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PubMed2002

Postdischarge clean wound infections: incidence underestimated and risk factors overemphasized.

BACKGROUND: Wound infections are a leading cause of postoperative morbidity and a cost to both the individual and community. The surgeon now has a reduced appreciation of wound-infection rates because of shorter hospital stays and an increasing reliance on the primary care physicians. The incidence of wound infections which occurred following clean surgical procedures, as well as whether they could have been predicted by the known risk factors, were analysed in the present prospective study. METHODS: A prospective audit of the first 30 postoperative days following clean general surgical wounds was undergone, with inpatient assessment by a research nurse, and subsequent outpatient followup by patient telephone interview. RESULTS: Of 1964 clean wounds over a 30-month period, 98.5% were traced. The overall clean-wound infection rate was 12.6% (inpatient:4.5%; outpatient: 8.1%). Inpatient infection rates(but not postdischarge wound-infection rates) were significantly correlated (P < 0.05)to the American Society of Anesthesiologists' rating, operation duration, preoperative day stay, and age. Infection rates varied with operation type: vascular (18.3%), breast (16.0%),abdominal (10.3%), hernia (8.0%), head and neck (7.1%). CONCLUSIONS: The overall wound-infection rate is higher than previously described with two thirds of infections occurring after discharge. While inpatient wound-infection rates fit known risk factors, postdischarge wound-infection rates do not. Certain clean-wound operations have a higher incidence of infection than others. Consideration needs to be given to the identification of risk factors for postdischarge wound infections,and to further trials of prophylactic antibiotics in clean surgery.

Antibiotic Prophylaxis↗
PubMed1999

Internal fixation of the sternum in median sternotomy dehiscence.

Sternal dehiscence may be defined as separation of the bony sternum and manubrium following median sternotomy. It may occur at any time postoperatively and has various etiologies. Restoration of sternal integrity in sternal dehiscence is a challenging problem, particularly when associated with deep-seated infection. This report reviews a single-stage technique that virtually eliminates the infected sternotomy wound and provides anatomic reduction and stabilization of the sternum. Complete debridement of infected and/or nonviable soft tissue, bone, and cartilage is followed by pulse irrigation. Parallel stainless steel mandibular reconstruction plates are then placed on each side of the remaining sternum and wired together. One or more transmanubrial compression plates may be added. Bilateral pectoralis major musculocutaneous flap advancement and primary skin closure is performed over two to three closed suction drains. From January of 1994 to July of 1996, this technique was used by the same surgeon in 26 male and 4 female patients aged 43 to 78 years (mean = 61). Indications for the operation were sternal dehiscence with infection (osteomyelitis and/or mediastinitis) in 14 patients and sternal dehiscence without infection in 16 patients. All patients survived to discharge with mean time on the ventilator, intensive care unit length of stay, and postoperative length of stay of 0.7, 2, and 8 days, respectively. Choice and duration of antibiotics were based on culture results and operative findings. Subsequent hardware removal was necessary in one patient for hardware loosening and three patients for late periplate infection. A closed wound was eventually achieved in all 30 patients, and sternal stability was restored in 29 patients. In the management of sternal dehiscence, the described technique of internal fixation can provide anatomic sternal reduction and stabilization, elimination of infection, and wound closure in a single-stage operation. Successful outcomes were achieved despite the presence of severe infection.

Adult↗
PubMed1993

[The rational use of drains in surgery].

The authors report their clinical experience in 100 cases in which various kinds of drainage were used. They outline the best present techniques, when it is wished to apply this free drainage in the abdominal cavity, at the end of the operation.

Adult↗
PubMed1993

Nosocomial infections in surgical patients in the United States, January 1986-June 1992. National Nosocomial Infections Surveillance (NNIS) System.

OBJECTIVES: To describe the distribution of nosocomial infections among surgical patients by site of infection for different types of operations, and to show how the risk of certain adverse outcomes associated with nosocomial infection varied by site, type of operation, and exposure to specific medical devices. DESIGN: Surveillance of surgical patients during January 1986-June 1992 using standard definitions and protocols for both comprehensive (all sites, all operations) and targeted (all sites, selected operations) infection detection. SETTING AND PATIENTS: Acute care US hospitals participating in the National Nosocomial Infection Surveillance (NNIS) System: 42,509 patients with 52,388 infections from 95 hospitals using comprehensive surveillance protocols and an additional 5,659 patients with 6,963 infections from 11 more hospitals using a targeted protocol. RESULTS: Surgical site infection was the most common nosocomial infection site (37%) when data were reported by hospitals using the comprehensive protocols. When infections reported from both types of protocols were stratified by type of operation, other sites were most frequent following certain operations (e.g., urinary tract infection after joint prosthesis surgery [52%]). Among the infected surgical patients who died, the probability that an infection was related to the patient's death varied significantly with the site of infection, from 22% for urinary tract infection to 89% for organ/space surgical site infection, but was independent of the type of operation performed. The probability of developing a secondary bloodstream infection also varied significantly with the primary site of infection, from 3.1% for incisional surgical site infection to 9.5% for organ/space surgical site infection (p < .001). For all infections except pneumonia, the risk of developing a secondary bloodstream infection also varied significantly with the type of operation performed (p < .001) and was generally highest for cardiac surgery and lowest for abdominal hysterectomy. Surgical patients who developed ventilator-associated pneumonia were more than twice as likely to develop a secondary bloodstream infection as nonventilated pneumonia patients (8.1% versus 3.3%, p < .001). CONCLUSIONS: For surgical patients with nosocomial infection, the distribution of nosocomial infections by site varies by type of operation, the frequency with which nosocomial infections contribute to patient mortality varies by site of infection but not by type of operation, and the risk of developing a secondary bloodstream infection varies by type of primary infection and, except for pneumonia, by type of operation.

Cause of Death↗
PubMed1976

Observations on the management of failed spinal operations.

A system is presented for the analysis of failure after spinal operations: 1) outright failure; 2) temporary relief; 3) failure in spondylolisthesis; and 4) infections. With this system it is possible to trace the causes of failure and to correct some of them. When they are used as a guide before operation, the recommendations made should help to prevent many failures.

Diagnostic Errors↗
PubMed1985

One row anastomosis in colonic operations with antibiotic prophylaxis.

Eighty-nine patients who underwent elective operations and 26 patients who underwent nonelective operations for diseases of the large intestine were studied for mortality and morbidity. In the patients who underwent elective operations, there was no anastomotic leakage or wound infection and only 1 per cent mortality. Additionally, 2 per cent nonfatal surgical complications were observed. In patients who underwent nonelective operation, a morbidity of 46.2 per cent and a mortality of 15.0 per cent were observed. Fourteen patients with acute illness were without serious complications postoperatively. All anastomoses except two were one row in elective operations without protective colostomy. All patients who underwent elective operation received antibiotic prophylaxis-a combination of cefotaxime and metronidazole.

Adolescent↗
PubMed2001

Antibiotic prophylaxis in clean surgery: clean non-implant wounds.

Wound infection after clean surgery (the majority being hernia, varicose vein and breast surgery) is often greatly underestimated. If a trained and blinded observer is involved using close and prolonged surveillance to at least 30 days postoperatively with appropriate definitions or wound scores, an infection rate of up to 15% or more may be found. Equally controversial is the value of prophylactic antibiotics in preventing postoperative wound infection; there is no clear cut evidence of efficacy and some random controlled trials (RCTs) have shown no differences at all. There is a need for guidelines to be drawn up but further RCTs may be needed. An alternative to antibiotics is the systemic warming of patients or the local warming of the operative site prior to surgery. In day case surgery in particular, patients may have been deprived of fluids for 12h prior to surgery; they may become cold whilst waiting for surgery dressed in a theatre gown; and their apprehension may not be controlled with anxiolytics. The inflammatory response may be obtunded with an increased risk of superadded infection or poor healing in cutaneous tissue resulting in wound separation and fat necrosis. Only a third of sampled purulent discharges grow skin organisms such as Staphylococcus aureus or epidermidis. In a study of 421 patients the 138 randomly assigned to local warming (Warm Up, Augustine Medical) had a wound infection rate of 3.6% compared with another group of 139 randomly assigned to systemic warming (Bair Hugger, Augustine Medical) of 5.8%. A standard-treated third group of 139 had a wound infection rate of 13.7% (P<0.001). The warmed patients also had significantly lower wound scores based on 4 systems, had higher skin temperatures and capillary flow prior to surgery and were prescribed fewer postoperative antibiotics by their family doctors in the 6 postoperative weeks (15.9% vs 6.5%; P=0.002). Wound infections are more common than generally accepted if they are looked for by close surveillance. Antibiotics may be avoided by the use of warming with the lessening of the risks of allergy, resistance and emergence. It is uncertain whether antibiotic prophylaxis has a role in clean wound surgery. Breast surgery carries the highest risk of wound infection and this may risk delay in receiving planned adjuvant chemotherapy or radiotherapy. Perioperative warming of the operative site may be of greatest value in this group of patients.

Anti-Bacterial Agents↗
PubMed1979

Irrigation of subcutaneous tissue with povidone-iodine solution for prevention of surgical wound infections.

Five hundred patients undergoing a variety of general surgical operative procedures were prospectively randomly allocated into a treatment group, in which the incisions were irrigated with povidone-iodine solution prior to skin closure or into a control group in which wounds were irrigated with saline solution. Wounds were classified according to the degree of bacterial contamination as clean, potentially contaminated, contaminated or dirty. For all categories of surgical incisions, povidone-iodine irrigation resulted in a significant decrease in wound infections over that for saline solution irrigation. Over-all incidence of wound sepsis in the treatment group was seven of 242 patients, 2.9 per cent, compared with the control rate of 39 wound infections of 258 patients, 15.1 per cent--p less than 0.001.

Adolescent↗
PubMed1983

Adult inguinal hernia: pathophysiology and repair.

An anatomic and physiologic rationale is presented for the correction of inguinal hernias utilizing a simplified anterior approach, which opens and overlaps the transversalis-transversus abdominis posterior wall. The absence of tension is vital. It permits an uninterrupted repair of the direct and indirect components without additional reinforcement. A prospective randomized study is currently in progress comparing this two-layer technique to the author's three-layer modified Shouldice operation. Three-hundred and twenty-six repairs have been followed for at least 20 months with a mean follow-up time of 29 months. There have been two recurrences in each group. A better evaluation will be available when 1000 operations have been collected with a mean follow-up time of 46 months.

Adolescent↗
PubMed1981

Aseptic barriers in surgery: their present status.

Aseptic barriers are employed in the form of surgical gowns, drapes, and wrappers for sterile goods. They possess many of the attributes of textiles, but must also protect sterile zones from microbial invasion. Surgeons rely on them to resist penetration by liquids and other bacterial vehicles. A large variety of both woven and nonwoven materials are being produced for this purpose. The user is faced with difficult choices. The provider of the barrier materials must assure the surgeon of their barrier quality under the usual conditions of their use in operating rooms. Identical standards of quality can be and should be applicable whether these materials are created to be used once and discarded or are reusable.

Antisepsis↗
PubMed1994

Antimicrobial prophylaxis in surgery: general concepts and clinical guidelines. French Study Group on Antimicrobial Prophylaxis in Surgery, French Society of Anesthesia and Intensive Care.

Bacteria are found in 90% of surgical incisions, regardless of surgical technique or environment. Initially, the number of pathogens is low, but proliferation is facilitated by favorable local conditions and weakened host defense mechanisms. The principles of presurgical administration of antibiotics are well defined, but a few controversies persist. An ideal antimicrobial agent would not induce bacterial resistance in pathogenic organisms, would penetrate tissues effectively, would have a long enough half-life so that a single injection could guarantee protection throughout the operation, would have a low toxicity, would not interfere with anesthetics, would be easy to administer, and would be cost-effective.

Anti-Bacterial Agents↗
PubMed1988

A comparative study of perioperative complications with Kock pouch urinary diversion in highly irradiated versus nonirradiated patients.

To define the nature and risk of complications associated with Kock pouch urinary diversion after high dose radiation (more than 4,500 rad), we analyzed the clinical course of 44 irradiated patients and a comparable group of 42 selected retrospectively from the nonirradiated patient cohort. Of the 42 patients in the irradiated group 18 had received 4,500 to 5,700 rad and 24 had received 6,000 to 8,700 rad. With standard statistical methods we found no difference between the irradiated and control groups when compared for age, sex ratio, followup interval, surgical procedure, operative time or estimated blood loss. There were 2 operative mortalities in the irradiated and 1 in the control groups. In the immediate postoperative period there was no difference between the irradiated and control groups when compared for hospital stay, incidence of urine leak or fascial dehiscence. The irradiated group had 8 urine leaks (20 per cent) and 3 patients (7.5 per cent) required surgical repair. The control group had 5 urine leaks and 1 patient (2.3 per cent) required repair. Diarrhea severe enough to require further hospitalization or medication was significantly more frequent in the irradiated group (18 versus 2 per cent) but the postoperative stay was not significantly different (13 versus 11 days). We conclude that Kock pouch urinary diversion may be performed safely in highly irradiated patients.

Combined Modality Therapy↗