Surgical Site Infections In Children Research Articles

Surgical Site Infections in Pediatric Plastic Surgery

INTRODUCTION: Surgical site infections (SSIs) are responsible for significant morbidity and healthcare costs. The US Department of Health and Human Services has identified the reduction of SSIs as a national priority for patient safety and quality improvement. Preventing SSIs is dependent on a clear understanding of modifiable risk factors for targeted intervention. In Pediatric Plastic Surgery, our understanding of risk factors for SSIs has been limited by small sample size, nonstandard definitions, and single-center retrospective data. The objective of this study is to use a large prospective national database to analyze clinical risk factors for SSI in children undergoing plastic surgery operations. METHODS & MATERIALS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Peds) is a quality improvement database that prospectively collects demographic data, perioperative risk factors, and 30-day postoperative morbidity outcomes across 56 participating pediatric institutions. Data for patients less than 18 years old undergoing plastic surgery operations were extracted from the NSQIP-Peds 2012 and 2013 databases using CPT codes. Risk factors for SSI were determined with univariate analyses and multivariate logistic regression. RESULTS: Among 11,656 patients, there were 5520 (47%) craniofacial, 4431 (38%) skin/soft tissue, 747 (6.4%) extremity, 728 (6.2%) transcranial, 211 (1.8%) breast/chest wall, and 19 (0.2%) gastrointestinal/genitourinary operations. Mean age at surgery was 5.5 (± 3.8) years and 52% were male. The overall rate of SSI was 0.7%. There were 57 (0.5%) superficial SSIs, 11 (0.1%) deep SSIs, and 10 (0.1%) organ space SSIs. On univariate analysis, inpatient status (p<0.05), increased total operative time (p<0.01), increased length of hospital stay (p<0.01), and younger age at time of surgery (p<0.05) were risk factors for SSI. Following multivariate logistic regression analyses, increased total operative time (p<0.01) was an independent predictor of SSI. Children undergoing extremity or transcranial operations had a higher proportion of SSI than children undergoing skin/soft tissue, craniofacial, breast/chest wall, and/or gastrointestinal/genitourinary operations (p<0.05). Wound classification and ASA classification were not predictive of SSI. CONCLUSIONS: The overall rate of SSI in children undergoing plastic surgery operations is low. This analysis of a large prospective multicenter database provides a high level of evidence regarding risk factors for SSI in the pediatric plastic surgery population and has implications for quality improvement by identifying modifiable factors for targeted intervention.

Increasing Compliance With an Antibiotic Prophylaxis Guideline to Prevent Pediatric Surgical Site Infection: Before and After Study.

To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. A multidisciplinary task force at a pediatric hospital developed an evidence-based AP guideline. Subsequently, the guideline was posted in operating rooms and the online formulary, only recommended antibiotics were available in operating rooms, incoming trainees received orientation, antibiotic verification was included in time-out, computerized alerts were set for inappropriate postoperative prophylaxis, and surgeons received e-mails when guideline was not followed. AP indication and administration were documented for surgical procedures in July 2008 (preintervention), September 2011 (postintervention), and April-May 2013 (follow-up). Compliance was defined as complete--appropriate antibiotic, dose, timing, redosing, and duration when prophylaxis was indicated; partial--appropriate drug and timing when prophylaxis was indicated; and appropriate use--complete compliance when prophylaxis was indicated, no antibiotics when not indicated. Compliance at preintervention and follow-up was compared using χ(2) tests. AP was indicated in 43.9% (187/426) and 62.0% (124/200) of surgical procedures at preintervention and follow-up, respectively. There were significant improvements in appropriate antibiotic use (51.6%-67.0%; P < 0.001), complete (26.2%-53.2%; P < 0.001) and partial compliance (73.3%-88.7%, P = 0.001), correct dosage (77.5%-90.7%; P = 0.003), timing (83.3%-95.8%; P = 0.001), redosing (62.5%-95.8%, P = 0.003), and duration (47.1%-65.3%; P < 0.002). A multifaceted intervention improved compliance with a pediatric AP guideline.

Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study.

To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI. Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18). In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.

A statewide collaborative to reduce pediatric surgical site infections.

Surgical site infections (SSIs) are preventable events associated with significant morbidity and cost. Few interventions have been tested to reduce SSIs in children. A quality improvement collaboration was established in Ohio composed of all referral children's hospitals. Collaborative leaders developed an SSI reduction bundle for selected cardiac, orthopedic, and neurologic operations. The bundle was composed of 3 elements: prohibition of razors for skin preparation, chlorhexidine-alcohol use for incisional site preparation, and correct timing of prophylactic antibiotic administration. The incidence of SSIs across the collaborative was compared before and after institution of the bundle. The association between 1 of the bundle elements, namely correct timing of antibiotic prophylaxis, and the proportion of centers achieving 0 SSIs per month was measured. Eight pediatric hospitals participated. The proportion of months in which 0 SSIs per center was recorded was 56.9% before introduction of the bundle, versus 81.8% during the intervention (P < .001). Correct timing of preoperative prophylactic antibiotics also significantly improved; 39.4% of centers recorded correct timing in every eligible surgical procedure per month ("perfect timing") before the intervention versus 78.7% after (P < .001). The achievement of 0 SSIs per center in a given month was associated with the achievement of perfect antibiotic timing for that month (P < .003). A statewide collaborative of children's hospitals was successful in reducing the occurrence of SSIs across Ohio.

Does delay in appendectomy affect surgical site infection in children with appendicitis?

PurposeThe purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy. MethodsPediatric patients undergoing appendectomy in 2010–2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI. Results1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p=0.51; SA patients, p=0.91; CA patients, p=0.44) or with increased time from admission to operation (all patients, p=0.997; SA patients, p=0.69; CA patients, p=0.96). However, greater length of symptoms was associated with an increased risk of SSI (p<0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p<0.0001). ConclusionWe found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.

Building Consensus

Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in "high risk" patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based "Best Practice" Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible. In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI in high-risk children undergoing spinal fusion. Not applicable.

Accuracy of American College of Surgeons National Surgical Quality Improvement Program Pediatric for laparoscopic appendectomy at a single institution

BackgroundIn October 2008, the American College of Surgeons revealed the National Surgical Quality Improvement Program (NSQIP) Pediatric in an effort to improve quality of surgical care in children. A 5% disagreement rate of data reported between institutions is accepted. The two goals of this study were to (1) determine if the random sampling performed with NSQIP data collection was representative of the population, and (2) verify that data captured in NSQIP was accurate. MethodsFor children undergoing laparoscopic appendectomy from April 2010–April 2011, demographic data, length of stay (LOS), and rates of surgical site infection (SSI) and postoperative abscess recorded in NSQIP (group 1) were compared with data from chart review (group 2). Secondarily, all NSQIP data were examined for accuracy by comparing relevant data points to existing databases. All disagreements were further examined with review of the medical chart. Unpaired t-test and χ2 with Fisher's exact test were used in the statistical analysis. ResultsNSQIP Pediatric captured data from 126 children (group 1); group 2 had 525 children. There were no significant differences in age, body mass index, gender, race or LOS between the two groups. Rate of SSI was 1.6% in group 1 and 1.7% in group 2 (P = 0.92). Abscess rate was 1.6% in group 1 and 3.4% in group 2 (P = 0.28). There were six errors in the NSQIP database. One child was listed as having two SSI. One child with postoperative abscess was missed and another was not counted as they were not categorized correctly. Recorded LOS was incorrect for two children and the other had incorrect age. ConclusionsNSQIP Pediatric captured a representative sample of patients undergoing laparoscopic appendectomy. Errors were found in the reporting of outcomes for SSI and postoperative abscess in children undergoing laparoscopic appendectomy. Given the low incidence of these outcomes, there is little effect on percentages of complications reported.

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Introduction: Postoperative HAI cause important morbidity and mortality in children undergoing cardiac surgery for congenital heart disease. Multiple risk factors for HAI have been identified. Perioperative antibiotic prophylaxis (PAP) regimens can decrease surgical site infections (SSI) but are extrapolated from data in adults. Hypothesis: Compliance with PAP reduces the risk of SSI in children undergoing cardiac surgery. Most causative organisms will be resistant to PAP. Methods: We performed an IRB-approved retrospective cohort study to assess HAI in children?18 yo who had cardiac surgery from July 2010-Dec 2011. Potential pre-, intra-, and post-operative risk factors and adherence to PAP were abstracted from the electronic medical record. Risk factors were assessed. Results: Of the 430 patients who underwent cardiac surgery, 24 developed 27 HAI within 3 mo of surgery. These were: 4 central-line associated bloodstream infections (CLABSI), 4 non-CLABSI bacteremias, 4 endocarditis, 5 SSI, and 7 ventilator-associated pneumonias. Appropriate PAP was provided to 54% vs. 70% of patients with and without an HAI (HR 1.97, CI95% 0.88, 4.40, p=0.097), but no significant difference in SSI was observed. Sixty percent of SSI pathogens were non-susceptible to PAP. In univariate analysis, prior hospitalization; length of surgery, cardiopulmonary bypass, and cross-clamp time; PICU and hospital length of stay (LOS); delayed sternal closure; duration of medical devices; and blood transfusions, as well as use of PAP >48 hrs, were potential risk factors. Intra-operative transfusions (HR 2.61, CI95% 0.91, 7.46, p=0.07), post-operative transfusions (HR 4.29, CI95 1.24, 14.79, p=0.02), and PICU LOS (HR 1.02, CI95% 1.01, 1.04, p<0.0001) remained associated with HAI in multivariate analysis by Cox proportional hazards. Conclusions: Adherence to PAP can decrease risk of HAI in children undergoing cardiac surgery. Blood transfusions and PICU LOS are significant risk factors for HAI, likely reflective of severity of illness. Further studies should assess potential interventions to reduce HAI, including the role of the age of transfused blood products, improving adherence to PAP, and skin decontamination.

Risk factors for surgical site infection in children at the teaching hospital Gabriel Touré, Bamako

A six-month prospective surveillance study of postoperative surgical site infections (SSIs) was undertaken between January and June 2010 in paediatric patients aged <15 years, in the University Hospital Gabriel Touré, Mali. SSI was documented in 43 out of 352 children (12.2%). SSIs were significantly more common after emergency operations, in patients with a National Nosocomial Infection Surveillance System (NNISS) score of 2 or 3, and in patients operated on by trainee rather than by experienced surgeons. Children with anaemia or malnutrition were significantly more likely to develop infection postoperatively. Patients' sex, duration of preoperative stay and the number of patients in the hospital room were not considered as risk factors for infection (P>0.05).

Antibiotic prophylaxis and the prevention of surgical site infection

Surgical site infection (SSI) is one of the most common complications of surgery in both adults and children. The purpose of the present review is to highlight the progress in the understanding of SSIs and the current role of antimicrobial prophylaxis (AMP). An SSI is diagnosed by a constellation of clinical findings occurring within 30 days of surgery. Pathologic organisms responsible for the development of an SSI are mainly limited to Gram-positive bacteria. Two well documented risk factors for the development of SSI in children are wound classification by the Centers for Disease Control (CDC) and procedure duration. Administration of appropriate AMP prior to skin incision has been shown to reduce the incidence of SSI in selected procedures. However, there is a lack of consensus on which procedures in children require AMP. Improvement in the perioperative care of children has reduced both the incidence and outcomes of SSI. However, several controversies still exist in the use of AMP in children. Future work by pediatricians, pediatric surgeons, and pediatric infectious disease specialists will enable us to better understand the specific indications and appropriate AMP in children.

Health Care–Associated Infections in Children

HEALTH CARE–ASSOCIATED INFECTIONS (HAI) REsult in significant morbidity, prolong hospitalization, increase health care costs, and contribute to patient deaths. Among the aggressive national and local endeavors to address HAI, the subtle (and not so subtle) differences between pediatric and adult patients are often overlooked. Rates of central line–associated bloodstream infections (CLABSI), surgical site infections (SSI), and respiratory viral infections differ between children and adults, reflecting the unique susceptibilities of each population. Efforts to reduce the rates of HAI in children are often hampered by the lack of pediatric-specific research, lack of national pediatricspecific quality measures to guide prevention of SSI, and the implementation of infection prevention practices validated only in adult populations. The US Centers for Disease Control and Prevention/ National Healthcare Safety Network surveillance definitions for HAI in children and adults are in general the same, differing slightly for patients 1 year or younger. The commonality of definitions, however, belies the fact that children and adults differ in both susceptibility to infection and in the steps necessary to prevent these infections. Furthermore, identification of pediatric-specific risk factors for infection and the solutions needed to reduce pediatric HAI have not been well investigated. Central line–associated bloodstream infections, SSI, and viral infections in pediatric patients illustrate the important but overlooked differences between adult and pediatric HAI. Pediatric patients younger than 2 years and those requiring care in neonatal intensive care units (ICUs) and pediatric ICUs have especially high rates of HAI, and bloodstream infections are the most common HAI in all pediatric age groups. Pediatric patients have higher rates of bloodstream infections and viral lower respiratory tract infections than adult patients, whereas rates of catheter-related urinary tract infections, ventilator-associated pneumonia, and SSI are higher in adult patients, although rates for particular pediatric surgical procedures may be high. Data on CLABSI illustrate the difference between children and adults. Reported rates for CLABSI are frequently higher in pediatric ICUs than in adult ICUs. In adults, implementation of a multifaceted insertion bundle has been demonstrated to reduce the rates of CLABSI substantially. In contrast with adult data, maximizing insertion-bundle adherence is not sufficient to eliminate CLABSI in children. Data from the National Association of Children’s Hospitals and Related Institutions collaborative demonstrate that the main driver for reducing CLABSI in pediatric patients in the ICU involves optimizing the daily maintenance and care of central line catheters. Unique considerations are involved in the prevention of CLABSI in pediatric patients. Difficult intravenous access often requires placement of catheters in locations that have higher infection rates. In addition, catheters need to be maintained for longer periods of time because of difficult vascular access and the need to obtain blood. Maintenance practices must be tailored to the maturity of an infant’s skin. In very lowbirthweight infants, chlorhexadine may cause a chemical dermatitis or burn, and chlorhexadine-impregnated biopatches may cause pressure ulcers. However, individual neonatal ICUs and pediatric ICUs have been able to decrease their rates of CLABSI substantially, in some cases by incorporating novel technological approaches such as the use of closed intravenous systems to prevent maintenance-related intravascular catheter infections. The Surgical Care Improvement Project (SCIP) is a national quality improvement project to reduce surgical complications. Six of the 9 publicly reported SCIP measures focus on reducing SSI. Adherence rates to individual SCIP measures provide a benchmark to track infection prevention measures, and emerging data suggest that adherence with core SCIP measures may reduce SSI. Although several of the SCIP measures to reduce infection are appropriate for children, some measures such as postoperative glucose control for cardiac surgery and postoperative temperature control after colorectal surgery are intended for adults. It is perhaps not surprising that SCIP measures, and the requirement for hospitals to track and report SCIP adherence, do not apply to patients younger than 18 years. What is surprising is that similar measures are not in place for prevention of SSI in children. It is important that a national quality improvement program to reduce HAI does not apply to pediatric patients. The Surgical Care Improvement Project measures are tracked by the Joint Commission, the agency that accredits and certifies

Risk Factors and Outcomes of Surgical Site Infection in Children

Indices for prediction of surgical site infection (SSI) are well documented in the adult population; however, these factors have not been validated in children. A retrospective case-control study was performed by examining the medical records of children (0 to 18 years) who developed an SSI within 30 days of selected class I and class II procedures at our institution from 1996 to 2008. Two controls were selected from among patients undergoing identical procedures within 12 months of each case. Statistical analysis was performed using Wilcoxon test for continuous and chi-square test for categorical variable. Factors thought a priori to be associated with risk of SSI and statistically significant variables from a univariate analysis were used to create a logistic regression model. Of 16,031 patients, 159 children (0.99%) developed an SSI. Univariate analysis showed race, postoperative location, skin preparation, urinary catheter, procedure duration, and implantable device as risk factors for development of an SSI. Independent predictors of SSI in multiple conditional logistic regression were age (adjusted odds ratio [aOR] 4.97 neonate vs adolescent; 95% CI 1.38 to 17.90), race (aOR 2.36 for African American vs white; 95% CI 1.32 to 4.18), postoperative location (aOR 6.55 ICU vs home; 95% CI 1.58 to 27.21), urinary catheter placement (aOR 3.56; 95% CI 1.50 to 8.48), and implantable device (aOR 3.05; 95% CI 1.14 to 8.21). Wound classification and antibiotic administration were not independent predictors of SSI. Postoperative location, urinary catheter insertion, and use of an implantable device are potentially modifiable risk factors for an SSI in children. The higher risk of SSI in younger patients and non-white race suggest a possible developmental, socioeconomic, or genetic marker for impaired host defense.

Risk factors and risk adjustment for surgical site infections in pediatric cardiothoracic surgery patients

The complexity of congenital cardiac defects and the aggressive medical management required to support patients through their recovery place children at high risk for surgical site infection (SSI). We conducted a retrospective review of children undergoing cardiothoracic surgery at a tertiary care referral center between January 1, 2000, and June 30, 2001. Preoperative, intraoperative, and postoperative data were assessed by multivariate analysis. Of 726 surgical procedures performed in 626 patients, SSIs occurred after 46 procedures performed in 46 patients (6.3%). Infections were superficial (n = 22; 47.8%), deep tissue (n = 7; 15.2%), or organ space (n = 17; 37.0%), including 5 episodes of mediastinitis. Median time to SSI was 10 days; 36% of the infections were identified after discharge. On multivariate analysis, children with SSIs were more likely to have been <30 days old (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.2-70), to have a perioperative medical device, and to use parenteral nutrition (OR, 3.3; 95% CI, 1.4-7.9). Multiple severity of illness scores, the Risk Adjustment for Congenital Heart Surgery (RACHS-1) category, and longer duration of postoperative antimicrobials were not associated with SSI. The use of perioperative medical interventions increases the risk of SSI in young children after cardiac surgery. Prolonged postoperative courses of antimicrobials should be avoided in the absence of documented infection.

Cultivating Quality: Reducing Surgical Site Infections in Children Undergoing Cardiac Surgery

At Children's Hospital Boston, the cardiovascular operating room nurses led an initiative aimed at reducing surgical site infections (SSIs) in pediatric patients undergoing cardiac surgery. After first standardizing how skin preparation was performed, the nurses sought to determine which agents might be most effective. A literature review yielded relevant research; a survey of other pediatric surgery centers was also conducted. Based on what they learned, the nurses were able to recommend, implement, and evaluate a practice change. This has resulted in reduced SSI rates and improved patient outcomes.

Surgical Site Infection in Children: Prospective Analysis of the Burden and Risk Factors in a Sub-Saharan African Setting

Surgical site infections (SSI) add substantially to the morbidity of surgical patients. Our hypothesis was that the SSI rate is high in our setting, but there were no data regarding the prevalence and risk factors. Three hundred twenty-two children who had surgery (elective 144, emergency 178) between January, 2001 and September, 2005 were studied prospectively. All patients with clean-contaminated, contaminated, and dirty incisions received prophylactic antibiotics. Data were collected using a tool that captured demographics, diagnosis, co-morbid conditions, type of surgical incision, nature of surgery, type of anesthesia, use of perioperative antibiotics, and duration of surgery. Information also was collected postoperatively on the development of SSI, type of infection, associated signs, the day the infection was identified, the findings in cultures of swabs from infected incisions, duration of hospital stay, and outcome. The chi-square test for categorical variables was used to test for significance of association. The p value for significance was set at 0.05. Seventy-six patients (23.6%) consisting of 40 boys and 36 girls developed SSI. The median age was nine months (range, 2 days-12 years) for those who developed SSI and 15 months (range, 1 day-13 years) for those who did not. The SSI rate was 14.3% in clean incisions, 19.3% in clean-contaminated incisions, 27.3% in contaminated incisions, and 60% in dirty incisions (p < 0.05). The infection rate was 25.8% in emergency procedures and 20.8% in elective procedures (p > 0.05). The infection rate was 31% in operations lasting >or= 2 h and 17.3% in operations lasting < 2 h (p < 0.05). Infection was detected before the eighth postoperative day in 56 of the patients (74.6%) with SSI, and bacteria were cultured from the incision in 32 patients (42.7%). The average length of stay was 26.1 days (range, 8-127 days) in patients with SSI and 18.0 days (range, 1-99 days) in those without SSI (p < 0.05). The mortality rate of patients with SSI was 10.5%, with six of the eight deaths related directly to the SSI, compared with a mortality rate of 4.1% in patients without SSI (p < 0.05). The burden of SSI in this setting is high. The degree of incisional contamination and a long duration of surgery (>or= 2 h) are important risk factors.

Prospective study of antibiotic protocols for managing surgical site infections in children

Purpose We adopted antibiotic (Ab) protocols for managing surgical site infections in children and assessed their effectiveness. Methods We used our protocols on 1313 children between 2004 and 2005. All wounds were monitored for 30 days and classified as clean, clean-contaminated, contaminated, or dirty-infected. Infections were defined as superficial, deep, or organ/space. A retrospective study involving 721 children who had surgery in 2003 was also performed. χ 2 Statistical analysis was performed. Results Postprotocol, all Abs were administered accurately by anesthesiologists and infections developed in only 22 cases (1.7%): 0.2% (clean), 2.6% (clean-contaminated), 5.8% (contaminated), and 20.8% (dirty-infected), respectively; 21 were superficial or deep and 1 was organ/space. Age at surgery and sex did not influence incidence, neither did length of surgery for clean-contaminated, contaminated, and dirty-infected wounds; clean wounds were excluded because all surgery was minor. Overall, incidence of infections was 1.2% for elective surgery and 4.5% for emergency surgery ( P < .01). Preprotocol, only 67% had Ab and infections developed in 27 cases (3.7%), which is significantly higher than in postprotocol ( P < .01). Conclusions Accurate administration of Ab and careful supervision by an infection control team appear to be effective for preventing wound infections in children.

Risk Factors for Surgical Site Infection in Children

To assess the appropriateness of using the indices developed by the Study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance (NNIS) project to determine risk factors for surgical site infection (SSI) in children and, if not appropriate, to explore the factors related to SSI in children so these factors could be used in a risk index for pediatric patients. Cohort study during more than 4 years. La Paz University Hospital, a national reference center that serves Health Area 5 of Madrid, Spain, which has approximately 500,000 inhabitants. Convenience sample consisting of the 3,646 children admitted for surgery who had a postsurgical stay of more than 2 days. A model with 8 predictive factors (degree of surgical contamination; duration of surgery; type of surgery; use of a peripheral venous catheter, central venous catheter, or urinary catheter; number of diagnoses; and SSI exposition time) was created. Its relation to the SSI rate was better than that of the SENIC or NNIS indices. Its sensitivity, specificity, and area under the receiver-operating characteristic curve were higher than that of the SENIC index. The model that we created seems to be more adequate for predicting SSI and evaluating pediatric patients' intrinsic risk than the SENIC and NNIS indices.

Risk factors for surgical site infections after pediatric cardiovascular surgery.

Although risk factors for surgical site infection (SSI) after cardiovascular (CV) surgery have been well-documented among adults, few studies have been conducted in children. We performed a case-control study to identify risk factors for hospitalized SSI in children undergoing CV surgery. National Nosocomial Infections Surveillance System criteria were used prospectively to identify cases of hospitalized SSI in patients who underwent CV surgery. Seventy-nine patients who underwent CV surgery without hospitalized SSI were randomly selected as controls. Cases were compared with controls to determine preoperative, intraoperative and postoperative risk factors for hospitalized SSI. Multivariable logistic regression was performed. An SSI developed in 19 of the 826 patients who underwent CV surgery (2.3 cases per 100 surgeries) during the study period. Infection was limited to soft tissue in 12, whereas deeper infection occurred in 7. Causative agents included Staphylococcus aureus (11), coagulase-negative Staphylococcus (5) and Escherichia coli (2). One patient did not have a pathogen isolated. In a multivariable analysis, duration of surgery (odds ratio, 1.4; 95% confidence interval, 1.2 to 1.8) and age <1 month (odds ratio, 14; 95% confidence interval, 3.3 to 58.4) were independently associated with SSI. Age <1 month and longer duration of surgery were independently associated with hospitalized SSI after CV surgery in children.

Surgical site infections following pediatric liver transplantation: risks and costs.

Infectious complications following orthotopic liver transplantation (OLT) represent a significant cause of morbidity and mortality in both adults and children. In adults, surgical site infections complicating OLT have been shown to significantly increase resource utilization, but their impact in children has not been studied. In this study we identify risk factors for surgical site infections in children undergoing primary OLT for end-stage liver disease and estimate their impact on patient survival, graft survival, length of stay, and charges. All pediatric liver transplants (n = 77) less than 16 years of age from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database were included in the analysis. Surgical site infections (n = 25) were defined as wound infections, abdominal abscesses, and bacterial or fungal infections of the liver, intestine, or peritoneum during the initial transplant admission. Risk of infection was estimated using logistic regression, survival rates were estimated using the Kaplan-Meier method, and length of stay and charges were compared using Student's t-test. Multivariate analysis of charges was performed using linear regression. Of the 77 patients, 25 (32.5%) developed a surgical site infection. Several factors were associated with increased risk of infections, including a leak at the biliary anastomosis (odds ratio [OR] 115, P = 0.003), preoperative white blood cell count (OR = 1.28, P = 0.009), surgery > 7 h (OR = 15.0, P = 0.011), HLA mismatches (OR = 6.0, P = 0.03), and female gender (OR = 8.0, P = 0.038). Surgical site infections did not significantly decrease either patient survival or graft survival, and increased hospital stay by an average of 21 days (P = 0.14). After controlling for other factors, patients who developed surgical site infections incurred on average $132,507 (P = 0.03) more in charges than patients who did not develop infections. Surgical site infections in pediatric patients following liver transplantation are significantly influenced by surgical technique and endogenous patient characteristics. Though survival outcomes are not different, the development of such infections has significant implications for resource utilization in the care of these patients.