Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration

Background

Surgical site infections (SSIs) result in significant postoperative morbidity and mortality. Although many of these infections can be prevented by timely administration of preoperative antibiotics, data suggest that many patients do not receive such therapy.

Methods

A multidisciplinary team was convened that reviewed published guidelines, made antibiotic recommendations, and addressed administration issues. Responsibility for antibiotic administration was shifted from preoperative nursing staff to the anesthetist. Electronic quick orders were developed to encourage appropriate antibiotic selection and simplify order creation.

Results

Timely administration of preoperative antibiotics improved from 51% to 98% from February 2005 to February 2006. Appropriate antibiotic administered improved from 78% to 94%. The clean wound infection rate decreased from 2.7% to 1.4% over the same time period.

Conclusion

A multidisciplinary approach to prophylactic antibiotic use, including computer-guided decision support, facilitates appropriate preoperative antibiotic use, resulting in a significant decrease in surgical wound infections.     

Intracellular delivery of adenosine triphosphate enhanced healing process in full-thickness skin wounds in diabetic rabbits

Background

Small unilamellar lipid vesicles were used to encapsulate adenosine triphosphate (ATP-vesicles) for intracellular energy delivery and were tested for diabetic skin wounds in rabbits.

Methods

Diabetes was induced by alloxan. The mean peak blood glucose concentration was 505 mg/dL. One ear was made ischemic and 80 full-thickness wounds were created in 10 animals. ATP-vesicles or saline was used and healing was compared.

Results

On the non-ischemic ears, mean closure time for ATP-vesicles-treated wounds was 13.7 days versus 16.4 days for saline-treated wounds (P < .05). On the ischemic ears, mean closure time for ATP-vesicles-treated wounds was 15.3 days versus 19.3 days for saline-treated wounds (P < .01). Histological study indicated better healing and re-epithelialization in the ATP-vesicles-treated wounds.

Conclusions

Intracellular delivery of ATP accelerated the healing process of diabetic skin wounds on ischemic and non-ischemic rabbit ears. The mechanisms deserve further study but may be related to improved cellular energy supplies.     

Effects of medicinal mushroom (Sparassis crispa) on wound healing in streptozotocin-induced diabetic rats

Background

The impaired wound healing in diabetes mellitus is a major clinical problem. Sparassis crispa (SC) is a medicinal mushroom and its β-glucan content is more than 40%. This study investigated whether oral administration of SC could improve the impaired wound healing in diabetic rats.

Methods

Full-thickness skin wounds were created on the backs of streptozotocin (STZ)-induced diabetic rats. Diabetic rats were then divided into 2 groups: SC-treated group that was orally administered doses of 1,000 mg/kg body weight per day of SC for 4 weeks and a control group without SC administration. Moreover, collagen synthesis of purified β-glucan from SC was estimated in vitro.

Results

Wound closure was significantly accelerated by oral administration of SC. Furthermore, in SC-treated wounds there were significant increases in macrophage and fibroblast migration, collagen regeneration, and epithelialization compared with the control group. The levels of type I collagen synthesized by cultured human dermal fibroblasts for the SC group were significantly higher than those for the control group.

Conclusions

SC can improve the impaired healing of diabetic wounds. This effect might involve an increase in the migration of macrophages and fibroblasts, and β-glucan from SC directly increases the synthesis of type I collagen. Therefore, the use of SC may be extended to the clinical setting and prove an effective promoter of wound healing in patients with diabetes.     

Primary closure of stoma site wounds after ostomy takedown

Background

Ostomy reversal is considered a contaminated surgery and, thus, primary closure is believed to increase infection. Various closure techniques have been described and postulated to be superior to primary closure in regards to decreasing stoma site wound infections. The literature has varied in its support for this hypothesis.

Methods

A retrospective review was performed evaluating several variables including stomal closure method, patient demographics, steroid/immunosuppressant use, chemotherapy or radiation, perioperative antibiotics, and surgical indication to determine whether there was any association with the development of wound infections.

Results

Of 75 patients undergoing ostomy reversal, delayed primary closure/packing/secondary intention was used in 49 (65%), and 26 underwent primary closure (35%). Four patients (5.3%) developed stoma site infections; all had delayed primary closure or packing of their wound (P = .39). No variable was associated significantly with an increased risk of stoma site wound infections.

Conclusions

Primary closure does not increase the rate of infection.     

Is replacement of albumin in major abdominal surgery useful?

Study Objective

To evaluate retrospectively serum albumin concentrations as well as morbidity and mortalitiy of abdominal surgical patients who -if hypoalbuminemic- did not receive human albumin solutions versus those who did receive such solutions.

Design

Retrospective observational study.

Setting

Academic community hospital.

Measurements

The records of 76 consecutive patients who had undergone elective abdominal surgery were reviewed. Preoperative and postoperative serum albumin concentrations up to the seventh day after surgery were recorded. Morbidity and mortality were followed until the time of discharge from the hospital.

Results

38 patients who received albumin replacement if they were hypoalbuminemic versus 38 patients who did not receive albumin replacement showed no significant difference in cumulative (P < 0.52) or individual postoperative complications (infections P < 0.35, cardiovascular complications P < 1.0, organ failure P < 0.67, thromboembolic incidents P < 0.26), and mortality (P < 0.47).

Conclusions

Postoperative serum albumin concentration had no correlation with postoperative morbidity. There is no justification for perioperative albumin replacement in abdominal cancer surgical patients.     

Wound infection after colostomy closure for imperforate anus in children: utility of preoperative oral antibiotics

Background/Purpose

There is little published data on the efficacy of surgical infection prophylaxis in children. The purpose of this study was to assess wound infection rate in children undergoing colostomy closure for imperforate anus and evaluate the impact of bowel preparation and antibiotics.

Methods

Children younger than 18 years with imperforate anus who had a colostomy closure between January 1996 and December 2007 were identified. Data collected included demographics, bowel preparation, antibiotics, operative details, and postoperative infections. Comparison of mechanical bowel preparation and intravenous antibiotics with and without oral antibiotics was compared using χ² tests. Significance was defined as P < .05.

Results

A total of 118 patients were identified. Primary skin closure was done in 97%. Mechanical bowel preparation was used in 93%, intravenous antibiotics in 97%, and oral preoperative antibiotics in 52%. Wound infections occurred in 14% (n = 17). The addition of oral antibiotics to the standard regimen of mechanical bowel preparation with intravenous antibiotics did not alter infection rate (13% versus 17%, P = .64).

Conclusion

Wound infection in children undergoing elective colostomy closure for imperforate anus was 14%. Infection rate was not affected by use of oral antibiotics. Future studies may allow specific guideline development for infection prophylaxis in pediatric patients.     

Differential use of Erk1/2 and transforming growth factor beta pathways by mid- and late-gestational murine fibroblasts

Background

Previously, we demonstrated the rapid closure of mid-gestational excisional murine wounds at 32 hours. In this study, we theorized that mid-gestational wounds would be completely regenerated, whereas late-gestational wounds would heal with scar formation at 48 hours. Furthermore, we theorized that mid- and late-gestational fibroblasts differentially use the transforming growth factor β and mitogen-activated protein kinase pathways.

Methods

Three-millimeter excisional cutaneous wounds were made on murine mid- (embryonic day 15 [E15]) and late-gestational (E18) fetuses and harvested at 48 hours for histology. Percent wound closure was calculated. E15 and E18 fibroblasts were cultured overnight for in vitro scratch wound assay in the presence of the activin receptor-like kinase 4-5-7, Erk1/2, and p38 inhibitors.

Results

E15 wounds healed in a regenerative manner, whereas E18 wounds exhibited scar formation. In vitro scratch closure was similar in the E15 and E18 groups at 8 hours; yet, it increased in E15 compared with E18 groups with activin receptor-like kinase 4-5-7 and Erk1/2 inhibitors. p38 inhibition resulted in reduced scratch closure in both groups.

Conclusion

The scarless mid-gestational excisional wounds compared with the scar-forming late-gestational wounds provides a model to study scar formation. This study also suggests that variable transforming growth factor β and Erk1/2 signaling may influence differences in wound closure between mid- and late-gestational wounds.     

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. χ² 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.     

Nontransplant surgical interventions in progressive familial intrahepatic cholestasis

Background

Progressive familial intrahepatic cholestasis (PFIC) is a family of rare childhood diseases that was universally fatal until the development of liver transplant. In the last 20 years, the use of nontransplant surgery to treat PFIC has become the standard of care. There are various surgical techniques that have been performed. There are no reviews evaluating the outcome of these operations.

Methods

A systematic search of the literature for articles evaluating the outcome of nontransplant surgical interventions in PFIC patients was performed. Data from these studies was abstracted and summarized.

Results

No trials have been performed addressing nontransplant surgical interventions in PFIC patients. We analyzed 11 case series and case reports. Generally, patients had successful outcomes (81%) with cessation of progression of disease and resolution of symptoms. Treatment failures were often associated with more advanced disease.

Discussion

There is no evidence to demonstrate a superiority of one type of nontransplant surgical intervention in PFIC patients. We propose the development of a registry and standardization of outcomes measurements to allow improved comparison of results.     

The use of vacuum assisted closure therapy in the management of Fournier's gangrene

Background

Vacuum Assisted Closure (VAC; Kinetic Concepts, Inc., San Antonio, TX) has been used to successfully treat a variety of complex wounds. This technique was investigated for use in managing Fournier's gangrene following initial debridement.

Methods

Ten patients with Fournier's gangrene were treated in this study. After initial surgical debridement, 5 were treated using conventional therapy and 5 were treated with VAC at each dressing change. The effectiveness and cost of VAC for this indication were assessed; patient and physician satisfaction were also determined.

Results

Conventional and VAC treatment were equally effective in healing the wounds. The total costs of each treatment were similar. With the use of VAC, patients had fewer dressing changes, less pain, fewer skipped meals, and greater mobility. Hands-on treatment time was decreased for physicians using VAC.

Conclusions

VAC therapy is an effective and economical way to manage Fournier's gangrene. Patients and physicians were more satisfied with VAC therapy than with conventional treatment.     

Modern wound care for the poor: a randomized clinical trial comparing the vacuum system with conventional saline-soaked gauze dressings

Background

A clinical randomized trial was performed to determine whether a simple homemade wound vacuum-dressing system (HM-VAC) is a feasible alternative to the use of conventional saline-soaked gauze dressings (WET) for the treatment of complex wounds in a resource-poor hospital.

Methods

Forty patients were analyzed to compare the HM-VAC and the WET dressings. The HM-VAC was assembled with tools available in most operating room worldwide. The primary outcome measure was the time of complete wound healing. Additionally, the costs of both methods were calculated.

Results

The time required to achieve complete healing was 16 days in the HM-VAC group compared with 25 days in the WET group (P = .013). The HM-VAC costs US $360 per case, and the WET technique costs US $271 per case (P = .008).

Conclusions

The HM-VAC should be considered in underdeveloped countries to provide modern management for complex wounds because healing is significantly faster compared with conventional wound care. Although the HM-VAC is more costly than the conventional approach, it is probably affordable for most resource-poor hospitals.     

The sartorius muscle flap: an important adjunct for complicated femoral wounds involving vascular grafts

Introduction

Femoral wound complications can threaten vascular grafts. Muscle flaps can be used to facilitate soft-tissue coverage and graft salvage. We report a series of sartorius flaps performed by vascular surgeons in the treatment of complicated femoral wounds.

Methods

Rotational sartorius flaps were performed to attempt salvage of underlying vascular grafts. We reviewed a prospective database to determine the outcomes of sartorius flaps on facilitating wound healing and graft salvage and patency.

Results

From 2005 to 2008, 21 sartorius flaps were performed in infected or threatened femoral wounds. Original operations included femoral endarterectomy with patch repair in 8, aortofemoral graft in 6, axillofemoral graft in 4, and femoral-distal bypass in 3 patients. Complete wound healing occurred in 18 patients (86%). Primary wound closure was achieved in 7 patients. Secondary wound closure was achieved in 11 patients with mean healing time of 2.3 months. All vascular reconstructions remained patent at the 9.5-month follow-up.

Conclusions

Sartorius muscle flaps are effective at facilitating complicated femoral wound healing while maintaining graft salvage and patency.     

Lights, camera, surgery: a novel pilot project to engage medical students in the development of pediatric surgical learning resources

Background/Purpose

It is important to engage junior medical students in the pediatric surgical environment to showcase possible future career choices. Our aim was to assess how the students valued their experience in the realm of clinical learning, exposure to surgical careers, and development of skill sets necessary for creating learning resources.

Methods

A novel pilot project entitled Lights, Camera, Surgery engaged 13 medical students in the production of instructional videos of basic surgical procedures. An electronic survey questionnaire allowed the students to provide formal feedback on the project outcomes.

Results

Of the students who responded, 87.5% expressed appreciation of the enhanced clinical experience. All of the students either agreed or strongly agreed that the project afforded them valuable leadership experience, practical skills in creating educational learning resources, and opportunities to explore careers in surgery. All of the students either agreed or strongly agreed that the project allowed them to gain valuable skills in educational video production. The project videos are now available as educational tools.

Conclusions

Engaging medical students in the production of surgical videos potentially improves leadership skills and promotes the use of educational resources while affording them opportunities to explore pediatric surgery as a future career choice.     

Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections

Background

Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs) increase morbidity and mortality. We examined the impact of the MRSA bundle on SSIs.

Methods

Data regarding the implementation of the MRSA bundle from 2007 to 2008 were obtained, including admission and discharge MRSA screenings, overall MRSA infections, and cardiac and orthopedic SSIs. Chi-square was used for all comparisons.

Results

A significant decrease in MRSA transmission from a 5.8 to 3.0 per 1,000 bed-days (P < .05) was found after implementation of the MRSA bundle. Overall MRSA nosocomial infections decreased from 2.0 to 1.0 per 1,000 bed-days (P = .016). There was a statistically significant decrease in overall SSIs (P < .05), with a 65% decrease in orthopaedic MRSA SSIs and 1% decrease in cardiac MRSA SSIs.

Conclusion

Our data demonstrate that successful implementation of the MRSA bundle significantly decreases MRSA transmission between patients, the overall number of nosocomial MRSA infections, and MRSA SSIs.     

More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center

Background

The purpose of this study was to determine the rate of surgical site infection for open elective umbilical hernia repairs and to identify the factors related to an increased risk of infection and/or recurrence.

Methods

A retrospective analysis of 152 open elective umbilical hernia repairs between 2003 and 2007 was performed.

Results

Overall, 19% of repairs became infected. Both high ASA classification (P = .01) and mesh repair (P = .01) significantly predicted wound infection, whereas age >60 years, body mass index >30, smoking, immunosuppression, diabetes, and hernia size did not. Only 2 of 17 infected mesh repairs required removal of the mesh. The recurrence rate was 1.5% for mesh and 9.2% for suture repairs.

Conclusions

Umbilical hernia repair is associated with a high rate of infection, and most superficial mesh infections can be treated with antibiotics alone. In addition, mesh repair of umbilical hernias decreased the rate of recurrence but increased the risk of infection compared with suture repairs.     

Thrombocytes are effectors of the innate immune system releasing human beta defensin-3

Background

Thrombocyte concentrate i.e. platelet-rich plasma (PRP) has become a popular adjunct for many surgical procedures. It is believed to improve bone and soft tissue healing. Recently antimicrobial effects of the autologous preparation were reported by several groups. In this study we investigated the antimicrobial effect of PRP against gram-negative microbes which frequently cause severe complications in orthopaedic trauma surgery.

Methods

Platelet-rich plasma was produced from liquid preserved thrombocyte concentrates. ELISA, Western blot and immunohistochemistry were preformed to investigate the release and content of platelet concentrates. A radial diffusion assay was used to detect antimicrobial effects of PRP.

Results

We detected the human beta defensin-3 in bactericidal concentrations in platelet preparations by ELISA, Western blot and immunohistochemistry. In antimicrobial testing we demonstrated effective inhibition of Escherichia coli (ATCC 11303), Bacterium megaterium (ATCC 14581), Klebsiella pneumoniae (ATCC 13883), Enterococcus faecalis (ATCC 29212) and Proteus mirabilis (ATCC21100).

Conclusion

With this study we demonstrate antimicrobial action of a popular adjunct for orthopaedic and trauma surgery against gram-positive and gram-negative bacteria. We have identified a possible mechanism of action via the secretion of HBD-3 as a first line defence in contaminated wounds and in elective application of PRP. This finding supports a broader spectrum of clinical indications for an autologous platelet preparation.     

Morbidity and mortality of colostomy and its closure in children

Background

This study evaluated the complications of colostomy and its closure in infants and children.

Methods

One hundred forty-six colostomies were performed in 86 neonates, 23 infants, and 37 children older than 1 year. These children underwent colostomies for anorectal malformation (84), Hirschsprung’s disease (47), and other miscellaneous (15) conditions like colonic atresia, volvulus, rectal tuberculosis, traumatic rectal perforation, and intestinal obstruction caused by ascariasis.

Results

Of these, 17 (11.6%) had early complications, and 80 (69.8%) had stomal complications. Three patients died, but only 1 death was directly related to colostomy. Colostomy prolapse, peristomal excoriation, and malnutrition were the major complications. The complications were not dependant on the children’s age or primary indication. Sigmoid colostomy had a lower malnutrition rate than transverse colostomy (34.9% v 16.9% P = .009). Among the 56 children who underwent colostomy closure, major complications include death (1.8%), anastomotic leak (7.1%), and wound infection (12.6%).

Conclusions

A divided sigmoid colostomy should be performed whenever possible. Proper stomal care, regular nutritional assessment, and early closure of the colostomy would minimize morbidity and mortality of colostomy and its closure.     

Definitive surgical management of antenatally diagnosed exomphalos

Background/Purpose

The management of exomphalos is controversial with many centers in the United Kingdom and elsewhere advocating a conservative nonsurgical approach for the larger examples. Nevertheless, this approach is not without problems or complication. The aim of the study was to ascertain the outcome of all infants with an antenatally diagnosed exomphalos treated recently at our institution using a policy of aggressive abdominal wall closure.

Methods

This is a retrospective review of all infants with exomphalos treated from January 1995 to September 2002.

Results

There were 35 infants, all of whom underwent surgery. These were separated into 3 groups: group A (all exomphalos minor) underwent primary closure (n = 11), group B (exomphalos major) underwent primary closure (n = 13), and group C (exomphalos major) underwent staged closure involving a silo (n = 11). Infants in group C had a lower birth weight (P = .05) and were less mature (P = .06). They required longer periods of ventilation (P < .001), a longer hospital stay (P = .001), and a longer period to achieve full enteral feeds (P < .001). Overall survival was 34 (97%) of 35 infants. One premature infant who was born with a ruptured exomphalos sac (birth weight, 862 g) died of nonsurgical complications (sepsis and respiratory failure) early after the creation of a silo.

Conclusions

An aggressive surgical approach in infants with exomphalos is a safe option resulting in effective abdominal wall closure. This requires a skilled multidisciplinary approach and possibly greater resources than other options.     

Adhesive bonds or percutaneous absorbable suture for closure of surgical wounds in children. Results of a prospective randomized trial

Background

Surgeons have become increasingly interested in replacing conventional sutures by means of adhesive bonds for the closure of skin wounds. There are several advantages to the use of adhesive bonds compared with the conventional sutures.

Methods

Between January and August 2001, all the wounds in children after groin surgery were closed with an adhesive, N-butylcyanoacrylate (Indermil, Locite Corp, ’s-Hertogenbosch, The Netherlands), or with a suture, polyglactin 5-0 (Vicryl), intracutaneously. Fifty Inguinal wounds were treated with Indermil and 50 with Vicryl. Wounds were evaluated for hematoma, infection, dehiscence, or formation of granuloma. A scale from 1 to 10 expressed the cosmesis by patient and surgeon.

Results

The most remarkable difference in wound healing was dehiscence of the wound in 26% of cases in the adhesive group and no dehiscence in the suture group. The cosmesis of the wounds was marked with an 8.6 in the suture group and in the adhesive group with a 6.8.

Conclusions

Wound dehiscence was seen significantly more frequent in the patients in whom the wound was closed with N-butylcyanoacrylate. The cosmesis of wounds closed with tissue glue was significantly lower then the cosmesis after suturing. Therefore, the authors advise, on the basis of this prospective randomized trial, that surgical wounds in children should be closed with a intracutaneous absorbable suture.     

Conflicts in wound classification of neonatal operations

Background/Purpose

This study sought to determine the reliability of wound classification guidelines when applied to neonatal operations.

Methods

This study is a cross-sectional web-based survey of pediatric surgeons. From a random sample of 22 neonatal operations, participants classified each operation as “clean,” “clean-contaminated,” “contaminated,” or “dirty or infected,” and specified duration of perioperative antibiotics as “none,” “single preoperative,” “24 hours,” or “>24 hours.” Unweighted κ score was calculated to estimate interrater reliability.

Results

Overall interrater reliability for wound classification was poor (κ = 0.30). The following operations were classified as clean: pyloromyotomy, resection of sequestration, resection of sacrococcygeal teratoma, oophorectomy, and immediate repair of omphalocele; as clean-contaminated: Ladd procedure, bowel resection for midgut volvulus and meconium peritonitis, fistula ligation of tracheoesophageal fistula, primary esophageal anastomosis of esophageal atresia, thoracic lobectomy, staged closure of gastroschisis, delayed repair and primary closure of omphalocele, perineal anoplasty and diverting colostomy for imperforate anus, anal pull-through for Hirschsprung disease, and colostomy closure; and as dirty: perforated necrotizing enterocolitis.

Conclusions

There is poor consensus on how neonatal operations are classified based on contamination. An improved classification system will provide more accurate risk assessment for development of surgical site infections and identify neonates who would benefit from antibiotic prophylaxis.