Wound Cellulitis Research Articles

THE IMPACT OF A CLOSING PROTOCOL (CP) IMPLEMENTATION ON WOUND MORBIDITY IN ABDOMINAL WALL RECONSTRUCTION (AWR) WITH MESH

Abstract Background Wound complications (WC) are associated with increased cost, recurrence, and mesh infection. Operative CPs have not been evaluated in AWR. Our aim was to evaluate the effect of a CP on wound infection (WI) and WC. Method A prospective, institutional database was used to compare AWR with and without CP. Descriptive statistics and a Bayesian Structured time series analysis (BSTA) were performed to evaluate rates of WI and WC. Data is reported as means unless stated. The CP involves antibiotic wound irrigation, glove and instrument exchange, re-draping the field, surgeon-only handling the mesh prior to mesh implantation. The introduction of on-going quality improvement efforts were accounted for in the model. Results A total of 2541 patients were examined with an age of 57.9 ± 12.6 years, 56.7% female, BMI 32.9 ± 9.8 kg/m2, 24.2% diabetic, and 41.2% former-smokers. Defect size was 203.1 ± 205.8 cm2 and 83.1% were CDC Class 1 or 2 wounds. Follow-up was 31.5 ± 41.4 months. Overall WI and WC rate decreased after CP (14.5% vs. 2.6% and 29.3% vs. 10.3%, P < 0.001). Specifically, the rate of wound cellulitis (9.7% vs. 2.7%, P < 0.001), wound infection (13.8 vs. 1.8%, P < 0.001), and mesh infection (2.1% vs. 0.6%, P < 0.004) were reduced after CP. For WI, BSTA revealed a relative effect of 83% (±2%, 95%CI:-87%,-78%; P = 0.0002) reduction compared to counterfactual. For WC, the BSTA revealed a relative effect reduction compared to counterfactual of 67% (±3%, 95%CI:-60%, -72%; P = 0.0002). Conclusion Introduction of a CP prior to mesh implantation in open AWR led to a significant reduction in overall wound infections and wound complications. The use of a CP should be strongly considered.

Sentinel lymph node biopsy based on anatomical landmarks and locoregional mapping of inguinofemoral sentinel lymph nodes in women with vulval cancer: an operative technique

Inguinal lymph node involvement is the most robust predictor of mortality in vulval cancer and sentinel lymph node (SLN) biopsy is a safe diagnostic modality. We describe a technique based on anatomical landmarks. Our aims are (1) to describe the territorial mapping of SLNs, (2) to evaluate the associated complication rate vis-à-vis those reported in the literature, and (3) to assess its accuracy in detecting SLNs. Data from women who underwent groin SLN biopsies for vulval cancer at a single cancer centre were prospectively collected. All subjects met the GROINSS-V eligibility criteria. The location of the SLN relative to the saphenous vein was recorded. All women were followed up and early and late complications were recorded. The recurrence rate at the time of the census was calculated. A total of 71 groins in 44 women were included. The SLN was primarily located over Cloquet’s node (85.2%). The incidence of early wound cellulitis and dehiscence were 2.8% and 11.3% while lymphocysts were present in 11.3% of groins. The negative nodal recurrence rate was 1.7%. Results showed that this reproducible technique allows access to 96.7% of SLNs, including both deep and superficial SLNs whilst minimising the need for extensive dissection and complications associated with overharvesting of lymph nodes.

Robotic vs Open Lateral Hernia Repair: A Multicenter Propensity Score–Matched Analysis of 30-day Outcomes

INTRODUCTION: Lateral ventral hernia repair (LVHR) is a challenging surgical dilemma due to location, different anatomical considerations, and low volume of cases. Our study aims to compare and assess early 30-day outcomes between open LVHR (oLVHR) and robotic-assisted LVHR (rLVHR) approach. METHODS: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who underwent elective LVHR based on European Hernia Society classification. A 1:1 propensity score match (PSM) analysis was conducted for balanced groups. Univariate analysis was performed to compare the 2 groups (oLVHR and rLVHR) across preoperative, intraoperative, and postoperative timeframes. RESULTS: ACHQC database identified 2,569 LVHR patients. A PSM analysis stratified 665 patients to each oLVHR and rLVHR group. Median length of stay is higher in the oLVHR 3 days (interquartile range [IQR] 1 to 5) vs rLVHR 1 day (IQR 0 to 2; p < 0.001). The surgical site infection rate was higher in the oLVHR 3% vs 1% (p = 0.006). Surgical site occurrence (SSO) such as wound cellulitis was also found at a higher rate in the oLVHR 21% vs the rLVHR 0% (p < 0.001). Seroma rate was higher in the rLVHR (6.5% vs 5.6%, p < 0.001). oLVHR had 18% postoperative complication compared with rLVHR 12% (p < 0.001). There was no difference in quality-of-life measures (HerQLes and PROMIS pain 3a surveys) between groups at 30 days and 1 year. CONCLUSION: Robotic-assisted LVHR is safe with decreased length of stay and SSO compared with the conventional open approach. However, it does carry a higher seroma rate with no clinical significance.

Normal Saline Versus Betadine use to Reduce the Incidence of Wound Infection in Cesarean Section, A Cross Sectional Comparative Study

Aims and Objectives: The aims and objectives of this study was to observed the difference between using betadine or normal saline irrigation of wound prior to skin closure in reducing the surgical site infections. Design of the Study: It’s a case-control study Study Settings: The study was conducted at Department of Obstetrics &amp;Gynecology Rashid Latif Medical College, Lahore from June 2021 to November 2021. Material and Methods: For current study 200 pregnant women were selected and equally divided them into two different groups i.e. Group A and Group B. All individuals of Group A, used betadine liquid for surgical wound irrigation while the individuals of Group B, were used normal saline for such purpose. The observed raw data were statistically analyzed by SPSS 21, one –way ANOVA in which analysis of variance followed by mean standard deviation (Mean±SD) and P values (p&lt;0.05) for significant. Results: The findings of current study indicated that wound irrigation with betadine liquid or normal saline have their own importance. The results are significant (p&lt;0.05) in comparative analysis of Group A and Group B regarding allergy, postoperative wound cellulitis, postoperative wound abscess, postoperative fever and obstetric hemorrhages. Conclusion: The findings of current study indicated that Normal saline irrigation is better than betadine because of skin irritation and allergy due to iodine and toxicity of povadine iodine solution against healthy cells. Keywords: Cesarean delivery, surgical site infection, Normal saline, Betadine, surgical wound irrigation

MRSA screening: incidence and maternal postpartum outcomes in an obstetric population at a tertiary care center.

To assess the incidence of MRSA positive patients in pregnancy, as well as the postpartum outcomes in MRSA positive patients. This is a retrospective cohort study of women who underwent universal MRSA universal at a tertiary medical center. A MRSA swab was routinely collected as part of the patient's prenatal care at 35-37weeks gestation or on admission to labor and delivery. Demographic information and decolonization antibiotics were collected by electronic medical record review, using ICD-9 codes. Outcome data were collected, including mode of delivery, hospital length of stay, endometritis, wound cellulitis, and wound infection. p < 0.05 was considered significant. A univariate logistic regression and a multivariable binary logistic regression model were used to analyze the strength of association between outcomes and MRSA status. Statistical analysis was performed with SAS, version 9.4. The incidence of MRSA during the 4year study period was 1.9% (82 MRSA positive out of 4369 total patients). 90.2% (74/82) of MRSA positive patients received decolonization antibiotics. No difference was noted in mode of delivery. Logistic regression failed to identify any significant differences in other relevant outcomes for MRSA positive women including endometritis 1.1 (0.1-17.5) [positive 0, versus negative 0.6% (n = 24)], wound cellulitis 5.9 (0.4-82.1) positive 0, versus negative 0.1% (Gorwitz et al. in J Infect Dis 197:1226-1234, 2008) and wound infection 3.3 (0.6-16.9) [positive 1.2%, versus negative 0.5% ( in Am J Infect Control 32:470-85, 2004)] when compared to MRSA negative women. When universal MRSA screening was performed at an academic tertiary care center, the overall incidence of MRSA was low. MRSA positive and subsequently decolinzed patients did not have any identified increase in postpartum infectious morbidity, as compared to MRSA negative patients.

Minimally Invasive Surgery in Morbidly Obese Women.

Minimally invasive gynecologic surgery provides a number of clinical advantages compared with open laparotomy. Over the past 25 years, important modifications and innovations have further expanded the utility of these techniques. Complications such as surgical site infection, venous thromboembolism, and wound cellulitis or dehiscence rise in concert with escalating obesity, so it stands to reason that these patients would derive the most benefit from minimally invasive surgery. Yet, surgical complexity also rises proportionally, requiring fastidious technique and allowing little margin for error. As nonsurgical interventions become more commonplace and the rate of morbid obesity continues to increase, those women actually requiring a gynecologic operation through an abdominal approach will be ever more likely to present a number of challenges to safe completion of minimally invasive surgery. This article frames the topic and offers some tips across the range of care to enhance the likelihood of achieving success in this patient population most in need of surgical expertise.

Does active smoking really matter before ventral hernia repair? An AHSQC analysis

Many studies implicate active smoking as a risk factor for postoperative wound complications and all 30-day morbidity, but the definitions of inclusion and exclusion criteria as well as outcome parameters are inconsistent. Critically, the ability of large databases and meta-analyses to generate statistically significant associations of active smoking with morbidity do not address whether those relationships are actually clinically meaningful. We investigated this relationship after open ventral hernia repair. Patients undergoing elective open ventral hernia repair in clean wounds with 30-day follow-up were extracted from the Americas Hernia Society Quality Collaborative. Current smokers (within 30 days of surgery) were 1:1 propensity matched to patients who had never smoked based on demographics, comorbidities, and operative characteristics. Wound complications and all 30-day morbidity were assessed. After matching 418 current smokers to 418 patients who had never smoked, the groups were similar with the exception of minor differences in body mass index (31.4 vs 33.3, P < .001) and incidence of chronic obstructive pulmonary disease (18% vs 6%, P < .001). Rates of surgical site occurrence were greater in active smokers (12.0% vs 7.4%, P = .03) driven by increased rates of wound cellulitis (2.4% vs 1.2%) and seroma (5.5% vs 1.2%); however, rates of surgical site infection (4.1 vs 4.1, P = .98), surgical site occurrences requiring a procedural intervention (6.2% vs 5.0%, P = .43), reoperation (1.9% vs 1.2%, P = .39), and all 30-day morbidity (7.5 vs 6.6, P = .60) were not significantly increased in active smokers. There were no instances of mesh excision. Active smoking prior to elective clean OVHR is associated with clinically insignificant differences in wound morbidity. Surgeons allowing perioperative smoking should monitor their outcomes to assure these findings are replicable in their own practice.

Incidence of Cellulitis in Lower Extremity Burns

Patients with burn wounds of the lower extremities are at increased risk of developing cellulitis. The probability of developing burn-associated cellulitis is presumed to be correlated with a medical history of diabetes, the etiology of the burn, delay in hospitalization of the patient during their initial presentation, and depth of the burn itself. This study aims to identify factors that place patients at increased risk for developing lower extremity burn wound cellulitis. A retrospective chart review was performed of all Nassau University Medical Center Burn Center admissions from January 2010 to January 2016. All patients admitted with burns of any etiology isolated to the lower extremity were included in this study. Patients who were evaluated and followed as an outpatient were not included in this study. Pediatric patients less than or equal to 12 years of age were excluded from this study. Of the 218 admissions for lower extremity burns during the 6-year study period, 34% of patients developed cellulitis. Risk factors for developing lower extremity burn wound cellulitis included being male, greater depth of burn, and burn-to-admission delay. This was true in both univariate and multivariate analysis. total body surface area was a risk factor on univariate analysis but was not found to be an independent risk factor on multivariate analysis. No difference was observed in the development of cellulitis in patients discharged on oral antibiotics compared with those not given antibiotics. Burn wound cellulitis is the second most common complication observed in burns. Identification of patients at risk for developing cellulitis is important. Admitting these patients at increased risk and excising and grafting the burned area is a reasonable solution in preventing this costly complication.

Do Groin Drains Reduce Postoperative Morbidity in Women Undergoing Inguinofemoral Lymphadenectomy for Vulvar Cancer?

Sentinel lymph node biopsy has been widely adopted in the surgical management of women with early-stage vulvar cancer, but many patients require inguinofemoral lymphadenectomy (IFL). Following IFL, many surgeons drain the groin to prevent lymphocyst formation despite a lack of evidence to support this practice. Our objective was to investigate whether groin drains after IFL are associated with reduced postoperative morbidity in women undergoing surgery for vulvar cancer. A retrospective cohort study of women diagnosed as having primary vulvar cancer who underwent vulvectomy/radical local excision and unilateral or bilateral IFL was conducted. Cases were ascertained from the weekly outcome reports of a statewide tertiary gynecologic oncology tumor board. Data including postoperative outcomes were abstracted from medical records. Patients were stratified into 1 of 2 groups according to whether a groin drain had been used. Seventy-one patients were included. Inguinal drains were used in 48 patients (67.6%) and 23 patients (32.4%) did not have their groin wound(s) drained. The most common postoperative complications recorded were wound infection (59.2%), groin lymphocyst (32.4%), and cellulitis (25.4%). The mean length of hospital admission was 11.5 days (2-40 days). Compared with patients in whom inguinal drains were placed, those in the "no drain" group had a significantly lower incidence of postoperative groin cellulitis (8.7% vs 25.4% P = 0.039). No significant differences were observed between patients in the "drain" and "no drain" groups in lymphocyst formation, wound infection, return to the operating room, duration of hospital stay, readmission post-discharge, and lower-limb lymphedema. In this study of patients undergoing inguinofemoral dissection for primary vulvar cancer, postoperative cellulitis occurred less frequently in patients without an inguinal drain. The incidence of other postoperative complications was no different whether or not a groin drain was used. Prospective studies may be warranted.

Surgical Findings and Outcomes in Premenopausal Breast Cancer Patients Undergoing Oophorectomy: A Multicenter Review From the Society of Gynecologic Surgeons Fellows Pelvic Research Network

Study ObjectiveTo describe the procedures performed, intra-abdominal findings, and surgical pathology in a cohort of women with premenopausal breast cancer who underwent oopherectomy. DesignMulticenter retrospective chart review (Canadian Task Force classification II-3). SettingNine US academic medical centers participating in the Fellows' Pelvic Research Network (FPRN). PatientsOne hundred twenty-seven women with premenopausal breast cancer undergoing oophorectomy between January 2013 and March 2016. InterventionSurgical castration. Measurements and Main ResultsThe mean patient age was 45.8 years. Fourteen patients (11%) carried a BRCA mutations, and 22 (17%) carried another germline or acquired mutation, including multiple variants of uncertain significance. There was wide variation in surgical approach. Sixty-five patients (51%) underwent pelvic washings, and 43 (35%) underwent concurrent hysterectomy. Other concomitant procedures included midurethral sling placement, appendectomy, and hysteroscopy. Three patients experienced complications (transfusion, wound cellulitis, and vaginal cuff dehiscence). Thirteen patients (10%) had ovarian pathology detected on analysis of the surgical specimen, including metastatic tumor, serous cystadenomas, endometriomas, and Brenner tumor. Eight patients (6%) had Fallopian tube pathology, including 3 serous tubal intraepithelial cancers. Among the 44 uterine specimens, 1 endometrial adenocarcinoma and 1 multifocal endometrial intraepithelial neoplasia were noted. Regarding the entire study population, the number of patients meeting our study criteria and seen by gynecologic surgeons in the FPRN for oophorectomy increased by nearly 400% from 2013 to 2015. ConclusionSince publication of the Suppression of Ovarian Function Trial data, bilateral oophorectomy has been recommended for some women with premenopausal breast cancer to facilitate breast cancer treatment with aromatase inhibitors. These women may be at elevated risk for occult abdominal pathology compared with the general population. Gynecologic surgeons often perform castration oophorectomy in patients with breast cancer as an increasing number of oncologists are using aromatase inhibitors to treat premenopausal breast cancer. Our data suggest that other abdominal/pelvic cancers, precancerous conditions, and previously unrecognized metastatic disease are not uncommon findings in this patient population. Gynecologists serving this patient population may consider a careful abdominal survey, pelvic washings, endometrial sampling, and serial sectioning of fallopian tube specimens for a thorough evaluation.

Do Iodine-Impregnated Adhesive Surgical Drapes Reduce Surgical Site Infections during Open Ventral Hernia Repair? A Comparative Analysis

This study evaluated the role of iodine-impregnated adhesive drapes to reduce surgical site infections and occurrences in open ventral hernia repairs. All patients undergoing open ventral hernia repair of clean wounds with a retromuscular repair using synthetic mesh by a single surgeon were prospectively evaluated from the American Hernia Society Quality Collaborative. Patients were divided into those that had an Ioban drape and those that did not. The primary endpoints of this study were postoperative surgical site occurrence and infections. One hundred and four patients met inclusion criteria and were analyzed. There were 56 patients that received a 3M™ Ioban™ drape and 48 patients did not. The two groups were similar based on baseline demographics, risk factors, and operative details. There were four (7%) surgical site occurrences in the Ioban group (one wound cellulitis, one superficial surgical site infection, one allergic reaction to the Ioban, and one sterile seroma). There was one (2%) surgical site occurrence in the non-Ioban group (one superficial wound dehiscence). For patients undergoing clean ventral hernia repair with synthetic mesh placed in the retrorectus plane, the use of an iodine-impregnated drape does not result in a reduction in surgical site occurrences or superficial surgical site infections.

Free Jejunal Flap for Pharyngoesophageal Reconstruction in Head and Neck Cancer Patients: An Evaluation of Donor-Site Complications.

Free jejunal transfer for pharyngoesophageal reconstruction has often been criticized for its associated donor-site morbidity. Conversely, the same argument has been invoked to support use of fasciocutaneous flaps, given their low incidence of donor-site complications. The purpose of the current study was to document donor-site complication rate with free jejunal flaps for pharyngoesophageal reconstruction, in the hands of an experienced surgeon. A retrospective chart review was performed for consecutive patients who underwent free jejunal transfer between 1992 and 2012 by the senior author (P.G.C.). Demographic data, abdominal complications, surgical characteristics of small bowel anastomoses, and postoperative bowel function were specifically noted. Overall, 92 jejunal flap reconstructions were performed in 90 patients. The mean follow-up time was 29 months. Twelve (13%) patients had prior abdominal surgery. Donor-site complications included ileus (n = 2), wound cellulitis (n = 1), wound dehiscence (n = 1), and small bowel obstruction (n = 1). Mean time to initiation of tube feeds after reconstruction was 5 days. A total of 77 (86.5%) patients were discharged on an oral diet. The perioperative mortality rate of 2% was not associated with any donor-site complication. Free jejunal transfer is associated with minimal and acceptable donor-site complication rates. The choice of flap for pharyngoesophageal reconstruction should be determined by the type of defect, potential recipient site complications, and the surgeon's familiarity with the flap. Potential donor-site complications should not be a deterrent for free jejunal flaps given the low rate described in this study.

Risk factors for wound morbidity after open retromuscular (sublay) hernia repair

Retrorectus repairs (RR) of abdominal wall hernias are growing in popularity, yet wound morbidity and predictors in this context have been characterized poorly. Models aimed at predicting wound morbidity typically do not control for technique and/or location of mesh. Our aim was to describe wound morbidity and risk factors specifically in the context of RR hernia repair. Our hypothesis was that the incidence of wound morbidity with mesh sublay would be less than predicted by a model that does not control for mesh position. Consecutive RR hernia repairs with at least a 90-day follow-up were identified in our prospective database and analyzed. The primary outcome measures were the incidence of surgical-site occurrence (SSO) and surgical-site infection (SSI) via modern, standardized definitions. For predictors of SSO, statistical analysis was performed with univariate analysis, χ(2), and logistic regression as well as multivariate regression. A total of 306 patients met the inclusion criteria. Eighty-four SSOs identified in 72 (23.5%) patients included 48 (15.7%) SSIs, 14 (4.6%) instances of wound cellulitis, 12 (3.9%) skin dehiscences, 6 (2.0%) seromas, and 4 (1.3%) hematomas but no instances of mesh excision or fistula formation. Treatment entailed antibiotics alone in 30 patients, 14 bedside drainage procedures, 9 radiographically assisted drainage procedures, and 10 returns to the operating room for debridement. After multivariate analysis, diabetes (OR 2.41), hernia width >20 cm (OR 2.49), and use of biologic mesh (OR 2.93) were statistically associated with the development of a SSO (P < .05). Notably, the mere presence of contamination was not independently associated with wound morbidity (OR 1.83, P = .11). SSO and SSI rates anticipated by a recent risk prediction model were 50-80% and 17-83%, respectively, compared with our actual rates of 20-46% and 7-32%. Based on a large cohort of patients, we identified factors contributing to SSOs specifically for RR hernia repairs. Paradoxically, biologic mesh was an independent predictor of wound morbidity. The development of clinically important mesh complications and rates of wound morbidity less than anticipated by recent predictive models suggest that the retromuscular (sublay) mesh position may be more advantageous.

Regional and national review of factors associated with burn wound cellulitis.

Burn wound cellulitis (BWC) is the second leading complication reported in burns. In this study we sought to identify demographic variables, burn factors, and other factors that may predispose patients to BWC. Regional data was obtained through retrospective medical record review of burn patients treated between May 2009 to April 2013 for BWC within 8 days of the injury. The patients were matched 1:2 with contemporaneously treated patients. Similarly, the National Burn Repository was queried to identify burn patients with BWC between the years 2002 to 2011, which were then compared to the remaining entries who did not have BWC reported. The data sets were analyzed separately. Univariate and multiple variable analyses were performed to evaluate risk factors for BWC. The risk factors that were consistent regionally and nationally were older age, male sex, African-American race (protective), lower extremity burns, scald burns, and full thickness burns. The treatment delay was only collected regionally, and was associated with an eight times increased risk. The factors that were inconsistent or significant in one sample only were smoking status, psychiatric conditions, upper extremity burns, and the place of injury. Cellulitis remains a significant problem for the burn community. Future prospective analyses need to clarify the impact of these factors as well as other factors on the development of BWC. Preventing BWC from occurring through earlier intervention or targeted prophylactic antibiotics may help reduce morbidity and decrease associated healthcare costs.

Ambulatory percutaneous nephrolithotomy: what is the rate of readmission?

Tubeless percutaneous nephrolithotomy (PCNL) has gained popularity in an attempt to decrease morbidity and accelerate discharge. Recently, ambulatory tubeless PCNL has been reported. There are no data, however, regarding readmission rates of patients who had ambulatory PCNL. Therefore, the aim of this study was to assess rates of emergency department (ED) visits and readmissions postambulatory PCNL. A retrospective chart review of all ambulatory PCNL cases at two institutions between March 2007 and December 2013 was performed. Preoperative, intraoperative, and postoperative data were collected including the amount of narcotics used, length of hospital stay, postoperative complications, returns to the ED, and readmissions. Fifty patients underwent ambulatory PCNL, including two bilateral cases, making up a total of 52 renal units. All patients were discharged home on the same day with a mean hospital stay of 208.32±73.43 minutes. The mean narcotic requirement was 41.13±46.76 mg of oral morphine equivalents. Six patients (12%) returned to the ED, all within 7 days. Four of these 6 patients were discharged; three with stent colic and one with wound cellulitis. Only two (4%) patients were readmitted-one with multiresistant Escherichia coli and one with uncomplicated stent colic. Overall stone-free rate was 90.4%. There were no major complications, while low grade (I-II) Clavien complications developed in 9 (18%) patients. Ambulatory PCNL is safe in highly selected patients with a stone-free rate of 90% and readmission rate of 4%. Prospective studies comparing standard PCNL with ambulatory PCNL are warranted.

Outbreak of invasive group A streptococcus infection: contaminated patient curtains and cross-infection on an ear, nose and throat ward

Outbreaks of group A streptococcus (GAS) infections may occur in healthcare settings and have been documented in surgical, obstetrics and gynaecology, and burns units. The environment may serve as a reservoir and facilitate transmission via contaminated equipment. To describe the investigation and control of an outbreak of healthcare-associated GAS infection on an ear, nose and throat (ENT) ward in a tertiary referral centre. Two patients with laryngeal cancer developed invasive GAS infection (bacteraemia) with associated tracheostomy wound cellulitis within a 48 h period. The outbreak team undertook an investigation involving a retrospective review of GAS cases, prospective case finding, healthcare worker screening and sampling of patient curtains. Immediate control measures included source isolation, a thorough rolling clean with a chlorine-based disinfectant and hydrogen peroxide decontamination of patient equipment. Prospective patient screening identified one additional patient with carriage of GAS from a tracheostomy wound swab. Staff screening identified one healthcare worker who acquired GAS during the outbreak and who subsequently developed pharyngitis. Environmental sampling demonstrated that 10 out of 34 patient curtains on the ward were contaminated with GAS and all isolates were typed as emm-1. This is the first outbreak report to demonstrate patient curtains as potential source for GAS cross-transmission, with implications in relation to hand hygiene and frequency of laundering. Based on this report we recommend that during an outbreak of GAS infection all patient curtains should be changed as part of the enhanced decontamination procedures.

Postoperative Infections in Obstetrics and Gynecology

Postoperative infection is the most commonly seen complication of surgery in obstetrics and gynecology. The use of antibiotic prophylaxis has greatly decreased though not completely eliminated this adverse outcome. Postoperative infections include wound cellulitis, wound abscess, endomyometritis, pelvic cellulitis, and pelvic abscess. Infections usually manifest as fever and greater than normal postoperative pain. Refractory fevers maybe because of septic pelvic vein thrombophlebitis or maybe noninfectious in origin. Broad-spectrum antibiotics should be initiated as soon as possible when diagnosis of postoperative infection is made; most patients will respond to treatment within 24 to 48 hours when appropriate antibiotics are selected.

Unrecognized Bladder Perforation Leading to Severe Progressive Cellulitis and Candidal Infection

Retropubic midurethral slings are a minimally invasive surgical procedure used in the treatment of stress urinary incontinence and are typically associated with high cure rates and low complication rates. Bladder perforation is a known intraoperative complication that, if left unrecognized, can have significant morbidity. A 47-year-old underwent a retropubic midurethral sling, anterior colporrhaphy, and cystoscopy. She developed a suprapubic wound cellulitis that progressed to involve the right trunk and flank as well as persistent fever for more than 48 hours despite broad-spectrum antibiotics. Upon return to the operating room, the patient was found to have an unrecognized bladder perforation with mesh in the bladder. Wound culture was remarkable for Candida parapsilosis and Escherichia coli. Unrecognized bladder perforation and nonbacterial causes of infection should be considered in patients with severe progressing cellulitis despite broad-spectrum antibiotic coverage after retropubic midurethral sling placement.

Morbidity of inguinofemoral lymphadenectomy in vulval cancer.

Background. The aim of this study is to detect possible risk factors for development of short- and long-term local complications after inguinofemoral lymphadenectomy for vulval cancer. Methods. This retrospective cohort study included 34 vulval cancer patients that received inguinofemoral lymphadenectomy. The detected complications were wound cellulitis, wound seroma formation, wound breakdown, wound infection, and limb lymphoedema. Followup of the patient ran up to 84 months after surgery. Results. Within a total of 64 inguinofemoral lymphadenectomies, 24% of the inguinal wounds were affected with cellulitis, 13% developed a seroma, 10% suffered wound breakdown, 5% showed lower limb edema within a month of the operation, and 21.4% showed lower limb edema during the long-term followup. No significant correlation could be found between saphenous vein ligation and the development of any of the local complications. The 3-year survival rate in our cohort was 89.3%. Conclusions. Local complications after inguino-femoral lymphadenectomy are still very high, with no single pre-, intra-, or postoperative factor that could be incriminated. Saphenous vein sparing provided no significant difference in decreasing the rate of local complications. More trials should be done to study the sentinel lymph node detection technique.

Rice Wine Intoxication in a Nondrinker

We report a case of alcohol intoxication via topical absorption in a patient with scald burns. A 51-year-old Korean woman sustained a 21% TBSA second-degree burn to bilateral legs and left arm after spilling boiling water while cooking. She was admitted for pain control and debridement and discharged after family members were taught dressing changes. Three days later, she returned to the hospital because she was increasingly confused and stuporous. Laboratory values were within normal limits except for a blood alcohol level of 233 mg/dl and burn wound cellulitis. She required antibiotics and further debridement. Additional history noted that the family dressed the wounds with Bacitracin two to three times a day and poured rice wine over the wounds and the dressings. Although percutaneous absorption of alcohol is physiologically possible, the presence of intact skin serves as a formidable barrier. Consistent application of ethanol on the skin, such as in the form of hand disinfectants, results in relatively low but measurable blood concentrations of ethanol and acetaldehyde.1 In the context of burn physiology where the skin is damaged or absent, the absorption of ethanol can be increased substantially.