Comparison of pediatric appendicitis outcomes between teaching and nonteaching hospitals

Purpose

The aim of the study was to determine the outcomes of pediatric appendicitis between a teaching and nonteaching institution.

Methods

A retrospective review of all patients younger than 18 years treated for appendicitis between 1998 and 2007 was performed. The teaching institution has its own general surgery residency program, and the nonteaching institution has no surgical resident involvement. Both hospitals are part of a larger system and were similar except for resident involvement. Study outcomes included postoperative morbidity and length of hospitalization (LOH). Patients with perforated appendicitis treated nonoperatively were excluded. Data were analyzed using Wilcoxon rank sum test and χ² analysis with P < .01 considered significant.

Results

Seven hundred ninety-two patients were treated at the teaching institution (mean age, 10.9 years; 62% male) and 1670 at the nonteaching institution (mean age, 11 years; 61% male). The perforated appendicitis rate was 31% at the teaching institution and 26% at the nonteaching institution (P = .008). Forty-five patients at the teaching institution and 14 at the nonteaching institution with perforated appendicitis were treated nonoperatively and excluded. For nonperforated appendicitis, despite similar rates of postoperative wound infection, abscess drainage, and readmission within 30 days between the 2 institutions, LOH was shorter in the teaching institution (1.4 ± 1.0 vs 1.8 ± 1.4 days; P < .0001). For perforated appendicitis, LOH and rates of wound infection, abscess drainage, and readmission within 30 days were similar between the 2 institutions.

Conclusions

Children with nonperforated appendicitis cared for at a teaching institution had similar postoperative morbidity and shorter LOH compared to a nonteaching institution. In patients with perforated appendicitis, postoperative morbidity and LOH were similar between teaching and nonteaching institutions. Overall, the presence of surgical trainees did not adversely impact on the quality of care for children with appendicitis.     

Outcome of laparoscopic appendectomy for perforated appendicitis in children

Background

The aim of this study was to evaluate the outcome of laparoscopic (LA) vs open appendectomy (OA) in patients with perforated appendicitis in our center.

Methods

Retrospective review from July 2002 to April 2007 (institutional review board-approved), evaluating 281 patients with perforated appendicitis based on surgical approach. We compared demographics, mean operative time, length of stay (LOS), infectious complications, and follow-up in patients with OA (n = 213) and LA (n = 68).

Results

Laparoscopic appendectomy patients were significantly older (12 vs 9.4 years), heavier (51.8 vs 36.6 kg) and more frequently girls (47.8% vs 34.3%). Mean operative time was longer in LA (72.6 vs 50.2 minutes). Median LOS was 5 days in LA and 6 days in OA. Few patients in each group required a drainage procedure for a persistent abscess (LA 4.4%, OA 4.7%; P = 1.000). Laparoscopic appendectomy patients had fewer wound infections (1.5% vs 9.5%; P = .034), and less follow-up visits were needed (>2 clinic visits 4.5% vs 16.4%; P = .013).

Conclusion

Laparoscopic appendectomy has a shorter median LOS, a trend toward less postoperative infectious complications, and fewer clinic visits than OA, which makes it a safe and effective procedure for patients with perforated appendicitis.     

Pediatric appendicitis in New England: epidemiology and outcomes

Background

Acute appendicitis is among the most common indications for surgery in children in the Western world. The epidemiology of acute appendicitis in the United States has not been recently analyzed in a population-based cohort study.

Methods

Here, we describe the epidemiology of acute appendicitis in the pediatric population in New England from 2000 to 2006.

Results

Our results show that there is clustering of perforated and nonperforated appendicitis by hospital catchment area (Moran I index 0.01 and 0.03, respectively). The overall incidence of nonperforated appendicitis decreased over our study period by 9.7% (P < .05), the proportion of perforated appendicitis did not change significantly over our study period, and there was a 38% decrease in the proportion of negative appendectomies (P < .05).

Conclusions

There were trends toward increased operative volume for pediatric surgeons as well as sharp increases in the use of laparoscopy and early discharge with home health services. Our results demonstrate that the epidemiology, outcomes, and trends in treatment of acute appendicitis continue to change.     

Tip appendicitis: clinical implications and management

Background

Tip appendicitis describes a rare condition involving inflammatory changes of the distal appendix. We discuss the significance and management of this entity when it is identified on computed tomography (CT) imaging.

Methods

CT scans performed at our institution between 2003 and 2007 were reviewed to identify cases of tip appendicitis. Patients were divided into 2 groups, determined by the confirmation of appendicitis on histopathology. Radiological findings and the clinical courses of both groups were documented and compared using univariate analysis.

Results

Of 18 patients with the CT finding of tip appendicitis, appendicitis was ultimately confirmed in 39%. Patients in this group had a higher rate of right lower quadrant (RLQ) tenderness (100% vs 55%, P = .04), leukocytosis (14.2 vs 10.5, P = .03), and clinical suspicion for acute appendicitis (43% vs 0%, P = .02). There were no complications or re-admissions.

Conclusions

The CT finding of tip appendicitis can be managed conservatively in a subset of patients with low clinical suspicion for acute appendicitis.     

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.     

Is it necessary to drain all postoperative fluid collections after appendectomy for perforated appendicitis?

Purpose

Children treated for perforated appendicitis can have significant morbidity. Management often includes looking for and draining postoperative fluid collections. We sought to determine if drainage hastens recovery.

Methods

Children with perforated appendicitis treated with appendectomy from 2006 to 2009 were reviewed. Patients with postoperative fluid that was drained were compared with patients with undrained fluid with regard to preoperative features and postoperative outcomes. Statistical analyses included paired Student's t tests, Mann-Whitney U test, and linear regression.

Results

Five hundred ninety-one patients were reviewed. Seventy-one patients had postoperative fluid, of whom 36 had a drainage procedure and 35 did not. There was no significant difference in white blood cell count at the time of assessment for drainage (16.4 ± 4.0 vs 14.6 ± 4.9, P = .14), days with fever (3.5 ± 3.0 vs 2.9 ± 2.5, P = .35), or readmission rate (19% vs 31%, P = .28). After multivariate linear regression, larger fluid volumes were associated with prolonged length of stay (LOS) (P = .03). For fluid collections between 30-100 mL, there was no significant difference in LOS between the drain and no-drain groups (9.8 ± 3.5 vs 10.9 ± 5.2 days, P = .51).

Conclusion

After appendectomy for perforated appendicitis, larger postoperative fluid collections are associated with prolonged LOS. Drainage of collections less than 100 mL may not hasten recovery.     

An evidence-based definition for perforated appendicitis derived from a prospective randomized trial

Purpose

Appendicitis is the most common urgent condition in general surgery, and yet there is no evidence-based definition for perforation. Therefore, all retrospective data published on perforated appendicitis are unreliable because of an ill-defined denominator. For approximately 2 years beginning in April 2005, we performed a prospective randomized trial investigating 2 different antibiotic regimens for perforated appendicitis. During this study, we strictly defined perforation as a hole in the appendix or a fecalith in the abdomen. Before this prospective study, perforation was staff surgeon opinion. We investigated the abscess rates in both the perforated and nonperforated appendicitis populations before and during the study to determine if our definition was safe and that there was not an increased risk of abscess formation in patients treated as nonperforated.

Methods

Records of all patients undergoing laparoscopic appendectomy for appendicitis during the immediate 2 years before using the definition were compared to those treated in the 2 years after the definition was implemented. Interval and incidental appendectomies were ruled out. The postoperative abscess rate (when perforation was not defined) was compared to the abscess rate of those for whom perforation was strictly defined.

Results

There were 292 patients treated for acute nonperforated appendicitis in the 2 years before the definition and 388 patients after the definition. There were 131 patients treated for perforated appendicitis before the definition and 161 after the definition was implemented. The abscess rate in those with perforated appendicitis increased from 14% to 18% after the definition was used. However, after the definition began to be used, the abscess rate for those patients treated as nonperforated decreased from 1.7% to 0.8%.

Conclusions

Defining perforation as a hole in the appendix or a fecalith in the abdomen is effective in identifying the patients at risk for postoperative abscess formation. Application of these criteria would allow substantial reduction in therapy for patients with purulent or gangrenous appendicitis who do not possess the same abscess risk. These data outline the first evidence-based definition of perforation.     

Appendicitis in northern aboriginal children: does delay in definitive treatment affect outcome?

Background

The treatment of northern aboriginal children (NAC) is often complicated by distance from a treating facility. We sought to compare outcomes of NAC requiring transfer with appendicitis to those who presented locally. We hypothesized that NAC with appendicitis experienced higher rates of perforation and increased length of stay (LOS).

Methods

A retrospective chart review of 210 appendectomies was performed. Charts were reviewed for age, sex, weight, days of symptoms before presentation, time of transfer, leukocyte count (white blood cell count), usage of antibiotics prior to transfer, time to operation, type of procedure and findings, pathology, postoperative outcomes, and LOS.

Results

Sixty-eight children were NAC, whereas 142 were local. The average transfer times for NAC was 10 hours (range, 4-20 hours). The two groups had similar ages (11.1 vs 10.7 years), time to presentation (1.64 vs 1.85 days), and LOS (2.91 vs 2.90 days). Significantly higher perforation rates (44 vs 28%; P = .02), higher white blood cell count (17.9 vs 16.0; P = .02), and longer times to operation after arrival (10.3 vs 7.0 hours; P = .0002) were noted in NAC. Postoperative complications were similar between groups. Forty-seven (69%) NAC received antibiotics prior to transfer, which did not affect rate of rupture.

Conclusion

NAC with appendicitis experience longer transfer times and higher perforation rates than local children without a difference in length of stay or complications. Pretransfer antibiotics do not reduce perforation rates but may impact complications. We endorse their use if a delay in transfer is anticipated.     

Emergent vs urgent appendectomy in children: a study of outcomes

Background

Emergent appendectomy (EA) in children is still considered surgical dogma and continues to be recommended as a standard of care. This study examined whether emergent operation has any outcome advantages over urgent operation.

Methods

The charts of children treated for appendicitis during a recent 28-month period at 2 children's hospitals, where appendectomies are not performed between midnight and 7 am, were reviewed. Outcomes were compared between patients who underwent EA (within 8 hours of presentation) vs those who underwent urgent appendectomy (UA, after 8 hours).

Results

Three hundred sixty-five children met the criteria for the study. One hundred sixty-one (44%) were in the EA group (5.3 ± 2.1 hours), and 204 (56%) were in the UA group (16.8 ± 9.7 hours). The incidence of gangrenous or perforated appendicitis was significantly higher in the EA group (47% vs 36%, P = .04). There were no significant differences between EA and UA in postoperative outcomes, including readmissions (3.7% vs 1.0%, P = .08), wound infections (0.6% vs 2.4%, P = .17), or postoperative abscesses (1.9% vs 1.5%, P = .77). There were no significant differences in average hospital stay or average hospital charges between EA and UA (3.2 days for both, $14,775 vs $14,850), respectively.

Conclusions

Emergent appendectomy in children has no advantages over UA with respect to gangrene and perforation rates, readmissions, postoperative complications, hospital stay, or hospital charges. Performance of a UA at a time convenient to the surgeon should be considered within the standard of care.     

Appendicitis in the obese child

Background/Purpose

Little data exist that examine the surgical challenges of obese children. We hypothesize that obesity affects the presentation, diagnosis, surgery, and postoperative course in children with appendicitis.

Methods

Cases of all children treated for appendicitis over 6 years were reviewed retrospectively. Demographics, presentation, pathology, and hospital course were examined.

Results

A total of 282 cases were reviewed; 25 were moderately obese and 31 very obese (VO), which were defined, respectively, as greater than 1.5 and greater than 2 standard deviations above the standardized mean weight for age. Groups were similar in age, sex, presentation, use of ultrasound, and surgical management. Compared with the nonobese group, median operative time was higher in the VO group (63.5 vs 55.5 minutes; P = .028), with the association between obesity and longer operative time maintained when stratifying for perforated/nonperforated and open/laparoscopic cases. Almost twice as many VO children were in the hospital for more than 5 days (nonobese 23.6%, VO 40.0% [odds ratio, 2.2; 95% confidence interval, 0.99-4.8]). This association between obesity and longer length of stay was seen when stratifying for both perforated and nonperforated cases. In the perforated group, higher rates of postoperative wound infections and significantly longer times to full diet and ambulation likely contributed to these longer stays.

Conclusions

Childhood obesity is associated with longer surgery and hospital stays and increased risk of postoperative infections. Obesity should be considered an important variable when looking at surgical outcomes in the pediatric population.     

Single-incision laparoscopic appendectomy vs multiport laparoscopic appendectomy in children: a retrospective comparison

Background

Minimally invasive surgery is commonly used to treat appendicitis. Single-incision laparoscopic surgery is an attractive modality to treat a commonly occurring problem with the advantage of minimal or possibly no scarring. We sought to compare our results of single-incision laparoscopic appendectomy (SILA) with those of patients undergoing traditional multiport laparoscopic appendectomy (MPLA).

Patients and Methods

A retrospective review of all patients who underwent a minimally invasive appendectomy from September 2009 to February 2010 was performed. The patients were divided into 2 groups based on if they had a SILA or a traditional MPLA. Outcomes including demographics, diagnosis, operative time, length of stay, narcotic usage, and complications were evaluated.

Results

A total of 110 patients underwent appendectomy. There were 50 patients who underwent SILA and 46 patients who underwent MPLA. Fourteen patients with perforated appendicitis were excluded. Mean age (11.1 vs 11.7 years, P = .43), weight (43.3 vs 50.9 kg, P = .27), and length of stay (1.1 vs 1.2 days, P = .56) were comparable between both groups. Operative time for SILA was slightly longer (33.8 vs 26.8 minutes, P = .01). Overall intravenous narcotic use was lower in the SILA group (0.9 vs 1.4 doses, P = .01), but there was no difference in the patients who also received ketorolac (0.8 vs 1.0 doses, P = .6). Four patients in the SILA group developed superficial wound infections and 1 patient in the SILA group was admitted for postoperative abscess.

Conclusions

Single-incision laparoscopic appendectomy is safe and effective in the pediatric population. Further studies should be performed to determine the impact on operative time and postoperative narcotic requirements.     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A comparative study with the open appendectomy—our experience

Purpose

Good outcomes have been reported with laparoscopic appendectomy (LA) for uncomplicated appendicitis in children, but the use of laparoscopy for complicated appendicitis in children is more controversial. This is related to a higher incidence of postoperative abdominal and wound infections. The purpose of this trial was to retrospectively compare LA and open appendectomy (OA) for complicated appendicitis and evaluate the efficacy of LA in children with complicated appendicitis.

Methods

The outcome of 128 patients with complicated appendicitis in children was retrospectively analyzed. There were 80 children in the LA group and 48 in the OA group. The appendectomies were performed by a single senior surgeon and his surgical trainees. There was no selection of cases for LA. Data collection included demographics, operative time, resumption of diet, infectious complications (wound infection and intraabdominal abscess), length of hospitalization, and duration of antibiotic use.

Results

There were no cases of LA that required conversion to OA. The operative time for LA (88.5 ± 28.8 minutes for LA vs 71.8 ± 30.6 minutes for OA; t = 3.10; P = .002) was longer. Patients in the LA group returned to oral intake earlier (1.8 ± 0.6 days for LA vs 2.8 ± 0.8 days for OA; t = −8.04; P < .01) and had a shorter length of hospital stay (6.5 ± 2.2 days for LA vs 7.8 ± 2.9 days for OA; t = −2.87; P = .005). The incidence of wound infection (1/80 [1.3%] for LA vs 6/48 [12.5%] for OA; P < .05) and postoperative intraabdominal abscess (2/80 [2.5%] for LA vs 7/48 [14.6%] for OA; P < .05) in LA group was lower. No significant difference was found in the duration of antibiotic administration between the 2 groups (5.8 ± 1.8 days for LA vs 6.3 ± 2.3 days for OA; t = −1.37; P = .174). No mortality was observed in either group.

Conclusions

The minimally invasive laparoscopic technique is feasible, safe, and efficacious for children with complicated appendicitis. Laparoscopic appendectomy should be the initial procedure of choice for most cases of complicated appendicitis in children.     

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Objective

The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.

Data Source

Data were obtained from PubMed, MEDLINE, and citation review.

Study Selection

We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions:

(1)

What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis?

(2)

For patients with perforated appendicitis treated with appendectomy:

a.

What perioperative intravenous antibiotics should be used?

b.

How long should perioperative intravenous antibiotics be used?

c.

Should oral antibiotics be used?

(3)

For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?

Results

Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.

Conclusions

Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.     

An evidence-based clinical protocol for diagnosis of acute appendicitis decreased the use of computed tomography in children

Purpose

The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.

Methods

Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.

Results

One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).

Conclusions

Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.     

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.     

Comparison of perioperative outcomes after combined thoracoscopic-laparoscopic esophagectomy and open Ivor-Lewis esophagectomy

Background

Thoracoscopic-laparoscopic esophagectomy (TLE) has gained popularity in specialized centers. This study compares the perioperative outcomes of TLE and Ivor-Lewis esophagectomy (ILE).

Methods

Forty-four consecutive TLEs were compared with 46 historical ILEs. Outcomes included surgical time and blood loss, hospital length of stay, 30-day mortality rate, and complications.

Results

TLE took longer to perform (543 vs 437 min; P < .01) than ILE, but produced less blood loss (407 vs 780 mL; P < .01). The median length of stay and 30-day mortality did not differ between groups. Cardiovascular (41% for TLE vs 30% for ILE; P = .19) and pulmonary complications (31% TLE vs 30% ILE; P = 1.0) occurred frequently in both groups, but TLE patients had fewer wound complications (4% TLE vs 17% ILE; P = .05).

Conclusions

Despite longer surgical times, TLE produced decreased intraoperative blood loss and wound complications. These findings suggest that with further technical refinement TLE may ameliorate the morbidity seen with ILE.     

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

Introduction

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

Methods

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

Results

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

Conclusion

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.     

Impact of a patient care pathway protocol on surgical site infection rates in cardiothoracic surgery patients

Background

We hypothesized that implementing a quality care initiative, including peri-incisional antibiotic administration, tight blood glucose control, and hair removal with clippers would reduce surgical site infection (SSI) rates in patients undergoing coronary artery bypass grafting (CABG), with or without valve replacement.

Methods

Patients undergoing CABG were studied retrospectively, before (n = 808) and after (n = 674) instituting a patient care protocol. The pathway included peri-incisional antibiotics, tight glucose control (80 mg/dL-110 mg/dL) throughout intensive care unit (ICU) stays, and hair removal with clippers.

Results

SSIs were significantly decreased in the experimental group (1.5%), compared with the control group (3.5%), (P = .001, odds ratio [OR] = .21). Significant independent predictors of infection included diabetes mellitus (P = .001, OR = 4.71), Nosocomial Infection Surveillance System (NNIS) wound class II (P = .044, OR = 2.07), and female gender (P = .001, OR = 2.83).

Conclusions

Protocols implementing timely perioperative antibiotics, tight blood glucose control, and avoidance of shaving decrease SSI rates in CABG patients.     

Bacteriologic features of surgical site infections following breast surgery

Background

Perioperative antibiotic prophylaxis to prevent surgical site infections (SSIs) after breast surgery is common practice. Breast SSIs were investigated to determine bacterial isolates, resistance patterns, and the appropriateness of cefazolin, the authors' institution's current regimen for perioperative antibiotic prophylaxis.

Methods

A retrospective review of 53 patients with culture-positive breast SSIs between June 1997 and August 2008 identified patient characteristics, bacterial isolates, and microbial resistance patterns.

Results

Among the 53 patients with positive cultures, 42% (n = 22) had undergone mastectomy, and 34% (n = 18) had undergone lumpectomy. Sixty-three bacterial isolates were identified, with 15% of SSIs being polymicrobial. Of the isolates, 49% (n = 31) were gram-negative bacteria. There was only 1 case of methicillin-resistant Staphylococcus aureus. Eight of 63 (13%) gram-negative isolates were cefazolin resistant.

Conclusions

Gram-negative SSIs constituted half of the SSIs in this breast surgery cohort. Of all breast isolates, 17.5% were resistant to cefazolin. On the basis of these findings, antibiotic prophylaxis regimens alternative to cefazolin should be considered.