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1.  Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania 
Background
Surgical site infection (SSI) is the second most common infectious complication after urinary tract infection following a delivery by caesarean section (CS). At Bugando Medical Centre there has no study documenting the epidemiology of SSI after CS despite the large number of CSs performed and the relatively common occurrence of SSIs.
Methods
This was a prospective cohort study involving pregnant women who underwent a CS between October 2011 and February 2012 at Bugando Medical Centre. A total of 345 pregnant women were enrolled. Preoperative, intraoperative and postoperative data were collected using a standardized questionnaire. Wound specimens were collected and processed as per standard operative procedures; and susceptibility testing was carried out using a disc diffusion technique. Data was analyzed using STATA version 11.
Results
The overall cumulative incidence of SSI was 10.9% with an incidence rate of 37.5 per 10,000 people/day (95% CI, 26.8-52.4). The median time from CS to the development of SSI was 7 days (interquartile range [IQR] = 6–9 days). Six independent risk factors for post caesarean SSI as identified in this study by multivariate analysis are: hypertensive disorders of pregnancy (HR: 2.5; 95% CI, 1.1-5.6; P = 0.021), severe anaemia (HR: 3.8; 95% CI, 1.2-12.4, P = 0.028), surgical wound class III (HR: 2.4; 95% CI, 1.1-5.0; P = 0.021), multiple vaginal examinations (HR: 2.5; 95% CI, 1.2-5.1; P = 0.011), prolonged duration of operation (HR: 2.6; 95% CI, 1.2-5.5; P = 0.015) and an operation performed by an intern or junior doctor (HR: 4.0; 95% CI, 1.7-9.2; P = 0.001). Staphylococcus aureus was the most common organism (27.3%), followed by Klebsiella pneumoniae (22.7%). Patients with a SSI had a longer average hospital stay than those without a SSI (12.7 ± 6.9 vs. 4 ± 1.7; P < 0.0001) and the case fatality rate among patients with a SSI was 2.9%.
Conclusion
SSIs are common among women undergoing CSs at Bugando Medical Centre. SSIs were commonly associated with multiple factors. Strategies to control these factors are urgently needed to control SSIs post CS at Bugando Medical Centre and other centres in developing countries.
doi:10.1186/2047-2994-3-25
PMCID: PMC4131772  PMID: 25126415
2.  Predictors of Surgical Site Infection after Hospital Discharge in Patients Undergoing Major Vascular Surgery 
Journal of vascular surgery  2015;62(4):1023-1031.e5.
Objective
Surgical site infection (SSI) is one of the most common post-operative complications following vascular reconstruction, producing significant morbidity and hospital readmission. In contrast to SSI that develops while patients are still hospitalized, little is known about the cohort of patients that develop SSI following discharge. In this study, we explore the factors that lead to post-discharge SSI, investigate the differences between risk factors for in-hospital versus post-discharge SSI, and develop a scoring system to identify patients that might benefit from post-discharge monitoring of their wounds.
Methods
Patients who underwent major vascular surgery from 2005–2012 for aneurysm and lower extremity occlusive disease were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, in-hospital SSI, or SSI after hospital discharge. Predictors of post-discharge SSI were determined by multivariable logistic regression and internally validated by bootstrap resampling. Risk scores were assigned to all significant variables in the model. Summative risk scores were collapsed into quartile-based ordinal categories and defined as low-, low/moderate-, moderate/high-, and high-risk. Multivariable logistic regression was used to determine predictors of in-hospital SSI.
Results
Of the 49,817 patients who underwent major vascular surgery, 4,449 (8.9%) were diagnosed with SSI (2.1% in-hospital; 6.9% post-discharge). By multivariable analysis, factors significantly associated with increased odds of post-discharge SSI include female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, neurological disease, prolonged operative time >4 hours, American Society of Anesthesiology classification IV or V, lower extremity revascularization or aortoiliac procedure, and groin anastomosis. The model exhibited moderate discrimination (bias-corrected c-statistic, 0.691) and excellent internal calibration. The post-discharge SSI rate was 2.1% for low-risk patients, 5.1% for low/moderate-risk patients, 7.8% for moderate/high risk patients, and 14% for high-risk patients. In a comparative analysis, comorbidities were the primary driver of post-discharge SSI whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI.
Conclusions
The majority of SSIs after major vascular surgery develop following hospital discharge. We have created a scoring system that can select a cohort of patients at high-risk for SSI following discharge. These patients can be targeted for transitional care efforts focused on early detection and treatment with the goal of reducing morbidity and preventing readmission secondary to SSI.
doi:10.1016/j.jvs.2015.04.453
PMCID: PMC4586313  PMID: 26143662
3.  Incidence of Surgical Site Infection Following Mastectomy With and Without Immediate Reconstruction Using Private Insurer Claims Data 
Objective
The National Healthcare Safety Network classifies breast operations as clean procedures with an expected 1–2% surgical site infection (SSI) incidence. We assessed differences in SSI incidence following mastectomy with and without immediate reconstruction in a large, geographically diverse population.
Design
Retrospective cohort study.
Patients
Commercially-insured women aged 18–64 years with ICD-9-CM procedure or CPT-4 codes for mastectomy from 1/1/2004–12/31/2011.
Methods
Incident SSIs within 180 days after surgery were identified by ICD-9-CM diagnosis codes. The incidence of SSI after mastectomy +/− immediate reconstruction was compared by the chi-square test.
Results
From 2004–2011, 18,696 mastectomy procedures among 18,085 women were identified, with immediate reconstruction in 10,836 (58%) procedures. The 180-day incidence of SSI following mastectomy with or without reconstruction was 8.1% (1,520/18,696). Forty-nine percent of SSIs were identified within 30 days post-mastectomy, 24.5% between 31–60 days, 10.5% between 61–90 days, and 15.7% between 91–180 days. The incidence of SSI was 5.0% (395/7,860) after mastectomy-only, 10.3% (848/8,217) after mastectomy plus implant, 10.7% (207/1,942) after mastectomy plus flap, and 10.3% (70/677) after mastectomy plus flap and implant (p<0.001). The SSI risk was higher after bilateral compared with unilateral mastectomy with (11.4% vs. 9.4%, p=0.001) and without (6.1% vs. 4.7%, p=0.021) immediate reconstruction.
Conclusions
SSI incidence was two-fold higher after mastectomy with immediate reconstruction than after mastectomy alone. Only 49% of SSIs were coded within 30 days after operation. Our results suggest stratification by procedure type will facilitate comparison of SSI rates after breast operations between facilities.
doi:10.1017/ice.2015.108
PMCID: PMC4693606  PMID: 26036877
4.  Increased Risk of Surgical Site Infection Among Breast-Conserving Surgery Re-Excisions 
Annals of surgical oncology  2014;22(6):2003-2009.
Purpose
To determine the risk of surgical site infection (SSI) after primary breast-conserving surgery (BCS) versus re-excision among women with carcinoma in situ or invasive breast cancer.
Methods
We established a retrospective cohort of women aged 18–64 years with ICD-9-CM procedure or CPT-4 codes for BCS from 6/29/2004–12/31/2010. Prior insurance plan enrollment of at least 180 days was required to establish the index BCS; subsequent re-excisions within 180 days were identified. SSIs occurring 2–90 days after BCS were identified by ICD-9-CM diagnosis codes. The attributable surgery was defined based on SSI onset compared to the BCS date(s). A chi-square test and generalized estimating equations model were used to compare the incidence of SSI after index and re-excision BCS procedures.
Results
23,001 women with 28,827 BCS were identified; 23.2% of women had >1 BCS. The incidence of SSI was 1.82% (418/23,001) for the index BCS and 2.44% (142/5,826) for re-excision BCS (p=0.002). The risk of SSI after re-excision remained significantly higher after accounting for multiple procedures within a woman (odds ratio 1.34, 95% confidence interval, 1.07–1.68).
Conclusions
Surgeons need to be aware of the increased risk of SSI after re-excision BCS compared to the initial procedure. Our results suggest that risk adjustment of SSI rates for re-excision would allow for better comparison of BCS SSI rates between institutions.
doi:10.1245/s10434-014-4200-x
PMCID: PMC4693603  PMID: 25358666
5.  Comparison of Two Computer Algorithms To Identify Surgical Site Infections 
Surgical Infections  2011;12(6):459-464.
Abstract
Background
Surgical site infections (SSIs), the second most common healthcare-associated infections, increase hospital stay and healthcare costs significantly. Traditional surveillance of SSIs is labor-intensive. Mandatory reporting and new non-payment policies for some SSIs increase the need for efficient and standardized surveillance methods. Computer algorithms using administrative, clinical, and laboratory data collected routinely have shown promise for complementing traditional surveillance.
Methods
Two computer algorithms were created to identify SSIs in inpatient admissions to an urban, academic tertiary-care hospital in 2007 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes (Rule A) and laboratory culture data (Rule B). We calculated the number of SSIs identified by each rule and both rules combined and the percent agreement between the rules. In a subset analysis, the results of the rules were compared with those of traditional surveillance in patients who had undergone coronary artery bypass graft surgery (CABG).
Results
Of the 28,956 index hospital admissions, 5,918 patients (20.4%) had at least one major surgical procedure. Among those and readmissions within 30 days, the ICD-9-CM-only rule identified 235 SSIs, the culture-only rule identified 287 SSIs; combined, the rules identified 426 SSIs, of which 96 were identified by both rules. Positive and negative agreement between the rules was 36.8% and 97.1%, respectively, with a kappa of 0.34 (95% confidence interval [CI] 0.27–0.41). In the subset analysis of patients who underwent CABG, of the 22 SSIs identified by traditional surveillance, Rule A identified 19 (86.4%) and Rule B identified 13 (59.1%) cases. Positive and negative agreement between Rules A and B within these “positive controls” was 81.3% and 50.0% with a kappa of 0.37 (95% CI 0.04–0.70).
Conclusion
Differences in the rates of SSI identified by computer algorithms depend on sources and inherent biases in electronic data. Different algorithms may be appropriate, depending on the purpose of case identification. Further research on the reliability and validity of these algorithms and the impact of changes in reimbursement on clinician practices and electronic reporting is suggested.
doi:10.1089/sur.2010.109
PMCID: PMC3279712  PMID: 22136489
6.  Can Additional Information be Obtained from Claims Data to Support Surgical Site Infection Diagnosis Codes? 
Infection control and hospital epidemiology  2014;35(Suppl 3):S124-S132.
Objective
International Classification of Diseases (ICD-9-CM) diagnosis codes are increasingly used to identify healthcare-associated infections, often with insufficient evidence demonstrating validity of the codes used. Absent medical record verification, we sought to confirm a claims algorithm to identify surgical site infections (SSIs) by examining the presence of clinically expected SSI treatment.
Methods
We performed a retrospective cohort study using private insurer claims data from persons < 65 years with ICD-9-CM procedure or CPT-4 codes for anterior cruciate ligament (ACL) reconstruction from 1/2004–12/2010. SSIs occurring within 90 days after ACL reconstruction were identified by ICD-9-CM diagnosis codes. Antibiotic utilization, surgical treatment, and microbiology culture claims within 14 days of SSI codes were used as evidence to support the SSI diagnosis.
Results
Of 40,702 procedures, 401 (1.0%) were complicated by SSI, 172 (0.4%) of which were specifically identified as septic arthritis. Most SSIs were associated with an inpatient admission (n=232, 58%), and/or surgical procedure(s) for treatment (n=250, 62%). Temporally-associated antibiotics, surgical treatment procedures, and cultures were present for 84% (338/401), 61% (246/401), and 59% (238/401) respectively. Only 5.7% (23/401) of procedures coded for SSI post-procedure had no antibiotics, surgical treatments, or cultures within 14 days of the SSI claims.
Conclusions
Over 94% percent of patients identified by our claims algorithm as having an SSI received clinically expected treatment for infection including antibiotics, surgical treatment, and culture, suggesting this algorithm has very good positive predictive value. This method may facilitate retrospective SSI surveillance and comparison of SSI rates across facilities and providers.
doi:10.1086/677830
PMCID: PMC4817837  PMID: 25222891
7.  Cesarean Section Surgical Site Infections in Sub-Saharan Africa: A Multi-Country Study from Medecins Sans Frontieres 
World Journal of Surgery  2014;39:350-355.
Background
Surgical site infections (SSI) are a significant cause of post-surgical morbidity and mortality and can be an indicator of surgical quality. The objectives of this study were to measure post-operative SSI after cesarean section (CS) at four sites in three sub-Saharan African countries and to describe the associated risk factors in order to improved quality of care in low and middle income surgical programs.
Methods
This study included data from four emergency obstetric programs supported by Medecins sans Frontieres, from Burundi, the Democratic Republic of Congo (DRC), and Sierra Leone. Women undergoing from August 1 2010 to January 31 2011 were included. CS post-operative SSI data were prospectively collected. Logistic regression was used to model SSI risk factors.
Findings
In total, 1,276 women underwent CS. The incidence of SSI was 7.3 % (range 1.7–10.4 %). 93 % of SSI were superficial. The median length of stay of women without SSI was 7 days (range 3–63 days) compared to 21 days (range 5–51 days) in those with SSI (p < 0.001). In multivariate analysis, younger age, premature rupture of the membranes, and neonatal death were associated with an increased risk of SSI, while antenatal hemorrhage and the Lubutu, DRC project site were associated with a lower risk of developing an SSI.
Conclusions
This study demonstrates that surgery can be performed with a low incidence of SSI, a proxy for surgical safety, in sub-Saharan Africa. Protocols such as perioperative antibiotics and basic infrastructure such as clean water and sterilization can be achieved. Simple data collection tools will assist policymakers with monitoring and evaluation as well as quality control assurance of surgical programs in low and middle income countries.
doi:10.1007/s00268-014-2840-4
PMCID: PMC4300431  PMID: 25358418
8.  Randomized Controlled Trial Evaluating Dialkylcarbamoyl Chloride Impregnated Dressings for the Prevention of Surgical Site Infections in Adult Women Undergoing Cesarean Section 
Surgical Infections  2016;17(4):427-435.
Abstract
Background: Surgical site infections (SSI) occur in 1.8%–9.2% of women undergoing cesarean section (CS) and lead to greater morbidity rates and increased treatment costs. The aim of the study was to evaluate the efficacy and cost-effectiveness of dialkylcarbamoyl chloride (DACC) impregnated dressings to prevent SSI in women subject to CS.
Methods: Randomized, controlled trial was conducted at the Mazovian Bródno Hospital, a tertiary care center performing approximately 1300 deliveries per year, between June 2014 and April 2015. Patients were randomly allocated to receive either DACC impregnated dressing or standard surgical dressing (SSD) following skin closure. In order to analyze cost-effectiveness of the selected dressings in the group of patients who developed SSI, the costs of ambulatory visits, additional hospitalization, nursing care, and systemic antibiotic therapy were assessed. Independent risk factors for SSI were determined by multivariable logistic regression.
Results: Five hundred and forty-three women undergoing elective or emergency CS were enrolled. The SSI rates in the DACC and SSD groups were 1.8% and 5.2%, respectively (p = 0.04). The total cost of SSI prophylaxis and treatment was greater in the control group as compared with the study group (5775 EUR vs. 1065 EUR, respectively). Independent risk factors for SSI included higher pre-pregnancy body mass index (adjusted odds ratio [aOR] = 1.08; [95% confidence interval [CI]: 1.0–1.2]; p < 0.05), smoking in pregnancy (aOR = 5.34; [95% CI: 1.6–15.4]; p < 0.01), and SSD application (aOR = 2.94; [95% CI: 1.1–9.3]; p < 0.05).
Conclusion: The study confirmed the efficacy and cost-effectiveness of DACC impregnated dressings in SSI prevention among women undergoing CS.
doi:10.1089/sur.2015.223
PMCID: PMC4960475  PMID: 26891115
9.  Improving Public Reporting and Data Validation for Complex Surgical Site Infections After Coronary Artery Bypass Graft Surgery and Hip Arthroplasty 
Open Forum Infectious Diseases  2014;1(3):ofu106.
Diagnosis codes in claims submitted for reimbursement following coronary artery bypass graft surgery and hip arthroplasty allow standardized and efficient identification of deep and organ/space surgical site infections.
Background
 Deep and organ/space surgical site infections (D/OS SSI) cause significant morbidity, mortality, and costs. Rates are publicly reported and increasingly used as quality metrics affecting hospital payment. Lack of standardized surveillance methods threaten the accuracy of reported data and decrease confidence in comparisons based upon these data.
Methods
 We analyzed data from national validation studies that used Medicare claims to trigger chart review for SSI confirmation after coronary artery bypass graft surgery (CABG) and hip arthroplasty. We evaluated code performance (sensitivity and positive predictive value) to select diagnosis codes that best identified D/OS SSI. Codes were analyzed individually and in combination.
Results
 Analysis included 143 patients with D/OS SSI after CABG and 175 patients with D/OS SSI after hip arthroplasty. For CABG, 9 International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes identified 92% of D/OS SSI, with 1 D/OS SSI identified for every 4 cases with a diagnosis code. For hip arthroplasty, 6 ICD-9 diagnosis codes identified 99% of D/OS SSI, with 1 D/OS SSI identified for every 2 cases with a diagnosis code.
Conclusions
 This standardized and efficient approach for identifying D/OS SSI can be used by hospitals to improve case detection and public reporting. This method can also be used to identify potential D/OS SSI cases for review during hospital audits for data validation.
doi:10.1093/ofid/ofu106
PMCID: PMC4324229  PMID: 25734174
coronary artery bypass graft surgery; hip arthroplasty; infection prevention and control programs; surgical site infection; surveillance and public reporting
10.  Incidence of Surgical Site Infection After Spine Surgery: What Is the Impact of the Definition of Infection? 
Background
Orthopaedic surgical site infections (SSIs) can delay recovery, add impairments, and decrease quality of life, particularly in patients undergoing spine surgery, in whom SSIs may also be more common. Efforts to prevent and treat SSIs of the spine rely on the identification and registration of these adverse events in large databases. The effective use of these databases to answer clinical questions depends on how the conditions in question, such as infection, are defined in the databases queried, but the degree to which different definitions of infection might cause different risk factors to be identified by those databases has not been evaluated.
Questions/purposes
The purpose of this study was to determine whether different definitions of SSI identify different risk factors for SSI. Specifically, we compared the International Classification of Diseases, 9th Revision (ICD-9) coding, Centers for Disease Control and Prevention (CDC) criteria for deep infection, and incision and débridement for infection to determine if each is associated with distinct risk factors for SSI.
Methods
In this single-center retrospective study, a sample of 5761 adult patients who had an orthopaedic spine surgery between January 2003 and August 2013 were identified from our institutional database. The mean age of the patients was 56 years (± 16 SD), and slightly more than half were men. We applied three different definitions of infection: ICD-9 code for SSI, the CDC criteria for deep infection, and incision and débridement for infection. Three hundred sixty-one (6%) of the 5761 surgeries received an ICD-9 code for SSI within 90 days of surgery. After review of the medical records of these 361 patients, 216 (4%) met the CDC criteria for deep SSI, and 189 (3%) were taken to the operating room for irrigation and débridement within 180 days of the day of surgery.
Results
We found the Charlson Comorbidity Index, the duration of the operation, obesity, and posterior surgical approach were independently associated with a higher risk of infection for each of the three definitions of SSI. The influence of malnutrition, smoking, specific procedures, and specific surgeons varied by definition of infection. These elements accounted for approximately 6% of the variability in the risk of developing an infection.
Conclusions
The frequency of SSI after spine surgery varied according to the definition of an infection, but the most important risk factors did not. We conclude that large database studies may be better suited for identifying risk factors than for determining absolute numbers of infections.
Level of Evidence
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-014-3933-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s11999-014-3933-y
PMCID: PMC4385381  PMID: 25212963
11.  Risk factors for unavoidable removal of instrumentation after surgical site infection of spine surgery 
Medicine  2016;95(43):e5118.
Supplemental Digital Content is available in the text
Abstract
Surgical site infection (SSI) after spine instrumentation is difficult to treat, and often requires removal of instrumentation. The removal of instrumentation after spine surgery is a severe complication that can lead to the deterioration of activities of daily living and poor prognosis. Although there are many reports on SSI after spine surgery, few reports have investigated the risk factors for the removal of instrumentation after spine surgery SSI. This study aimed to identify the risk factors for unavoidable removal of instrumentation after SSI of spine surgery. We retrospectively reviewed 511 patients who underwent spine surgery with instrumentation at Kagoshima University Hospital from January 2006 to December 2014. Risk factors associated with SSI were analyzed via multiple logistic regression analysis. Parameters of the group that needed instrumentation removal were compared with the group that did not require instrumentation removal using the Mann–Whitney U and Fisher's exact tests. The posterior approach was used in most cases (453 of 511 cases, 88.6%). SSI occurred in 16 of 511 cases (3.14%) of spine surgery with instrumentation. Multivariate logistic regression analysis identified 2 significant risk factors for SSI: operation time, and American Society of Anesthesiologists physical status classification ≥ 3. Twelve of the 16 patients with SSI (75%) were able to keep the instrumentation after SSI. Pseudarthrosis occurred in 2 of 4 cases (50%) after instrumentation removal. Risk factors identified for instrumentation removal after spine SSI were a greater number of past surgeries, low preoperative hemoglobin, high preoperative creatinine, high postoperative infection treatment score for the spine, and the presence of methicillin-resistant Staphylococcus aureus. In these high risk cases, attempts should be made to decrease the risk factors preoperatively, and careful postoperative monitoring should be conducted.
doi:10.1097/MD.0000000000005118
PMCID: PMC5089094  PMID: 27787365
instrumentation; spine surgery; surgical site infection; unavoidable removal
12.  Implementation of a Bundle of Care to Reduce Surgical Site Infections in Patients Undergoing Vascular Surgery 
PLoS ONE  2013;8(8):e71566.
Background
Surgical site infections (SSI’s) are associated with severe morbidity, mortality and increased health care costs in vascular surgery.
Objective
To implement a bundle of care in vascular surgery and measure the effects on the overall and deep-SSI’s rates.
Design
Prospective, quasi-experimental, cohort study.
Methods
A prospective surveillance for SSI’s after vascular surgery was performed in the Amphia hospital in Breda, from 2009 through 2011. A bundle developed by the Dutch hospital patient safety program (DHPSP) was introduced in 2009. The elements of the bundle were (1) perioperative normothermia, (2) hair removal before surgery, (3) the use of perioperative antibiotic prophylaxis and (4) discipline in the operating room. Bundle compliance was measured every 3 months in a random sample of surgical procedures and this was used for feedback.
Results
Bundle compliance improved significantly from an average of 10% in 2009 to 60% in 2011. In total, 720 vascular procedures were performed during the study period and 75 (10.4%) SSI were observed. Deep SSI occurred in 25 (3.5%) patients. Patients with SSI’s (28,5±29.3 vs 10.8±11.3, p<0.001) and deep-SSI’s (48.3±39.4 vs 11.4±11.8, p<0.001) had a significantly longer length of hospital stay after surgery than patients without an infection. A significantly higher mortality was observed in patients who developed a deep SSI (Adjusted OR: 2.96, 95% confidence interval 1.32–6.63). Multivariate analysis showed a significant and independent decrease of the SSI-rate over time that paralleled the introduction of the bundle. The SSI-rate was 51% lower in 2011 compared to 2009.
Conclusion
The implementation of the bundle was associated with improved compliance over time and a 51% reduction of the SSI-rate in vascular procedures. The bundle did not require expensive or potentially harmful interventions and is therefore an important tool to improve patient safety and reduce SSI’s in patients undergoing vascular surgery.
doi:10.1371/journal.pone.0071566
PMCID: PMC3742500  PMID: 23967222
13.  Risk Factors for Surgical Site Infection Following Major Breast Surgery 
Background
Surgical site infections following breast surgery result in increased length of hospital stay, antibiotic utilization, and morbidity. Understanding SSI risk factors is essential to develop infection prevention strategies and improve surgical outcomes.
Methods
A retrospective case-control design was used to determine independent risk factors for surgical site infection in subjects selected from a cohort of patients who had mastectomy, breast reconstruction or reduction surgery between January 1998 and June 2002 at a tertiary-care university affiliated hospital. SSI cases within 1 year after surgery were identified using ICD-9-CM diagnosis codes for wound infection or complication and/or positive wound cultures. The medical records of 57 case patients with breast SSI and 268 randomly selected uninfected control patients were reviewed. Multivariate logistic regression was used to identify independent risk factors for SSI.
Results
During the 4.5-year study period, 57 patients developed SSIs involving a breast incision and 10 patients developed SSIs involving a donor site incision. Significant independent risk factors for SSI involving the breast incision included insertion of a breast implant or tissue expander (odds ratio (OR) 5.3, 95% confidence interval (CI):2.5–11.1), suboptimal prophylactic antibiotic dosing (OR 5.1, 95% CI: 2.5–0.2 ), transfusion (OR 3.4, 95% CI: 1.3–9.0), mastectomy (OR 3.3, 95% CI: 1.4–7.7), previous chest irradiation (OR 2.8, 95% CI: 1.2–6.5), and current or recent smoking (OR 2.1, 95% CI: 0.9–4.9). Local infiltration of an anesthetic agent was associated with significantly reduced risk of SSI (OR 0.4, 95% CI: 0.1–0.9).
Conclusions
Suboptimal prophylactic antibiotic dosing is a potentially modifiable risk factor for SSI following breast surgery. Risk of SSI was increased in patients undergoing mastectomy and in patients who had an implant or tissue expander placed during surgery. Knowledge of these risk factors can be used to develop a specific risk stratification index to predict SSI in breast surgery and infection preventive strategies tailored for breast surgery patients.
doi:10.1016/j.jamcollsurg.2008.04.021
PMCID: PMC3618680  PMID: 18722936
14.  Stratification of Surgical Site Infection by Operative Factors and Comparison of Infection Rates after Hernia Repair 
Objective
The National Healthcare Safety Network does not risk adjust surgical site infection (SSI) rates after hernia repair by operative factors. We investigated whether operative factors are associated with risk of SSI after hernia repair.
Design
Retrospective cohort study.
Patients
Commercially-insured enrollees aged 6 months–64 years with ICD-9-CM procedure or CPT-4 codes for inguinal/femoral, umbilical, and incisional/ventral hernia repair procedures from 1/1/2004–12/31/2010.
Methods
SSIs within 90 days after hernia repair were identified by ICD-9-CM diagnosis codes. Chi-square and Fisher’s exact tests were used to compare SSI incidence by operative factors.
Results
A total of 119,973 hernia repair procedures were included in the analysis. The incidence of SSI differed significantly by anatomic site, with rates of 0.45% (352/77,666) for inguinal/femoral, 1.16% (288/24,917) for umbilical, and 4.11% (715/17,390) for incisional/ventral hernia repair. Within anatomic sites, the incidence of SSI was significantly higher for open versus laparoscopic inguinal/femoral (0.48% [295/61,142] versus 0.34% [57/16,524], p=0.020) and incisional/ventral (4.20% [701/16,699] versus 2.03% [14/691], p=0.005) hernia repairs. The rate of SSI was higher following procedures with bowel obstruction/necrosis than procedures without obstruction/necrosis for open inguinal/femoral (0.89% [48/5,422] versus 0.44% [247/55,720], p<0.001) and umbilical (1.57% [131/8,355] versus 0.95% [157/16,562], p<0.001), but not incisional/ventral hernia repair (4.01% [224/5,585] versus 4.16% [491/11,805], p=0.645).
Conclusions
The incidence of SSI was highest after open procedures, incisional/ventral repairs, and hernia repairs with bowel obstruction/necrosis. Our findings suggest that stratification of hernia repair SSI rates by some operative factors may be important to facilitate accurate comparison of SSI rates between facilities.
doi:10.1017/ice.2014.44
PMCID: PMC4683022  PMID: 25695175
15.  The preventive surgical site infection bundle in patients with colorectal perforation 
BMC Surgery  2015;15:128.
Background
Incisional surgical site infection (SSI) is one of the most frequent complications that occur after colorectal surgery. Surgery for colorectal perforation carries an especially high risk of incisional SSI because fecal ascites contaminates the incision intraoperatively, and in patients who underwent stoma creation, the incision is located near the infective origin and is subject to infection postoperatively. Although effectiveness of the preventive SSI bundle of elective colorectal surgery has been reported, no study has focused exclusively on emergency surgery for colorectal perforation.
Methods
Patients with colorectal perforation who underwent emergency surgery and stoma creation from 2010 to 2015 at our center were consecutively enrolled in the study. In March 2013, we developed the preventive incisional SSI bundle for patients with colorectal perforation undergoing stoma creation. The effectiveness of the bundle in these patients was determined and the rates of incisional SSI between before and after March 2013 were compared.
Results
We enrolled 108 patients with colorectal perforation who underwent emergency operation during the study period. Thirteen patients were excluded because they died within 30 days after surgery, and 23 patients without stoma were excluded; thus, 72 patients were analyzed. There were 47 patients in the pre-implementation group and 25 patients in the post-implementation group. The rate of incisional SSI was significantly lower after implementation of preventive incisional SSI bundle (43 % vs. 20 %, p = 0.049). Postoperative hospital stay was significantly shorter after implementation of the bundle (27 vs. 18 days respectively; p = 0.008).
Conclusions
The preventive incisional SSI bundle was effective in preventing incisional SSI in patients with colorectal perforation undergoing emergency surgery with stoma creation.
doi:10.1186/s12893-015-0115-0
PMCID: PMC4683779  PMID: 26680600
Abdominal infection; Surgical site infection; Wound infection; Perforation; Peritonitis
16.  The Effects of Local Warming on Surgical Site Infection 
Surgical Infections  2015;16(5):595-603.
Abstract
Background: Surgical site infections (SSI) account for a major proportion of hospital-acquired infections. They are associated with longer hospital stay, readmissions, increased costs, mortality, and morbidity. Reducing SSI is a goal of the Surgical Care Improvement Project and identifying interventions that reduce SSI effectively is of interest. In a single-blinded randomized controlled trial (RCT) we evaluated the effect of localized warming applied to surgical incisions on SSI development and selected cellular (immune, endothelial) and tissue responses (oxygenation, collagen).
Methods: After Institutional Review Board approval and consent, patients having open bariatric, colon, or gynecologic-oncologic related operations were enrolled and randomly assigned to local incision warming (6 post-operative treatments) or non-warming. A prototype surgical bandage was used for all patients. The study protocol included intra-operative warming to maintain core temperature ≥36°C and administration of 0.80 FIO2. Patients were followed for 6 wks for the primary outcome of SSI determined by U.S. Centers for Disease Control (CDC) criteria and ASEPSIS scores (additional treatment; presence of serous discharge, erythema, purulent exudate, and separation of the deep tissues; isolation of bacteria; and duration of inpatient stay). Tissue oxygen (PscO2) and samples for cellular analyses were obtained using subcutaneous polytetrafluoroethylene (ePTFE) tubes and oxygen micro-electrodes implanted adjacent to the incision. Cellular and tissue ePTFE samples were evaluated using flow cytometry, immunohistochemistry, and Sircol™ collagen assay (Biocolor Ltd., Carrickfergus, United Kingdom).
Results: One hundred forty-six patients participated (n=73 per group). Study groups were similar on demographic parameters and for intra-operative management factors. The CDC defined rate of SSI was 18%; occurrence of SSI between groups did not differ (p=0.27). At 2 wks, warmed patients had better ASEPSIS scores (p=0.04) but this difference was not observed at 6 wks. There were no significant differences in immune, endothelial cell, or collagen responses between groups. On post-operative days one to two, warmed patients had greater PscO2 change scores with an average PscO2 increase of 9–10 mm Hg above baseline (p<0.04).
Conclusions: Post-operative local warming compared with non-warming followed in this study, which included intra-operative warming to maintain normothermia and FIO2 level of 0.80, did not reduce SSI and had no effect on immune, endothelial cell presence, or collagen synthesis. PscO2 increased significantly with warming, however, the increase was modest and less than expected or what has been observed in studies testing other interventions.
doi:10.1089/sur.2013.096
PMCID: PMC4593881  PMID: 26125454
17.  The epidemiology and cost of surgical site infections in Korea: a systematic review 
Purpose
To conduct a systematic literature review of the epidemiological and economic burden of surgical site infection (SSI) in Korea.
Methods
A search of the EMBASE, Medline and KoreaMed databases for English and Korean language publications was conducted. Searches for epidemiological and economic studies were conducted separately and limited to 1995 to 2010 to ensure the pertinence of the data.
Results
Twenty-six studies were included. The overall incidence of SSI in Korea was 2.0 to 9.7%. The National Nosocomial Infections Surveillance risk index was positively correlated with the risk of developing an SSI. Specific risk factors for SSI, identified through multivariate analyses included; diabetes, antibiotic prophylaxis and wound classification. SSIs were associated with increased hospitalisation cost, with each episode of SSI estimated to cost about an additional ₩2,000,000. A substantial portion of the increased cost was attributed to hospital room costs and the need for additional medication. Studies also found that post-operative stays for patients with SSIs were 5 to 20 days longer, while two studies reported that following cardiac surgery, patients with SSIs spent an additional 5 to 11 days in the intensive care unit, compared to patients without SSIs.
Conclusion
Data from the included studies demonstrate that SSI represents a significant clinical and economic burden in Korea. Consequently, the identification of high-risk patient populations and the development of strategies aimed at reducing SSI may lead to cost-savings for the healthcare system.
doi:10.4174/jkss.2011.81.5.295
PMCID: PMC3228997  PMID: 22148121
Surgical site infection; Epidemiology; Cost
18.  Does Minimally Invasive Surgery Have a Lower Risk of Surgical Site Infections Compared With Open Spinal Surgery? 
Background
Surgical site infection (SSI) ranges from 1.9% to 5.5% in most large series. Minimally invasive surgery (MIS) has been postulated to reduce SSI rates.
Questions/purposes
(1) Is MIS associated with a lower incidence of SSI compared with open spinal surgery? (2) Are there other independent risk factors associated with SSI? (3) What bacteria are most common in spinal SSI?
Methods
Medical records of 2299 patients who underwent transforaminal lumbar interbody fusion, laminectomy, or discectomy were analyzed and selected for a nested case-control analysis. Twenty-seven cases with SSI were matched with 162 control subjects without SSI stratified based on procedure performed within 28 days of the case’s date of surgery. Patients were identified from an institutional database at a tertiary care hospital. MIS involved spinal procedures performed through a tubular retractor system. Univariate and multivariate analyses were performed.
Results
Patients undergoing open spinal surgery were 5.77 times more likely to develop SSI compared with MIS approaches (odds ratio [OR], 5.77; 95% confidence interval [CI], 1.0–32.7; p = 0.048). Also, from the multivariate regression model, diabetes (OR, 4.7; 95% CI, 1.3–17.0; p = 0.018), number of levels operated on (OR, 3.5; 95% CI, 1.6–7.5; p = 0.001), and body mass index (OR, 1.2; 95% CI, 1.0–1.3; p = 0.010) were predictive of an increased risk in SSI. Staphylococcus aureus was most frequently identified, being present in 12 of 21 (52.4%) patients in whom positive cultures were obtained. Four of the 12 patients had methicillin-resistant S aureus infection.
Conclusions
In our series, MIS has a lower incidence of SSI. The risk factors predictive of SSI should be further evaluated in well-designed prospective trials.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-013-3158-5
PMCID: PMC4016449  PMID: 23846605
19.  Procedure-specific Surgical Site Infection Incidence Varies Widely within Certain National Healthcare Safety Network Surgery Groups 
Background
The National Healthcare Safety Network (NHSN) classifies surgical procedures into 40 categories. The objective of this study was to determine surgical site infection (SSI) incidence for clinically defined subgroups within 5 heterogeneous NHSN surgery categories.
Methods
This is a retrospective cohort study using the longitudinal State Inpatient Database. We identified 5 groups of surgical procedures (amputation; biliary, liver and pancreas [BILI]; breast; colon and hernia) using ICD-9-CM procedure codes in community hospitals in California, Florida and New York from January 2009 through September 2011 in persons aged ≥18 years. Each of these 5 categories was classified to more specific surgical procedures within the group. 90-day SSI rates were calculated using ICD-9-CM diagnosis codes.
Results
There were 62,901 amputation, 33,358 BILI, 72,058 breast, 125,689 colon and 85,745 hernia surgeries in 349,298 people. 90-day SSI rates varied significantly within each of the 5 subgroups. Within the BILI category, bile duct, pancreas and laparoscopic liver procedures had SSI rates of 7.2%, 17.2%, and 2.2%, respectively (p<0.0001 for each) compared to open liver procedures (11.1% SSI).
Conclusion
90-day SSI rates varied widely within certain NHSN categories. Risk adjustment for specific surgery type is needed in order to make valid comparisons between hospitals.
doi:10.1016/j.ajic.2015.02.012
PMCID: PMC4573529  PMID: 25818024
surgical site infection; surveillance; risk adjustment; National Healthcare Safety Network
20.  Dialkylcarbamoyl chloride-impregnated dressing for the prevention of surgical site infection in women undergoing cesarean section: a pilot study 
Archives of Medical Science : AMS  2015;12(5):1036-1042.
Introduction
Incisional surgical site infections (SSIs) occur in approximately 1.8–9.2% of patients undergoing cesarean section (CS) and contribute to prolonged hospitalization time and increased treatment costs. Dressings impregnated with dialkylcarbamoyl chloride (DACC) are an innovative approach to wound treatment based on a solely physical mechanism of action, and therefore can be used safely and without time restrictions in women during the puerperal and lactation period.
Material and methods
A single-blinded randomized, controlled pilot study was conducted at the Mazovian Bródno Hospital, a tertiary care hospital, between December 2013 and March 2014, and it evaluated the presence of superficial and deep SSIs in patients during the first 14 days after a CS. Patients were randomly allocated to receive treatment with either a DACC dressing or a standard surgical dressing.
Results
One hundred and forty-two patients after planned or emergency CS were enrolled in the study. No significant differences between the groups were observed with regard to patients’ basic demographic and perioperative characteristics. The rate of superficial and deep SSIs was 2.8% in the group of patients who received a DACC dressing compared to 9.8% in the group with a standard surgical dressing (p = 0.08). Patients with SSIs who received a standard surgical dressing required systemic antibiotic therapy significantly more frequently (p = 0.03). Based on the logistic regression model developed, the pre-pregnancy body mass index was the only statistically significant risk factor for SSI (p = 0.015).
Conclusions
The results of the pilot study indicate a decreasing tendency of the SSI rate in patients after a CS who received DACC impregnated dressings.
doi:10.5114/aoms.2015.47654
PMCID: PMC5016568  PMID: 27695495
dialkylcarbamoyl chloride; surgical site infection; cesarean section
21.  Which Kind of Provider’s Operation Volumes Matters? Associations between CABG Surgical Site Infection Risk and Hospital and Surgeon Operation Volumes among Medical Centers in Taiwan 
PLoS ONE  2015;10(6):e0129178.
Background
Volume-infection relationships have been examined for high-risk surgical procedures, but the conclusions remain controversial. The inconsistency might be due to inaccurate identification of cases of infection and different methods of categorizing service volumes. This study takes coronary artery bypass graft (CABG) surgical site infections (SSIs) as an example to examine whether a relationship exists between operation volumes and SSIs, when different SSIs case identification, definitions and categorization methods of operation volumes were implemented.
Methods
A population-based cross-sectional multilevel study was conducted. A total of 7,007 patients who received CABG surgery between 2006 and 2008 from19 medical centers in Taiwan were recruited. SSIs associated with CABG surgery were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) codes and a Classification and Regression Trees (CART) model. Two definitions of surgeon and hospital operation volumes were used: (1) the cumulative CABG operation volumes within the study period; and (2) the cumulative CABG operation volumes in the previous one year before each CABG surgery. Operation volumes were further treated in three different ways: (1) a continuous variable; (2) a categorical variable based on the quartile; and (3) a data-driven categorical variable based on k-means clustering algorithm. Furthermore, subgroup analysis for comorbidities was also conducted.
Results
This study showed that hospital volumes were not significantly associated with SSIs, no matter which definitions or categorization methods of operation volume, or SSIs case identification approaches were used. On the contrary, the relationships between surgeon’s volumes varied. Most of the models demonstrated that the low-volume surgeons had higher risk than high-volume surgeons.
Conclusion
Surgeon volumes were more important than hospital volumes in exploring the relationship between CABG operation volumes and SSIs in Taiwan. However, the relationships were not robust. Definitions and categorization methods of operation volume and correct identification of SSIs are important issues for future research.
doi:10.1371/journal.pone.0129178
PMCID: PMC4459823  PMID: 26053035
22.  External Validation of the Ventral Hernia Risk Score for Prediction of Surgical Site Infections 
Surgical Infections  2015;16(1):36-40.
Abstract
Background: Previously, we reported that the Ventral Hernia Risk Score (VHRS) was more accurate in a Veterans Affairs (VA) population in predicting surgical site infection (SSI) after open ventral hernia repair (VHR) compared with other models such as the Ventral Hernia Working Group (VHWG) model. The VHRS was developed using single-center data and stratifies SSI risk into five groups based on concomitant hernia repair, skin flaps created, American Society of Anesthesiologists (ASA) score ≥3, body mass index ≥40 kg/m2, and incision class 4. The purpose of this study was to validate the VHRS for other hospitals.
Methods: A prospective database of all open VHRs performed at three institutions from 2009–2011 was utilized. All 436 patients with a follow-up of at least 1 mo were included. The U.S. Centers for Disease Control and Prevention (CDC) definition of SSI was utilized. Each patient was assigned a VHRS, VHWG, and CDC incision classification. Receiver-operating characteristic curves were used to assess predictive accuracy, and the areas under the curve (AUCs) were compared for the three risk-stratification systems.
Results: The median follow-up was 20 mos (range 1–49 mos). During this time, 111 patients (25.5%) developed a SSI. The AUC of the VHRS (0.73; 95% confidence interval [CI] 0.67–0.78) was greater than that of the VHWG (0.66; 95% CI 0.60–0.72; p<0.01) and the CDC incision class (0.68; 95% CI 0.61–0.74; p<0.05).
Conclusions: The VHRS provides a novel, internally and externally validated score for a patient's likelihood of developing a SSI after open VHR. Elevating skin flaps, ASA score ≥3, concomitant procedures, morbid obesity, and incision class all independently predicted SSI. It remains to be determined if pre-operative patient selection and risk reduction, surgical techniques, and post-operative management can improve outcomes in the highest-risk patients. The VHRS provides a starting point for key stakeholders to discuss the management of ventral hernias.
doi:10.1089/sur.2014.115
PMCID: PMC4363797  PMID: 25761078
23.  Surgical site infection prophylaxis strategies for cardiothoracic surgery: a decision-analytic model 
Background
Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of invasive surgical site infection (SSI) in the USA. Antimicrobial prophylaxis for SSI typically includes a cephalosporin. Vancomycin is used to provide MRSA coverage, but administration timing is challenging. Linezolid is an attractive agent for SSI prophylaxis, particularly for the prevention of SSI due to MRSA.
Methods
We developed a decision-analytic model to evaluate linezolid use for cardiothoracic SSI prophylaxis. A theoretical cohort of 10,000 cardiothoracic surgery patients was followed through 2 stages: 1) occurrence of SSI, and 2) mortality after SSI. All patients were administered cefuroxime, vancomycin, or linezolid between 1–180 minutes prior to surgical incision. SSIs were categorized into three pathogen categories: 1) methicillin-susceptible Gram-positive, 2) methicillin-resistant Gram-positive, and 3) other organisms. The most effective strategy resulted in the fewest SSIs. Assumptions for antibiotic effectiveness, impact of administration time, and pathogens were based on the published literature.
Results
Compared with cefuroxime, there was a 1% increase in the total number of SSIs in the linezolid group (mean SSI increase = 7), while there was a 12% increase in the vancomycin group (mean SSI increase = 86). Linezolid prophylaxis resulted in fewer SSIs due to methicillin-resistant Gram-positive infections (n=108) compared with cefuroxime (n = 200, 46% reduction in the linezolid group) and vancomycin (n = 119, 9% reduction in the linezolid group).
Conclusions
This simulation indicates that linezolid may offer benefits for SSI prophylaxis over existing prophylactic agents, particularly for the prevention of SSI due to Gram-positive methicillin-resistant pathogens.
doi:10.3109/00365548.2012.700118
PMCID: PMC3684012  PMID: 22831753
Surgical site infection; prophylaxis; decision-analytic model; linezolid; vancomycin
24.  Seasonal Variation of Common Surgical Site Infections: Does Season Matter? 
OBJECTIVE
To evaluate seasonal variation in the rate of surgical site infections (SSI) following commonly performed surgical procedures.
DESIGN
Retrospective cohort study.
METHODS
We analyzed 6 years (January 1, 2007, through December 31, 2012) of data from the 15 most commonly performed procedures in 20 hospitals in the Duke Infection Control Outreach Network. We defined summer as July through September. First, we performed 3 separate Poisson regression analyses (unadjusted, multivariable, and polynomial) to estimate prevalence rates and prevalence rate ratios of SSI following procedures performed in summer versus nonsummer months. Then, we stratified our results to obtain estimates based on procedure type and organism type. Finally, we performed a sensitivity analysis to test the robustness of our findings.
RESULTS
We identified 4,543 SSI following 441,428 surgical procedures (overall prevalence rate, 1.03/100 procedures). The rate of SSI was significantly higher during the summer compared with the remainder of the year (1.11/100 procedures vs 1.00/100 procedures; prevalence rate ratio, 1.11 [95% CI, 1.04–1.19]; P =.002). Stratum-specific SSI calculations revealed higher SSI rates during the summer for both spinal (P =.03) and nonspinal (P =.004) procedures and revealed higher rates during the summer for SSI due to either gram-positive cocci (P =.006) or gram-negative bacilli (P =.004). Multivariable regression analysis and sensitivity analyses confirmed our findings.
CONCLUSIONS
The rate of SSI following commonly performed surgical procedures was higher during the summer compared with the remainder of the year. Summer SSI rates remained elevated after stratification by organism and spinal versus nonspinal surgery, and rates did not change after controlling for other known SSI risk factors.
doi:10.1017/ice.2015.121
PMCID: PMC4748703  PMID: 26008876
25.  Efficacy of Single-Dose Antimicrobial Prophylaxis for Preventing Surgical Site Infection in Radical Gastrectomy for Gastric Carcinoma 
Journal of Gastric Cancer  2014;14(3):156-163.
Purpose
Information regarding antimicrobial prophylaxis (AMP) for gastric cancer surgery is limited. The present study investigated the efficacy of single-dose AMP for the prevention of surgical site infection (SSI) in patients undergoing gastrectomy for gastric carcinoma.
Materials and Methods
Between 2011 and 2013, 1,330 gastric carcinoma surgery patients were divided into two AMP administration groups depending on the duration of treatment. Postoperative outcomes including morbidity and SSI were compared between the two groups overall and in matched patients. Risk factors for SSI were analyzed.
Results
The extended group (n=1,129) received AMP until postoperative day 1 and the single-dose group (n=201) received singledose AMP only during an operation. Postoperatively, there were no significant differences between the two groups with respect to overall morbidity, mortality, or length of hospital stay. The SSI rate of the single-dose group was not significantly different from that of the extended group overall (4.5% vs. 5.5%, respectively, P=0.556) or in matched patients (4.5% vs. 4.0%, respectively, P=0.801). There was no increase in the SSI rate of the single-dose group compared to the extended group in subgroups based on different clinicopathological and operative factors. Univariate and multivariate analyses revealed male gender, open surgery, and operating time (≥180 minutes) as independent risk factors for SSI.
Conclusions
Single-dose AMP showed no increase in the postoperative SSI rate compared to postoperative extended use in patients undergoing gastrectomy for gastric carcinoma. The efficacy of single-dose AMP requires further investigation in randomized clinical trials specific to gastric cancer surgery.
doi:10.5230/jgc.2014.14.3.156
PMCID: PMC4199882  PMID: 25328760
Antibiotic prophylaxis; Surgical wound infection; Stomach neoplasms

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