Independent risk factor for surgical site infection after orthopedic surgery

No significant progress has been made in the study of orthopedic surgical site infection (SSI) after different orthopedic surgery, and the analysis and prevention of risk factors for orthopedic SSI urgently need to be solved. A total of 154 patients underwent orthopedic surgery from April 2018 to December 2020. General information such as gender, age, marriage, diagnosis, surgical site, and anesthesia method was recorded. Statistical methods included Pearson chi-square test, univariate and multivariate logistic regression analyses, and receiver operating characteristic (ROC) curves. Based on Pearson’s chi-square test, sex (P = .005), age (P = .027), marriage (P = .000), diagnosis (P = .034), and surgical site (P = .000) were significantly associated with SSI after orthopedic surgery. However, in the multiple linear regression analysis, only the surgical site (P = .035) was significantly associated with SSI after orthopedic surgery. In terms of multivariate logistic regression level, surgical site (odds ratio [OR] = 1.568, P = .039) was significantly associated with SSI. ROC curves were constructed to determine the effect of the surgical site on SSI after different orthopedic surgery (area under the curve [AUC] = 0.577, 95% CI = 0.487–0.0.666). In summary, the surgical site is an independent risk factor for SSI after orthopedic surgery, and “trauma” is more likely to develop SSI than spine, arthrosis, and others.     

Surgical site infection surveillance for neurosurgical procedures: a comparison of passive surveillance by surgeons to active surveillance by infection control professionals

ISSUE: Surveillance methods for surgical site infections (SSIs) range from patient self-report to active surveillance by infection control professionals (ICPs). Surgeon questionnaires surveying SSIs are typically suboptimal due to bias, lack of standardized criteria to diagnose infection, and poor response rate. Although concurrent surveillance of SSIs by ICPs at our medical center documented an incidence of 2.2 SSIs per 100 procedures, the neurosurgeons perceived a much higher rate of SSIs. PROJECT: The neurosurgeons provided a list of patients they had clinically identified with SSIs over a 7 month period. This list was compared with a line listing of SSIs independently identified by ICPs via concurrent surveillance utilizing the Centers for Disease Control and Prevention (CDC) definitions. RESULTS: A total of 766 procedures were performed. Active surveillance by ICPs detected 17 infections (2.2/100 procedures). Of the 14 cases identified by the neurosurgeons, 3 did not meet the CDC definition of a nosocomial infection. The ICPs identified 6 SSIs not documented by the neurosurgeons. Compared to active surveillance by ICPs, the sensitivity and specificity of the neurosurgeon's identification of SSIs was 64% and 99.6%, respectively. The positive predictive value was 78.6% and the negative predictive value was 99.2%. LESSONS LEARNED: An active surveillance program is necessary for accurate identification of SSIs. The primary problem with passive surveillance by surgeons is failure to capture cases; surgeons missed 36% of cases compared to active surveillance by ICPs.     

Postdischarge surveillance: the impact on surgical site infection incidence in a Brazilian university hospital

OBJECTIVE: This prospective cohort study was carried out in a surgical unit of a university hospital in Brazil. The purpose of the study was to determine the incidence of surgical site infection (SSI) in patients during hospitalization and after discharge from the hospital. METHOD: In a sample of 630 patients who underwent surgical procedures, association among diagnosis of SSI (in-hospital or postdischarge), class of the surgery (elective or emergency), hospitalization period, patient's clinical condition (American Society of Anesthesiologists [ASA] score), classification of surgical site, and duration of surgical procedure were verified. RESULTS: Fifty SSIs were diagnosed while the patients were still in the hospital, and 140 postdischarge. Hospitalization periods >5 days and worse clinical condition (ASA III) were associated with a higher SSI incidence. Classification of SSI was not correlated to the incidence of in-hospital SSI, except for clean surgeries. Surgical procedures of >5 hours duration were correlated to SSI during hospitalization, and procedures of >2 hours duration correlated to a postdischarge SSI. Most SSIs (73.7%) were diagnosed postdischarge. CONCLUSION: Results show a high incidence of postsurgical infection detected during postdischarge surveillance, which suggests the need for postdischarge follow-ups for surgical patients.     

Risk factors for surgical site infection and delayed wound healing after orthopedic surgery in rheumatoid arthritis patients

Objective: To investigate the prevalence and the risk factors of surgical-site infection (SSI) and delayed wound healing (DWH) in patients with rheumatoid arthritis (RA) underwent orthopedic surgery.

Methods: We reviewed the records of 1036 elective orthopedic procedures undertaken in RA patients. Risk factors for SSI and DWH were assessed by logistic regression analysis using age, body mass index, disease duration, pre-operative laboratory data, surgical procedure, corticosteroid use, co-morbidity, and use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) and biological DMARDs (bDMARDs) as variables.

Results: SSI and DWH were identified in 19 cases and 15 cases, respectively. One case of SSI and three cases of DWH were recorded among 196 procedures in patients using bDMARDs. Foot and ankle surgery was associated with an increased risk of SSI (odds ratio (OR), 3.167; 95% confidence interval (CI), 1.256–7.986; p?=?0.015). Total knee arthroplasty (TKA; OR, 4.044; 95% CI, 1.436–11.389; p?=?0.008) and disease duration (OR, 1.004; 95% CI, 1.000–1.007; p?=?0.029) were associated with an increased risk of DWH.

Conclusions: Our results indicated foot and ankle surgery, and TKA and disease duration as risk factors for SSI and DWH, respectively. bDMARDs was not associated with an increased risk of SSI and DWH.     

When continuous surgical site infection surveillance is interrupted: the Royal Hobart Hospital experience

BACKGROUND: The prevalence of surgical site infections (SSI) is second only to urinary tract infections in hospitalized patients. They continue to threaten the health of hospitalized patients and impact negatively on the financial solvency of hospitals through prolonged hospitalization, increased rates of rehospitalization, and significantly increased health care costs. METHODS: We describe the effect of a 12-year surveillance program that included postdischarge follow-up and feedback to clinicians on the rate of SSI and the effect when surveillance is interrupted. Surgical procedures performed at the Royal Hobart Hospital (RHH), a university teaching hospital in Australia, between 1988 and 2001 were monitored for evidence of SSI in hospitals and for up to 30 days postoperatively. The surveillance program was inadvertently disrupted for 15 months from October 1990 to January 1992 and then recommenced. It has been ongoing since that time, apart from a 3-month interruption in 1998. Infection rates were determined on a regular basis, and these results were provided to surgeons, theatre staff, and surgical ward staff every 6 months. Patients included all adult surgical patients with an incisional wound, excluding burn patients and day-only surgical patients. RESULTS: Over the 12-year active surveillance period, 47,581 surgical procedures were followed for SSI. In-hospital SSI rates declined significantly over the study period from 4.7% (95% CI: 3.9%-5.6%) in 1988-1989 to 1.2% (95% CI: 0.8%-1.7%) in 2001 (P < .0001). Infection rates fell rapidly following the commencement of the program. This decline was halted during the period from October 1990 to January 1992 when the program was suspended. In-hospital SSI rates declined once again following the recommencement of the surveillance program, and these lower rates have been maintained. In contrast, postdischarge infection rates rose significantly from 1.2% (95% CI: 0.8%-1.7%) in 1988-1989 to 2.1% (95% CI: 1.6%-2.7%) in 2001 (P < .0001). CONCLUSION: The introduction of a program of continuous SSI surveillance at the RHH was associated with a reduction in the in-hospital and total SSI rate. This phenomenon was repeated following the recommencement of the program after a temporary interruption. Increasing numbers of SSIs are arising after hospital discharge. Many of these patients are readmitted to the hospital for further management of the SSI. Surveillance programs that do not perform postdischarge surveillance will have difficulty in capturing this data. Our experience supports the Study on the Efficacy of Nosocomial Infection Control (SENIC) findings, showing that health care facilities can achieve improved levels of infection management with active surveillance programs.     

Process surveillance: auditing infection control policies and procedures

The infection control team in a university hospital designed, implemented, and evaluated a program to audit infection control policies. Process surveillance techniques of observation and monitoring were used during surveys of patient care areas to evaluate infection control practices. Nineteen unit surveys have been completed in a 2-year period. Analysis of the program has demonstrated it to be an effective method to determine compliance with infection control policies.     

Incidence of surgical site infection after craniotomy: comparison between three months and twelve months of epidemiological surveillance

Objective: To determine the incidence of surgical site infection in patients undergoing craniotomy and to compare 12-month and 3-month post-discharge surveillance periods in terms of their impact on the incidence of surgical site infection in those patients.Methods: This was a retrospective cohort study involving 173 adult patients submitted to “clean” craniotomy, with or without implants, during the six-month period, at a university hospital in the city of São Paulo, Brazil. All the patients were evaluated in the pre-, trans- and postoperative periods and were followed for 12 months to analyze the development of surgical site infections.Results: Of the 173 patients undergoing craniotomy during the study period, 20 developed an surgical site infection during the first, and 12 months after discharge, the overall incidence of surgical site infection therefore being 11.56%, compared with a 1-month incidence of 8.67% and a 3-month incidence of 10.98%. Among the 106 patients who received implants, the 1-, 3-, and 12-month incidence of surgical site infection was 7.54% (n?=?8), 8.49% (n?=?9), and 9.43% (n?=?10), respectively. Among the 67 patients who did not receive implants, the 1-, 3-, and 12-month incidence of surgical site infection was 10.44% (n?=?7), 14.92% (n?=?10), and 14.92% (n?=?10), respectively.Conclusion: The incidence of surgical site infection after craniotomy is high. Reducing the duration of the post-discharge surveillance period from 12 months to 3 months did not cause significant losses in the numbers of surgical site infection identified or a substantial decrease in their incidence.     

Pathophysiology of surgical site infection in total hip arthroplasty

This article is a case report of a 69-year-old man who underwent a right total hip replacement procedure and developed a surgical site infection. Areas of concern in prevention and treatment of hip arthroplasty infection are presented, focusing on the pathophysiologic process involved. A review of the patient risk factors and the pathophysiologic action potentiating risk for infection include host immunity, nutritional status, diabetes, age, use of steroids or immunosuppressive drugs, rheumatoid arthritis, and urinary tract or other infections. The case report identifies the patient's age, multiple instrumentation of the bladder resulting in bacteriuria and the reinfusion of 400 cc of autologous shed blood via cell saver, a controversial risk subject, as the primary risk factors for surgical site infection in this patient. Readmission to the hospital on day 16 after the operation was completed on identification of 2 pathogenic organisms, methicillin-resistant Staphylococcus aureus and Acinetobacter calcoaceticus bio anitratus. The infection was successfully treated with oral ciprofloxacin and intravenous administration of tobramycin, preventing progression from superficial to deep infection and preserving the prosthesis.     

Efficacy of surveillance in nosocomial infection control in a surgical service

OBJECTIVE: The purpose of this study was to assess the efficacy of surveillance of nosocomial infection in infection control at a service of general surgery. DESIGN: A surveillance study that included 1483 patients with a prospective identification of nosocomial infection was carried out. Its results were discussed with the staff, and a program on nosocomial infection control was implemented. One year after the pre-intervention study, a similar study that included 1506 patients was done. The main outcome measure was nosocomial infection. Incidence rates, incidence rate ratios, crude and multiple-risk factor adjusted for by Poisson regression analysis, and their 95% confidence interval rates were estimated. RESULTS: The characteristics of the patients enrolled in both studies were compared. After the intervention, the trend was to attend patients with more severe conditions: higher frequency of liver failure, chronic obstructive lung disease, higher proportion of dirty surgical wounds, and higher scores of both Study on the Efficacy of Nosocomial Infection Control (SENIC) and National Nosocomial Infections Surveillance indices. There were no significant differences in emergency surgery, duration of surgery, age, and sex. After the intervention, unnecessary chemoprophylaxis was drastically reduced, and a significant reduction in preoperative stay was observed. The nosocomial incidence rate fell from 18.4 to 14 per 1000 patient-days. This reduction yielded an incidence rate ratio of 0.56 (95% confidence interval, 0.43%-0.74%) adjusted for several variables (SENIC index, serum creatinine level, serum albumin level, antihistamine H2 level, surgical wound, body mass index, chemoprophylaxis, and community-acquired infection). Significant reductions in surgical site infection and urinary tract infection were observed, but the rate of respiratory tract infection remained unchanged. CONCLUSIONS: Surveillance was effective in reducing nosocomial infection.     

Determinants of surgical site infection after breast biopsy

BACKGROUND: Surgical site infections (SSI) following clean and clean-contaminated ambulatory surgery at Bon Secours Cottage Health Services are monitored utilizing a postdischarge surveillance form in addition to traditional surveillance. From January 2000 to December 2002, the clean procedure SSI rate was 0.73% (31/4266) versus 1.58% (15/950) for breast biopsy, P = .04. A case-control study was performed to identify risk factors for infection. METHODS: A case patient was identified as any patient having an ambulatory breast biopsy from January 2000 to December 2002 with SSI identified by the Centers for Disease Control and Prevention (CDC) definition of nosocomial infection. For each case patient, 3 randomly selected control patients were matched by date and procedure. RESULTS: Factors significantly associated with the development of SSI were duration of surgery (case mean, 71.7 minutes vs control mean, 34.7 minutes, P < .01) and presence of surgical drains (26.7% of cases vs 6.7% of controls, P = .04). Factors determined not to be associated with SSI were obesity (P = .88) and preoperative needle localization (P = .88). CONCLUSIONS: We conclude that there is a significant difference between the breast biopsy infection rate and the clean procedure infection rate in ambulatory surgery. Duration of surgery and presence of surgical drains were associated with increased infection rate.     

Postoperative contact dermatitis caused by skin adhesives used in orthopedic surgery: Incidence,characteristics, and difference from surgical site infection

Skin adhesives are used to close clean surgical wounds. We aimed to investigate the incidence of skin adhesive-related contact dermatitis and the characteristics that differentiate it from a surgical site infection.We retrospectively analyzed patients whose surgical wound was closed using a liquid skin adhesive (Dermabond Prineo skin closure system, Ethicon, NJ) by a single surgeon between March 2018 and June 2020. Medical records were reviewed to evaluate complications indicating contact dermatitis, including wound infections and hematomas.We included 143 patients (men, 59; women, 84; mean age, 60.8 years). No patient had an early surgical site infection or wound dehiscence, but 4 (2.8%) developed postoperative contact dermatitis (week 7, 1; week 4, 2; day 9, 1). Manifestations included eczema and pruritus, without local heat or wound discharge. All cases resolved without complications, including infection.Contact dermatitis occurred in 2.8% of patients who received liquid skin adhesive, and the symptoms differed from those of surgical site infection. Patients should be informed about the risk of contact dermatitis before applying a liquid skin adhesive.