Colon and rectal surgery surgical site infection reduction bundle: To improve is to change

Background

Despite the introduction of the Surgical Care Improvement Project, surgical site infections remain a source of morbidity. The aim of this study was to determine the value of implementing a colorectal bundle on SSI rates.

腹部手术后是否需预防性引流

Abdominal drainage is the most common technique applied in the abdominal surgery. According to the aim of drainage, it can be divided into curative drainage and preventive drainage, but there is no obvious difference between the 2 drainages. Abdominal drainage is not necessary after parenchymal viscera operation, but necessary after spleenectomy in preventing infection. For cavity viscera operation, abdominal drainage is applied according to the infectious condition, but scholars at home and abroad have different opinions on this point. Surgeons should pay attention to the placement of the drainage tube in patients who received preventive drainage.     

Determining risk factors for surgical wound dehiscence: a literature review

Postoperative wound healing plays a significant role in facilitating a patient's recovery and rehabilitation. Surgical wound dehiscence (SWD) impacts on mortality and morbidity rates and significantly contributes to prolonged hospital stays and associated psychosocial stressors on individuals and their families. A narrative review of SWD was undertaken on English‐only studies between 1945 and 2012 using three electronic databases Ovid CINHAL, Ovid Medline and Pubmed. The aim of this review was to identify predisposing factors for SWD and assessment tools to assist in the identification of at‐risk patients. Key findings from the included 15 papers out of a search of 1045 revealed the most common risk factors associated with SWD including obesity and wound infection, particularly in the case of abdominal surgery. There is limited reporting of variables associated with SWD across other surgical domains and a lack of risk assessment tools. Furthermore, there was a lack of clarity in the definition of SWD in the literature. This review provides an overview of the available research and provides a basis for more rigorous analysis of factors that contribute to SWD.     

The Significance of the Intraoperative Repeated Dosing of Antimicrobials for Preventing Surgical Wound Infection in Colorectal Surgery

Purpose It is widely accepted that antimicrobial prophylaxis is useful for the prevention of surgical wound infection, especially in colorectal surgery. While many reports support the finding that the first dose should be administered immediately before surgery, there is less evidence concerning the ideal timing for the second dose. The purpose of this study is to examine the significance of intraoperative repeated dosing.Methods A surgical series of 131 patients with primary colorectal cancer was retrospectively analyzed for 14 parameters, including the protocols of antimicrobial administration to determine the clinical risk factors for surgical wound infection.Results The overall surgical wound infection rate of the 131 patients was 16.0% (21/131). When the operation finished within 4 h after the first dose (n = 29), wound infection was observed in only one patient (3.4%). In a prolonged operation exceeding 4 h after the first dose, the surgical wound infection rates were 8.5% and 26.5%, respectively, for those with (n = 47) and without (n = 49) intraoperative repeated dosing, which were significantly different based on both a univariate analysis (P = 0.031) and a multivariate analysis (P = 0.0079).Conclusion Intraoperative repeated antimicrobial dosing is therefore recommended to prevent the surgical wound infection for prolonged colorectal surgery.     

改善感染患者的营养支持疗效

The aim of nutritional support is to maintain the metabolic function of cells, organs and the whole body, and also to reduce the total energy consumption, finally promotes the patients to recover. Infectious patients are often in the status of high catabolism and negative nitrogen balance. It is necessary for such patients to receive nutritional support, however, the performance is difficult because of the high catabolism status and disorder of physiological function. What is more, inappropriate performance may lead to even worse outcome. Accordingly, the current clinical researches focus on how to improve the effects of nutritional support in infectious patients. Several aspects on this issue including the time, route, dose, metabolic intervention and immune modulation are discussed.     

Necrotizing fasciitis of the abdominal wall with lethal outcome: a case report

Necrotizing fasciitis is an acute surgical condition that demands prompt and multi-faceted treatment. Early recognition, aggressive surgical debridement, and targeted antibiotic therapy significantly affect the overall course of treatment and survival. The author reports here the case of a woman with necrotizing fasciitis of the abdominal wall and the course and methods of treatment. Two comorbidity factors (extreme obesity, diabetes) and the late diagnosis of necrotizing fasciitis, the latter masked by celullitis and phlegmona of the abdominal wall, resulted in overdue adequate surgical treatment. The combination of these factors contributed to medical treatment failure and, consequently, a lethal outcome.     

The association of surgical drains with surgical site infections – A prospective observational study

Background

Surgical drains are widely used despite limited evidence in their favor. This study describes the associations between drains and surgical site infections (SSI).

Lessons learned from the institution of the Surgical Care Improvement Project at a teaching medical center

Background

The Surgical Care Improvement Project (SCIP) was designed to reduce perioperative complications. We describe our institutional experience in 6 major areas: surgical site infection, venous thromboembolism prevention, use of perioperative β-blockade, serum glucose level greater than 200 mg/dL, normothermia, and the use of electric razors for hair removal.

Methods

This was a retrospective review of surgical cases. Evidence-based training and standardization of system and process were undertaken. Compliance with SCIP guidelines was determined.

Results

Overall SCIP compliance improved from 80% to 94% over a 2-year period. Standardized antibiotic dosing times improved compliance to more than 90%. Appropriate preoperative antibiotic choice improved to 100%. Cessation of antibiotics postoperatively within 24 hours remains a difficult task. Venous thromboembolism prophylaxis has been difficult to achieve because of postoperative bleeding concerns. Administration of β-blockers has remained one of the most difficult problems to correct because of the multiplicity of avenues by which a patient may arrive to the operating suite.

Conclusions

Achievement of the SCIP goals is a formidable, but achievable, process requiring individual, cultural, systems, and institutional changes to achieve success.     

Diagnosing surgical site infections using telemedicine: A Systematic Review

BackgroundSurgical site infections (SSI) are preventable post-operative complications. With the increase in use of telehealth modalities, there is a need to assess if telehealth modalities are safe for assessment of SSI.AimThis review aims to assess the accuracy of using telemedicine in the diagnosis of SSI in post-surgical adult patients as compared to in-person assessments.MethodsA comprehensive search on 6 databases (PubMed, MEDLINE, Embase, Web of Science, Scopus and CENTRAL) was performed from inception to 1 December 2020. Data was extracted to determine accuracy, feasibility, acceptability, and usability of using telemedicine to detect SSIs. The primary outcome of this review was to review the diagnostic accuracy of telemedicine to diagnose SSIs as compared to direct, in-person assessment. Methodological quality was evaluated using the MINORS criteria.ResultsSix studies met inclusion criteria. Results were summarized qualitatively. The overall methodological quality of the studies was moderate based on the MINORS score. Four studies utilized telephone surveillance, whilst two utilized mobile applications. Telemedicine modalities were able to accurately diagnose 66 SSIs, where an additional 15 were found on direct clinical review. The diagnostic accuracy across the studies ranged from 69.5 to 100%. Between 82.5 and 100% of patients were able to be contacted through these telemedicine modalities.ConclusionsTelemedicine modalities are a feasible option for post-operative follow-up, especially in the identification of SSIs. As technology becomes more affordable and widely available, future applications of telemedicine are limitless. However, further research is still required to ensure that telemedicine is a safe and effective tool.     

Questionnaire on Perioperative Antibiotic Therapy in 2003: Postoperative Prophylaxis

We distributed a questionnaire to institutions accredited by the Japan Surgical Society asking about the use of antibiotics in digestive tract surgery in Japan in 2003, and compared the results with those of a similar questionnaire distributed in 1993. The period of antibiotic administration for esophageal resection was at least 6 days in 64.9% of the 1993 questionnaire responses, but less than 4 days in 60.4% of the present questionnaire responses. For distal gastrectomy, antibiotics were given for 5 days postoperatively at 53.0% of the responding institutions in the 1993 survey, but for only 3 days, at 72.4%, in the present survey. An oral antibiotic was given as part of antibacterial colon preparation before colon resection at 70% or more of the institutions in the 1993 survey, while no antibiotic colon preparation was given at 80% of the institutions in the present survey. The period of antibiotic administration for laparoscopic cholecystectomy was at least 4 days in 72% of the institutions in the 1993 survey, but this decreased remarkably to fewer than 2 days at 80.8% of the institutions in the current survey. There were no differences in the selection of antibiotics between the two surveys. The period of antibiotic administration has decreased remarkably in the last decade.     

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目的　探讨手术中、手术后短时间高浓度氧疗对腹部污染手术切口感染的影响。方法　 2 0 0 1年 1月至 2 0 0 3年 4月行腹部污染手术 196例 ,随机分组。手术开始至术后 2h内观察组 (98例 )用防漏面罩供氧 (FiO26 0 % ) ,对照组 (98例 )用鼻导管供氧 (FiO2 2 8% )。除阑尾手术外术后 2h抽股动脉血测定血气分析 ,均测定末梢动脉血氧饱和度 ,记录有无氧中毒表现。观察切口至术后 15d ,切口丙级愈合为切口感染。结果　两组无氧中毒表现。术后 2h动脉血气分析 ,观察组PaO2 为 (16 5 3± 38 6 )mmHg ,对照组为 (118 1± 2 9 4 )mmHg ,两组比较 P<0 0 0 1。术后末梢动脉血氧饱和度两组均正常。观察组切口感染 5例 (5 1% ) ,对照组 14例 (14 3% ) ,两组比较P <0 0 5。结论　手术中、手术后短时间高浓度氧疗可减少腹部污染手术切口感染。     

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.     

Risk factors for clostridium difficile infection in general surgery patients

BackgroundClostridium Difficile Infection (CDI) is a significant cause of mortality. This study aims to identify predictors of CDI in general surgery patients.MethodsPatients who underwent general surgery operations in the 2019 National Surgical Quality Improvement Program database were identified with demographic, intervention, and outcome data abstracted. Patients with CDI and no CDI were compared by univariate analysis. Multivariable logistic regression (MLR) was performed to determine independent predictors of CDI.ResultsOf 436,831 surgical patients, 1,840 patients were diagnosed with CDI (0.4%). Patients with CDI have a higher mortality (2.1% vs 0.76%,p < 0.0001), longer length of stay (7 days vs 1 day, p < 0.0001), and are less likely to undergo a laparoscopic procedure (29.9% vs 37.5%, p < 0.0001). MLR identified older age, emergent operation, increased time to operation, surgical site infection, deep organ space infection, steroid use, metastatic cancer, smoking, and decreased body mass index (BMI) as independent predictors of CDI.ConclusionsCDI is rare following general surgery. Infections, delay to operation, and emergency operations are associated with CDI.     

Surgical attire,practices and their perception in the prevention of surgical site infection

IntroductionClean surgical scrubs, surgical gowns and headgear are worn by operative teams to decrease bacterial contamination and lower surgical site infection (SSI) rates.MethodsA detailed review was undertaken of peer-reviewed publications and other sources of material in the English language over the last 50 years included.ResultsSurgical scrubs should be clean and made of tightly woven material. Studies investigating single-use gowns and drapes versus reusable gowns report conflicting evidence. Double gloving may reduce SSI rates in procedures where no antibiotic prophylaxis was administered. Bacterial contamination of the operative field has been shown to be decreased by the wearing of surgical headgear by the operating team.ConclusionsFurther consideration and better trials are required to determine the impact of different theatre clothing on SSI rates.     

难治性腹壁深部手术部位感染的确定性手术治疗

目的探讨慢性腹壁深部手术部位感染的手术治疗的方法。方法12例腹腔手术患者发生深部手术部位感染,经换药或清创缝合仍未愈合,平均（15±3．2）个月。我们采取确定性手术整块切除腹壁窦道和瘢痕化窦道,全层腹壁间断一层缝合。结果11例切口一期愈合,1例发生浅部手术部位感染,经换药愈合,平均随访16个月（6个月至4年）,无感染或切口疝发生。结论腹壁切口窦道切除、腹壁间断全层缝合是治疗难治性腹壁深部手术部位感染的有效方法。     

Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program

Background

Surgical site infection (SSI) is a costly complication leading to increased resource use and patient morbidity. We hypothesized that postdischarge SSI results in a high rate of preventable readmissions.

Methods

We used our institutional American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing general surgery procedures from 2006 to 2011.

Results

SSIs developed in 10% of the 3,663 patients who underwent an inpatient general surgical procedure. SSI was diagnosed after discharge in 48% of patients. Patients with a diagnosis of SSI after discharge were less likely to have a history of smoking (15% vs 28%, P = .001), chronic obstructive pulmonary disease (3% vs 9%, P = .015), congestive heart failure (0% vs 3%, P = .03), or sepsis within 48 hours preoperatively (17% vs 32%, P = .001) compared with patients diagnosed before discharge. Over 50% of the patients diagnosed with SSI after discharge required readmission.

Conclusions

A diagnosis of SSI after discharge is associated with a high readmission rate despite occurring in healthier patients. We propose discharge teaching improvements and a wound surveillance clinic within the first week may result in a decreased readmission rate.     

Infección de sitio quirúrgico asociada a enterobacterias productoras de carbapenemasas. Un desafío para el cirujano actual

IntroductionInfections caused by carbapenemase-producing Enterobacteriaceae (CPE) are dramatically increasing worldwide, with an important impact on surgical patients. Our aim was to assess the clinical profile, outcomes, treatment, mortality and costs of CPE-related surgical site infection (SSI) in patients with abdominal surgery.MethodsReview of CPE-related SSI in patients with abdominal surgery from January 2013 to December 2018. Patient factors and interventions present previously to the SSI identification were recorded, and a mortality analysis was also performed in patients with abdominal surgery and CPE-related organ/space SSI.ResultsFifty patients were included: superficial incisional SSI 50%, deep incisional SSI 28%, organ/space SSI (or intra-abdominal infection) 70%. Klebsiella pneumoniae OXA-48 was present in 84%, and the most frequent were colorectal surgery (40%) and pancreatic surgery (20%). The antimicrobial susceptibility was: ceftazidime-avibactam 100%, amikacin 91.7%, tigecycline 89.1%, colistin 70.8%, meropenem 62.8%, imipenem 52.1%. An appropriate definitive antimicrobial treatment was administered in 86%, using a combined scheme in 76%. Global 30-day mortality rate for intra-abdominal infection was 20%, and mortality-related factors were: solid tumour (P = .009), solid metastasis (P = .009), septic shock (P = .02), blood transfusions (P = .03). Median global stay was 45 (IQR 26-67) days. Median global cost of hospitalization was €29,946 (IQR 15,405-47,749).ConclusionsThe clinical profile of patients with CPE-related SSI associates several comorbidities, interventions, prolonged stay and elevated costs. Mortality-related factors in intra-abdominal infection are solid tumour, metastasis, septic shock or blood transfusions.     

Female radical cystectomy patients have a higher risk of surgical site infections

Introduction

Surgical site infections (SSI) are common after radical cystectomy. The objectives of this study were to evaluate if female sex is associated with postoperative SSI and if experiencing an SSI was associated with subsequent adverse events.