Surgical wound infections diagnosed after discharge from hospital: epidemiologic differences with in-hospital infections

Bacground: The purpose of this study was to study postoperative infections detected in hospital and after discharge and to identify risk factors for such infections.Methods: A prospective cohort study was used, with a follow-up of 30 days after hospital discharge, on 1483 patients admitted to the general surgery service of a tertiary care hospital. The main outcome measure was surgical wound infection (SWI). Relative risks, crude and multiple risk factors adjusted for by logistic regression analysis, and their 95% confidence intervals (CIs) were estimated.Results: During follow-up 155 patients showed evidence of nosocomial infection, 134 in hospital and 21 at home, yielding a cumulative incidence of 10.5%. According to several variables (age, American Society of Anesthesiologists score, serum albumin, the SENIC and National Nosocomial Infections Surveillance indexes of intrinsic patient risk, length of hospital stay, etc.) there were no differences between patients with postdischarge SWI and uninfected patients; however, differences were detected between postdischarge SWI and in-hospital SWI, as well as between patients with in-hospital SWI and patients without infections. The analysis of risk factors showed that most predictors for in-hospital SWI did not behave in the same manner for postdischarge SWI. Stepwise logistic regression analysis identified cancer (odds ratio = 4.5, 95% CI = 1.7 to 12.2, p = 0.003) and surgeon performing the operation (for medium risk OR = 4.4, 95% CI = 0.9 to 21.3, p = 0.059; for high risk, OR = 3.0, 95% CI = 0.7–13.3, p = 0.144) as independent risk factors for postdischarge SWI.Conclusions: There were important epidemiologic differences between in-hospital SWI and postdischarge SWI; most risk factors for in-hospital SWI are not predictors for postdischarge SWI.     

Postoperative wound infections detected during hsopitalization and after discharge in a community hospital

Postoperative wound infections were evaluated in 1271 patients who had 1389 surgical procedures. There were 49 postoperative wound infections identified, of which 26 (53%) were discovered after discharge. Wound infections varied from 2.5% for clean wounds up to 13.3% for dirty wounds. Among the specialties, the infection rate ranged from no infection for otolaryngologists and urologists to 8.6% for general surgeons. With routine hospital surveillance, the overall infection rate was 1.8% or 2.2%, including readmissions for infection, but less than the actual rate of 3.8%. Persons who had three procedures had an infection rate of 27.3%; for two procedures, 8.1%; and for one procedure, 3.2%. Most postoperative wound infections detected after discharge were based on clinical grounds and not positive cultures. Rehospitalization was required for seven patients because of infection. This study demonstrates that postoperative wound infection surveillance must be continued after discharge.     

Surgical wound infections: An overview

There have been three major avenues by which control over infection has been increased: (1) Preservation of host defenses, (2) antisepsis and (3) asepsis. Despite the major successes we have had, infection remains the major limitor of surgical horizons.Asepsis, the newest but long the mainstay of infection control, has probably been developed to nearly its greatest capacity. Its forefronts lie in laminar flow ventilation, ultraviolet radiation and operating theater design, all expensive and relatively inefficient. Cost and the problem of endogenous bacteria limit further advances.Antisepsis, including preventive antibiotics, is also reaching its zenith. Resistant organisms, toxicity and cost limit further applications. We desperately need a “social contract” among surgeons to limit, by defined rules, the choice of agent, the total dose and the indications for use. Controlled studies of the effects of “preventive antibiotics” on hospital ecology and infection are needed. A return to antiseptics is being and should be explored.Preservation and enhancement of host defenses is the oldest but the most neglected of these ideas. It appears to be the most exploitable now. Enhancement by nutrition, maintenance of tissue perfusion, oxygenation and immune stimulation appear to have contributed to reduction of infection rates. More success in this area seems distinctly possible.     

Methods for identifying surgical wound infection after discharge from hospital: a systematic review

Background  

Wound infections are a common complication of surgery that add significantly to the morbidity of patients and costs of treatment. The global trend towards reducing length of hospital stay post-surgery and the increase in day case surgery means that surgical site infections (SSI) will increasingly occur after hospital discharge. Surveillance of SSIs is important because rates of SSI are viewed as a measure of hospital performance, however accurate detection of SSIs post-hospital discharge is not straightforward.     

Added hospital stay due to wound infections following cardiac surgery.

To determine the prolongation of hospital stay due to postoperative wound infections following cardiac surgery, a prospective cohort study was performed by matching multiple control patients without infection to each infected patient (= case). Out of 22 cases, no patient died. No case had to be excluded from the matching process because of a lack of suitable control patients. The maximum number of controls per case was 10. The mean added stay was 12.2 days constituting a considerable prolongation of stay due to wound infection in cardiac surgery.     

Early hospital discharge after percutaneous transluminal coronary angioplasty

To determine the safety and efficacy of early hospital discharge after percutaneous transluminal coronary angioplasty (PTCA), 100 patients were studied prospectively. A telemetry observation unit was established to monitor patients having uncomplicated procedures. A total of 170 lesions were dilated, with a procedural success rate of 96% and a clinical success rate of 91%. There were no deaths or patients who required emergency bypass surgery. Four patients developed abrupt vessel closure in the catheterization laboratory. No major complications developed in the telemetry observation unit or after discharge. Patients with high-risk lesion morphology, based on the American College of Cardiology/American Heart Association Task Force guidelines, tended to have a lower success rate and more procedural complications. Coronary dissections were angiographically detected in 33 patients and stratified into 6 types. To reduce possible adverse sequelae, all patients with complex dissections were triaged in the catheterization laboratory to an in-patient monitored unit for additional management. Accordingly, 20 patients were admitted to an in-patient unit for extended observation. Excluding 4 patients with myocardial infarction, 75% (12 of 16) were discharged the next day. Initial experience with early discharge suggests that under proper conditions the procedure is safe and effective. Patients with complex coronary dissections who are at high risk for abrupt vessel closure can be promptly identified after dilatation and triaged to an appropriate monitoring area. Early discharge after PTCA offers more efficient use of hospital facilities and the opportunity to reduce hospital costs.     

Continuity of care and patient outcomes after hospital discharge

BACKGROUND: Patients are often treated in hospital by physicians other than their regular community doctor. After they are discharged, their care is often returned to their regular community doctor and patients may not see the hospital physician. Transfer of information between physicians can be poor. We determined whether early postdischarge outcomes changed when patients were seen after discharge by physicians who treated them in the hospital. METHODS: This cohort study used population-based administrative databases to follow 938833 adults from Ontario, Canada, after they were discharged alive from a nonelective medical or surgical hospitalization between April 1, 1995, and March 1, 2000. We determined when patients were seen after discharge by physicians who treated them in the hospital, physicians who treated them 3 months prior to admission (community physicians), and specialists. The outcome of interest was 30-day death or nonelective readmission to hospital. RESULTS: Of patients studied, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% (95% confidence interval [CI], 4% to 5%) and 3% (95% CI, 2% to 3%) with each additional visit to a hospital physician rather than a community physician or specialist, respectively. The effect of hospital physician visits was cumulative, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had 1, 2, or 3 visits, respectively, with a hospital rather than a community physician. The effect was consistent across important subgroups. CONCLUSIONS: Patient outcomes could be improved if their early postdischarge visits were with physicians who treated them in hospital rather than with other physicians. Follow-up visits with a hospital physician, rather than another physician, could be a modifiable factor to improve patient outcomes following discharge from hospital.     

Bite wound infections

Patients with mammalian bite wounds account for hundreds of thousands of emergency department, urgent care center, and physician office visits in the United States each year. The types of wounds encountered by physicians range from insignificant scratches to life-threatening neck and facial injuries. Infectious complications of bite wounds are common, and the consequences of these infections are significant and sometimes disabling. This article reviews the infectious complications of cat, dog, and human bite wounds. The prevention of tetanus and rabies virus infection, the appropriate antimicrobial treatment of bacterial infections, and the frequent need for surgical consultation and intervention are emphasized.     

Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy

Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery.We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive débridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps.The number of débridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4-12 mo). Late local follow-up results, both functional and aesthetic, were good.We conclude that negative-pressure wound therapy-in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps-is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.     

Surgical treatment for deep sternal wound infection after cardiac surgery

Background Deep sterna wound infection(DSWI) after median sternotomy for cardiac surgery is one of the most complex and potentially life-threatening complications. Its very difficult to treat DSWI, and there is lack of agreement regarding the best therapy strategy. Thus, we aimed to summarize our experiences of surgical treatment for DSWI, in which satisfactory clinical results were obtained. Methods We retrospectively analyzed 17 cases who suffered from DSWI after cardiac surgery in our department from January 2010 to June 2015. There were 8 male and 9 female patients with their average age of 62.7 ± 9.5 years(range 42 ~ 75 years). All patients received reservation of part of sternum combined with vacuum-assisted suction drainage and bilateral pectoralis major myocutaneous advancement flaps. Results The average interval between cardiac surgery and diagnosed DSWI was 10.9 ± 6.5 days(range 5 ~ 21 days). Time of vacuum-assisted suction drainage was 11.6 ± 4.8 days(range 5 ~ 15 days) and wound healing time was 27.3 ± 7.2 days(range 23 ~ 35 days). All patients had an uneventful postoperative recovery and good wound healing. Follow-up time was 33.7 ± 13.3 months(range 8 ~74 months). No recurrent infection was observed. Conclusions Reservation of part of sternum combined with vacuum-assisted suction drainage and bilateral pectoralis major myocutaneous advancement flaps is a simple and effective surgical strategy for the treatment of DSWI after cardiac surgery.     

Corticosteroid use after hospital discharge among high-risk adults with asthma

Despite the efficacy of corticosteroid therapy, patients hospitalized for asthma exacerbations are at high risk for re-exacerbation and death after discharge. The objective of this prospective cohort study was to evaluate adherence to inhaled corticosteroids (ICS) and oral corticosteroids (OCS) after discharge in adults hospitalized for asthma exacerbations. ICS and OCS were equipped with electronic medication monitors and were provided at discharge. Adherence (use/prescribed use x 100%) was measured by self-report and canister weight (ICS), pill count (OCS), and electronic medication monitors (both ICS and OCS) 2 weeks after discharge. Poor adherence was defined as adherence of less than 50%. The Asthma Control Questionnaire was used to assess symptom control. Sixty patients were enrolled (age 42.2 years, 98.3% African American, 65.0% female, 46.7% with history of near-fatal asthma). Electronically measured adherence to both corticosteroids dropped to approximately 50% within 7 days of discharge. Poor adherence to both corticosteroids predicted significantly worse symptom control (p = 0.04). Self-report, canister weight, and pill count all had low sensitivity (29.2%, 65.0%, and 7.7%, respectively) for detecting poor adherence. We conclude that adherence to ICS and OCS deteriorates within days of hospital discharge but may not be recognized in a substantial proportion of patients.     

Locating and interviewing alcoholics 8 years after discharge from hospital

An 8-year follow-up of 85 alcoholic men resulted in 93% interviewed or confirmed deceased. The location and interview techniques used to achieve this high completion rate are reported and the "location" of deceased subjects is discussed. A list of the agencies that might have information on the whereabouts of subjects is provided. The time course of data collection is analyzed. The characteristics of subjects lost under specific follow-up inadequacies or constraints are considered. Our findings can be used by program evaluators as a basis for decisions concerning the best use of their follow-up resources.