) and a persistent problem in the hospital setting. Objective: To characterize SSI in a public teaching hospital located in the city of Cascavel-PR. Method: cross-sectional retrospective study of documentary source and quantitative approach. The SSIs notified from May 2017 to May 2018 were analyzed. The variables of interest were tabulated and submitted to descriptive statistical analysis. Results: there were 5,169 surgical procedures in the period, with 196 (100%) cases of SSI. Of these, there was a predominance in young adults aged between 21 and 40 years (39.3%). The specialty of Gynecology / Obstetrics (30.1%) and General Surgery (29.1%) presented the highest rates of SSI, most frequently in Potentially Contaminated surgeries (53.1%); with superficial incisional SSI (59.7%); and with clinical confirmation criteria (79.1%). Regarding the microorganisms isolated in the cultures, Pseudomonas aeruginosa (16.7%) and Enterococcus spp (16.7%) stood out. Conclusions: It is noted that there is a need to review SSI prevention measures, especially due to the proportion of clean surgeries that developed the adverse event. However, considering the values reported in the literature, the overall rate of SSI was discrete.

Implementing antimicrobial stewardship to reduce surgical site infections: Experience and challenges from two tertiary-care hospitals in Mumbai, India.

Surgical site infections (SSIs) contribute significantly to post-surgical morbidity globally. Antimicrobial stewardship programmes (ASPs) are essential to reduce SSI rates and to curb antimicrobial resistance, especially in low-and-middle-income countries. This prospective study aimed to show the reproducibility of ASP implementation and SSI prevention measures in a semi-private institution with high perioperative prophylactic antimicrobial consumption beyond guidelines. The prevalence of SSIs in clean surgeries was analysed in a government hospital adhering to SSI prevention guidelines including antimicrobial prophylaxis (phase 1; n=335) and in a surgical department unit of a semi-private hospital where the same guidelines were subsequently implemented (phase 2; n=235). SSI rates were compared to check the hypothesis that ASPs and infection control policies are reproducible with similar SSI rates. Moreover, antimicrobial prophylaxis costs were compared between units with and without guideline adherence. Among a total of 570 clean surgeries analysed, SSI rates were similar in both phases (6.0% vs. 5.1%; P=0.659). SSI rates were higher in patients aged >50 years in both phases (P=0.0009 and 0.045), whilst there was no difference in SSI rates between diabetics and non-diabetics (P=0.475 and 0.835). The cost of antimicrobial prophylaxis was lower in the guideline-oriented group (US$0.42 vs US$9 per patient; P=0.0042). Implementing SSI prevention guidelines, including proper antimicrobial prophylaxis, is feasible and reproducible among different hospital settings, leading to a significant decrease in prophylaxis costs. SSI rates do not differ following the same international standards.

Implementation of a surgical unit-based safety programme in African hospitals: a multicentre qualitative study

BackgroundA Surgical Unit-based Safety Programme (SUSP) has been shown to improve perioperative prevention practices and to reduce surgical site infections (SSI). It is critical to understand the factors influencing the successful implementation of the SUSP approach in low- and middle-income settings. We undertook a qualitative study to assess viability, and understand facilitators and barriers to implementing the SUSP approach in 5 African hospitals.MethodsQualitative study based on interviews with individuals from all hospitals participating in a WHO-coordinated before-after SUSP study. The SUSP intervention consisted of a multimodal strategy including multiple SSI prevention measures combined with an adaptive approach aimed at improving teamwork and safety culture.ResultsThirteen interviews (5 head surgeons, 3 surgeons, 5 nurses) were conducted with staff from five hospital sites. Identified facilitators included influential individuals (intrinsic motivation of local SUSP teams, boundary spanners, multidisciplinary engagement, active leadership support), peer-to-peer learning (hospital networking and positive deviance, benchmarking), implementation fitness (enabling infrastructures, momentum from previous projects), and timely feedback of infection rates and process indicators. Barriers (organisational ‘constipators’, workload, mistrust, turnover) and local solutions to these were also identified.ConclusionsParticipating hospitals benefitted from the SUSP programme structures (e.g. surveillance, hospital networks, formation of multidisciplinary teams) and adaptive tools (e.g. learning from defects, executive rounds guide) to change perceptions around patient safety and improve behaviours to prevent SSI. The combination of technical and adaptive elements represents a promising approach to facilitate the introduction of evidence-based best practices and to improve safety culture through local team engagement in resource-limited settings.

A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa: a multicentre, before–after, cohort study

Surgical site infections (SSIs) are the most frequent health-care-associated infections in developing countries. Specific prevention measures are highly effective, but are often poorly implemented. We aimed to establish the effect of a multimodal intervention on SSIs in Africa. We did a before-after cohort study, between July 1, 2013, and Dec 31, 2015, at five African hospitals. The multimodal intervention consisted of the implementation or strengthening of multiple SSI prevention measures, combined with an adaptive approach aimed at the improvement of teamwork and the safety climate. The primary outcome was the first occurrence of SSI, and the secondary outcome was death within 30 days post surgery. Data on adherence to SSI prevention measures were prospectively collected. The intervention effect on SSI risk and death within 30 days post surgery was assessed in a mixed-effects logistic regression model, after adjustment for key confounders. Four hospitals completed the baseline and follow-up; three provided suitable (ie, sufficient number and quality) data for the sustainability period. 4322 operations were followed up (1604 at baseline, 1827 at follow-up, and 891 in the sustainability period). SSI cumulative incidence significantly decreased post intervention, from 8·0% (95% CI 6·8-9·5; n=129) to 3·8% (3·0-4·8; n=70; p<0·0001), and this decrease persisted in the sustainability period (3·9%, 2·8-5·4; n=35). A substantial improvement in compliance with prevention measures was consistently observed in the follow-up and sustainability periods. The likelihood of SSI during follow-up was significantly lower than pre-intervention (odds ratio [OR] 0·40, 95% CI 0·29-0·54; p<0·0001), but the likelihood of death was not significantly reduced (0·72, 0·42-1·24; p=0·2360). Implementation of our intervention is feasible in African hospitals. Improvement was observed across all perioperative prevention practices. A significant effect on the overall SSI risk was observed, but with some heterogeneity between sites. Further large-scale experimental studies are needed to confirm these results and to improve the sustainability and long-term effect of such complex programmes. US Agency for Healthcare Research and Quality, WHO.