Evaluation of postdischarge surveillance of surgical site infections after total hip and knee arthroplasty

BACKGROUND: Artificial joint replacement of hip (HPRO) and knee (KPRO) are 2 of about 20 categories of operative procedures of the surveillance of surgical site infection (SSI) as stated by nosocomial infections surveillance systems in the United States and in Germany. Periprosthetic SSI can manifest itself after a long period. METHODS: Seven hundred fifty-six orthopedic patients from 2 centers were evaluated after HPRO (n = 508) or KPRO (n = 248). SSI was recorded during hospitalization and for 12 month postdischarge. The surveillance regimen was extended by also sending patients a questionnaire after 12 months postdischarge. All complaints were followed up by contacting the patients and any clinicians and general practitioners (GPs) involved. Stratified infection rates and standardized infection ratio (SIR) were calculated and compared with reference data of the national surveillance system. RESULTS: The total response rate to the postal questionnaire survey was 85.2%. SSI was recorded in 16 patients (3.15%) after HPRO; 12 were detected by predischarge surveillance, and the 4 cases found postdischarge were all organ/space SSI. In total, only 1 SSI was detected after KPRO before discharge and none after discharge (SSI rate 0.40%). Time between discharge and detection of SSI cases ranged from 8 days to 8 months. SIR of HPRO was 1.25 and SIR of KPRO was 0.36. CONCLUSION: Because 25% of SSIs after HPRO occurred after discharge and all were organ/space SSI, highlights the importance of postdischarge surveillance of nosocomial infections (NIs). Because all SSIs were reported already by current surveillance, the extended postdischarge surveillance appears to be unnecessary. The pursuit of shorter hospital stay after surgery may challenge the methods of surveillance systems in future.     

Significant pathogens isolated from surgical site infections at a community hospital in the Midwest

BACKGROUND: Studies examining the incidence of microorganisms isolated from surgical site infections (SSIs) have been conducted primarily at large academic health care centers. Results from these studies have revealed that methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a significant pathogen in SSIs. Minimal data are available from smaller, community hospitals on the incidence of microorganisms associated with SSIs, particularly the incidence of MRSA in SSIs. METHODS: A retrospective study was performed to identify the microorganisms associated with SSIs in patients who underwent class I and II surgeries at a small urban to rural community hospital from January 2003 through December 2004. RESULTS: A total of 10,672 surgeries was performed, and 89 SSIs were identified. Staphylococcus aureus was the most common pathogen (25.8%). Enterobacteriaceae were the second most frequently isolated organisms (12.4%), followed by streptococci species (11.2%), coagulase-negative staphylococci (10.1%), enterococci species (7.9%), and Pseudomonas aeruginosa (6.7%). MRSA was isolated from 4.5% of the SSIs. CONCLUSION: We have demonstrated that the spectrum of microorganisms isolated in SSIs at a community hospital is comparable with that reported in studies conducted at large academic health care centers, including the emergence of MRSA as a pathogen in SSIs. This information will guide future infection control initiatives to reduce SSIs.     

Electronic chart review as an aid to postdischarge surgical site surveillance: increased case finding

BACKGROUND: At the University of Michigan Hospitals and Health Centers, there is increasing use of an electronic medical record. Because orthopedic surgeons dictate all outpatient visits to the patient's electronic record, total knee arthroplasties were chosen to determine whether the use of electronic medical records increased case finding. METHODS: All patients who underwent a total knee arthroplasty during the study period (1996-1999) were followed prospectively with the use of the National Nosocomial Infection Surveillance System definitions. Traditional surveillance methods were used to ascertain infections. In addition, each patient's postdischarge outpatient clinic chart was reviewed electronically for 1 year after operation. RESULTS: From 1996 to 1999, 555 procedures were performed. Overall, 25 infections were identified after operation. Seven infections were identified through traditional surveillance methods, which resulted in an average surgical site infection rate of 1.3%. The use of electronic chart review surveillance after discharge revealed a rate of 4.5%, which was significantly higher than traditional surveillance (P <.01). Eighteen of 25 infections (72%) would not have been identified with the use of traditional surveillance methods. CONCLUSION: Postdischarge electronic chart review enhanced case finding significantly, which resulted in a more accurate infection rate. Awareness should be given to the institutions' surveillance methods and intensity when comparing to published rates.     

Postdischarge surveillance of surgical site infections: a multi-method approach to data collection

BACKGROUND: Surveillance of surgical site infections (SSIs) is an important clinical indicator of quality patient care, yet an increasing number of SSIs manifest after discharge and are not detected through standard surveillance methods. AIM: This study evaluated a multimethod approach to postdischarge surveillance of SSIs with use of a cesarean section procedure as a case study. METHOD: A postdischarge questionnaire was sent on day 30 to women (n = 277) who had undergone cesarean section. A follow-up telephone interview was conducted if the questionnaire had not been returned within 2 weeks, a diagnosis of infection could not be clearly determined from the responses given, or to confirm the diagnosis of infection. If follow-up could not be made, a chart audit was undertaken. RESULTS: A total response rate of 89% (247/277) was obtained. Twenty-one women with SSI were identified through questionnaire responses. Additional strategies of telephone follow-up and chart review of patients with possible infection and of nonresponders identified more postdischarge infections (33%, 14/42). The overall infection rate was 17% (42/247) compared with 2.8% (7/247) at discharge. CONCLUSION: Postdischarge surveillance approaches need to achieve the best possible response rate, reflect follow-up health care delivery patterns, be cost-effective, gather data from both patients and treating physicians, and use standard definitions to facilitate benchmarking with other health care facilities and surveillance systems. The inclusion of contacting nonresponders in any method of postdischarge surveillance is recommended to determine the most accurate infection rate.     

The need for unique risk adjustment for surgical site infections at a high-volume,tertiary care center with inherent high-risk colorectal procedures

Background

The aim of the present study was to create a unique risk adjustment model for surgical site infection (SSI) in patients who underwent colorectal surgery (CRS) at the Cleveland Clinic (CC) with inherent high risk factors by using a nationwide database.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent CRS between 2005 and 2010. Initially, CC cases were identified from all NSQIP data according to case identifier and separated from the other NSQIP centers. Demographics, comorbidities, and outcomes were compared. Logistic regression analyses were used to assess the association between SSI and center-related factors.

Results

A total of 70,536 patients met the inclusion criteria and underwent CRS, 1090 patients (1.5%) at the CC and 69,446 patients (98.5%) at other centers. Male gender, work-relative value unit, diagnosis of inflammatory bowel disease, pouch formation, open surgery, steroid use, and preoperative radiotherapy rates were significantly higher in the CC cases. Overall morbidity and individual postoperative complication rates were found to be similar in the CC and other centers except for the following: organ-space SSI and sepsis rates (higher in the CC cases); and pneumonia and ventilator dependency rates (higher in the other centers). After covariate adjustment, the estimated degree of difference between the CC and other institutions with respect to organ-space SSI was reduced (OR 1.38, 95% CI 1.08–1.77).

Conclusions

The unique risk adjustment strategy may provide center-specific comprehensive analysis, especially for hospitals that perform inherently high-risk procedures. Higher surgical complexity may be the reason for increased SSI rates in the NSQIP at tertiary care centers.

     

A prospective study of surgical site infections in a pediatric hospital in Mexico City

BACKGROUND: Pediatric surgical site infection (SSI) rates in the United States range from 2.5% to 4.4%. There is little data regarding their risk factors among children. We quantified SSI rates and identified risk factors of SSI in a tertiary care pediatric teaching hospital in Mexico City. METHODS: All neurosurgical, cardiovascular, and general surgical patients who underwent operation between Aug 1, 1998, and Jan 31, 1999, were followed-up daily during hospitalization. On postoperative day 30, a full review of microbiology reports and medical records was performed. Univariate and multivariate analyses were done to identify risk factors. RESULTS: Four hundred twenty-eight of 530 children completed follow-up. The overall SSI rate was 18.7%. Forty percent of SSI were superficial incisional, 21% were deep incisional, and 39% were organ/space infections. For clean, clean-contaminated, contaminated, and dirty procedures, SSI infection rates were 12.4%, 24.4%, 14.3%, and 32.4%, respectively. Open drains (OR = 2.3; 95% CI = 1.3-4.2; P <.005) and surgery that lasted 90 or more minutes (OR = 2.9; 95% CI = 1.6-5.1; P <.001) were associated with infection. CONCLUSIONS: Our rates are greater than comparable reported data among children. Duration of surgery and use of open drains were associated with SSI.     

Spectrum of Brevundimonas vesicularis infections in neonatal period: a case series at a tertiary referral center

Objectives

To report infections caused by Brevundimonas vesicularis and the treatment regimens administered based on antibiotic studies of this Gram-negative bacterium in the neonatal period.

Patients and methods

Eight hospitalized neonates with positive blood cultures for Brevundimonas spp. were studied. Demographic data, clinical and laboratory findings, nutritional regimens, presence of primary disease, and the antibiotic regimens administered during the treatment of these neonates were noted. Antimicrobial susceptibility tests were performed on isolates of the positive cultures.

Result

Four neonates were preterm, and four were full-term infants. The underlying diseases??with the exception of being a neonate??were congenital heart disease (4 patients), respiratory distress syndrome (2), multiple congenital cerebral anomalies (1), and meconium aspiration syndrome (1). Septicemia was observed in all eight patients, while three also had concurrent meningitis. Multidrug resistance to the antimicrobials, including piperacillin?Ctazobactam, ceftazidime, and aztreonam, were identified in all eight infants; however, susceptibility to amikacin and imipenem was retained. All study patients responded to the antibiotic treatments and subsequent cultures were sterile. One patient died due to other causes.

Conclusions

We consider that until larger series are available, B. vesicularis should be regarded as virulent. Consequently, in this era of multi-resistant Gram-negative bacteria, serious B. vesicularis infections in neonates should be treated with a broad-spectrum agent, such as third-generation cephalosporin until the results of susceptibility testing are available. Our case reports demonstrate that the susceptibility of this organism to all aminoglycosides and third-generation cephalosporin is not uniform, but that most of the isolates are susceptible to imipenem. More treatment experience and more exact results from antimicrobial susceptibility testing are required to improve on present treatment regimens for invasive B. vesicularis infections.     

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.     

Promoting quality through surveillance of surgical site infections: five prevention success stories

BACKGROUND: Public reports of successful quality improvement efforts are useful, but seldom available. We present 5 successful efforts to prevent surgical site infections (SSIs) with the use of prospectively collected surveillance data. METHODS: Before-and-after intervention studies were conducted in 5 acute care public hospitals in the national surveillance network for SSI in The Netherlands from 1992 to 2000. Patients undergoing surgery for total hip prosthesis (3 hospitals), knee prosthesis (2 hospitals), prosthesis of the femur head (1 hospital), or appendectomy (1 hospital) were included. Included were 1066 patients before intervention, and 1269 patients after intervention. Multidisciplinary evaluation of infection control policy led to subsequent changes of infection control measures, mainly involving the discipline of staff and organization of perioperative infection prevention procedures. RESULTS: All 5 hospitals drastically reduced their SSI rates to the national average or below. Absolute declines ranged from 2.1% to 13.9%, but not all reductions were statistically significantly different from 0%. CONCLUSION: Surveillance results provide a basis for improvement of infection prevention.     

Current strategies for prevention of surgical site infections

Surgical site infections (SSIs) are a common complication that follows all types of operative procedures. These infections are usually caused by the exogenous and endogenous microorganisms that enter the operative wound during the course of surgery. The general and procedure-specific risk factors for the development of SSI have been identified and are discussed in this article. Factors that influence the SSI rate and the current strategies for prevention of SSIs are also presented. Emphasis is placed on the efficacious use of antibiotic prophylaxis in surgery. A discussion of the principles of antibiotic prophylaxis, including choice of agents, route of administration, and timing, is offered. It appears that the use of less invasive laparoscopic surgical approaches, as practiced widely today, will be associated with an overall decreased incidence of SSI.     

Fifteen year surveillance of echinococcal heart disease from a referral hospital in Greece

Ten cases of hydatid heart disease were treated over a 15-yearperiod (1980–1995). Cysts were located in the left ventricularwall (four patients), right ventricular wall (one patient),interventricular septum (one patient), interatnal septum (onepatient), right atrium (one patient), pericardial cavity (onepatient) and in multiple loci (one patient). Apart from twoasymptomatic cases, clinical manifestations included chest pain(four patients), anaphylactic shock (one patient), constrictivepericarditis (one patient), congestive heart failure (one patient)and arterial embolism (one patient). Computed tomography wasfound useful in the detection of hydatid cysts and also in thedetermination of their morphology. Magnetic resonance was performedin three patients, with satisfactory imaging. Three out of the10 patients died: rupture of pulmonary echinococcal cyst (onepatient), massive pulmonary hydatid embolism (one patient) andrupture of an undiagnosed hydatid cyst of the right atrium duringcannulation for cardiopulmonary bypass (one patient). One otherpatient experienced recurrent systemic embolism and became hemiplegic.Six patients were successfully treated. In five patients, thecysts were excised by open heart surgery, while in one by pericardiectomy.In addition, antiparasitic drugs were successfully used in twopatients with long-term satisfactory results. In conclusion, cardiac echinococcosis is associated with anincreased risk of potentially lethal complications. Newer techniquesof cardiac imaging have helped locate the cysts while surgicalremoval may offer cure. Some patients responded to specificlong-term drug treatment.     

Prevalence of hospital-acquired infections in a tertiary referral hospital in northern Tanzania

Hospital-acquired infections (HAI) are a major and largely preventable cause of morbidity and morbidity worldwide. Very few reports on the prevalence of HAI in sub-Saharan Africa have been published and most of those that have appeared in the press have focused on surgical-wound infection. In the present, questionnaire-based, point-prevalence study, in which the doctor on the ward round was used as the primary informant, the prevalences of all HAI among all the inpatients at a tertiary referral hospital in northern Tanzania were estimated. On the day of the study, there were 412 inpatients (in 15 ward areas) and 61 cases of HAI were identified, giving an overall HAI prevalence of 14.8%. The prevalences of HAI were particularly high in the medical intensive-care unit (40%), the surgical (orthopaedic and general surgery) wards (36.7%), and one of the general medical wards (22.2%). Factors associated with a patient having a HAI were hospitalization for >30 days [odds ratio (OR) = 4.07; 95% confidence interval (CI) = 2.07-7.99]; being a patient on the orthopaedic and general surgical ward known as 'Surgical 2' (OR = 2.14; CI = 1.02-4.46); and being referred from another health facility (OR = 1.90; CI = 1.02-3.42). The most commonly identified HAI in the hospital were urinary-tract infections (14 cases), followed by surgical-wound infections (10 cases) and then lower respiratory-tract infections (six cases). Twenty HAI were 'unspecified'. The study was rapid and cheap to carry out. The results not only gave a baseline estimate of HAI in the study setting but also identified key areas for interventions to reduce HAI.     

Risk factors for surgical site infections in a free-standing outpatient setting

BACKGROUND: More information about risk factors for surgical site infections in outpatient settings is necessary for creation of surveillance systems in this field. OBJECTIVE: The aim of this study was to determine the incidence of surgical site infections (SSI) in an outpatient setting and to investigate whether the risk index of the National Nosocomial Infections Surveillance (NNIS) System is appropriate for outpatient settings. METHODS: A retrospective cohort design was used to investigate SSI following all hernia repairs and varicose veins operations over a 9-year period in a freestanding outpatient setting. The exposure variables studied were age, sex, and American Society of Anesthesiologists (ASA) score of the patient; duration of operation; performing surgeon's name; type of operation; type of anesthesia; and follow-up period. An univariable and a multivariable analysis were performed to determine risk factors for SSI. RESULTS: A total of 1095 operations were performed: 714 on varicose veins and 381 on hernia repairs. The median follow-up period was 43 days. The crude SSI rate was 1.2% (varicose veins operations, 1.5%; hernia repair operations, 0.5%). According to the results of the logistic regression model, only 1 factor remained significant: Patients with spinal anesthesia were 11 times as likely to develop a SSI as patients with any other type of anesthesia (95% CI, 2.15-200.5). CONCLUSION: The NNIS risk index was not suitable for assessing SSI rates in this outpatient setting and for these specific procedures.