Bryan Knepper

Surgical Site Infection after Colon Surgery: National Healthcare Safety Network Risk Factors and Modeled Rates Compared with Published Risk Factors and Rates

p d The Inpatient Prospective Payment System stipulates that hospitals must report rates of colon surgical site infection (SSI) to the National Healthcare Safety Network (NHSN) beginning in 2012, and colon SSI rates will be linked to reimbursement beginning in 2014. For the last decade, the se of pay-for-performance has been promoted in the belief hat economic incentives and penalties can accelerate imrovements in the quality and outcomes of care. Without n appropriate risk-stratification model, surgeons and hositals would be penalized for performing operations on atients at higher risk for SSI developing, including those ith more severe surgical disease or comorbid conditions. herefore, pay-for-performance can result in unintended utcomes, such as the exclusion of severely ill patients from are. NHSN used logistic regression to develop procedurespecific risk-adjustment models; this replaces the older National Nosocomial Infection Surveillance risk index system. This new tool is based largely on nonmodifiable patient and procedure factors and predicts the expected rate of SSI after various surgical procedures. The procedures and variables included in the model-building process were voluntarily reported from 2006 to 2008 in emergent, urgent, and elective settings. Formal assessment of data accuracy was not performed. Eight risk factors were found

Avoidable antibiotic exposure for uncomplicated skin and soft tissue infections in the ambulatory care setting.

BACKGROUND Uncomplicated skin and soft tissue infections are among the most frequent indications for outpatient antibiotics. A detailed understanding of current prescribing practices is necessary to optimize antibiotic use for these conditions. METHODS This was a retrospective cohort study of children and adults treated in the ambulatory care setting for uncomplicated cellulitis, wound infection, or cutaneous abscess between March 1, 2010 and February 28, 2011. We assessed the frequency of avoidable antibiotic exposure, defined as the use of antibiotics with broad gram-negative activity, combination antibiotic therapy, or treatment for 10 or more days. Total antibiotic-days prescribed for the cohort were compared with antibiotic-days in 4 hypothetical short-course (5-7 days), single-antibiotic treatment models consistent with national guidelines. RESULTS A total of 364 cases were included for analysis (155 cellulitis, 41 wound infection, and 168 abscess). Antibiotics active against methicillin-resistant Staphylococcus aureus were prescribed in 61% of cases of cellulitis. Of 139 cases of abscess where drainage was performed, antibiotics were prescribed in 80% for a median of 10 (interquartile range, 7-10) days. Of 292 total cases where complete prescribing data were available, avoidable antibiotic exposure occurred in 46%. This included use of antibiotics with broad gram-negative activity in 4%, combination therapy in 12%, and treatment for 10 or more days in 42%. Use of the short-course, single-antibiotic treatment strategies would have reduced prescribed antibiotic-days by 19% to 55%. CONCLUSIONS Approximately half of uncomplicated skin infections involved avoidable antibiotic exposure. Antibiotic use could be reduced through treatment approaches using short courses of a single antibiotic.

Prophylactic antibiotics in open fractures: a pilot randomized clinical safety study.

Objective: To develop preliminary data on Staphylococcus aureus colonization and surgical site infections (SSIs) in patients with open fractures who received standard antibiotic prophylaxis compared with a regimen including targeted methicillin-resistant Staphylococcus aureus (MRSA) coverage. Design: Randomized prospective clinical trial. Patients: Adult patients who presented to the emergency department with an open fracture between April 2009 and July 2011. Interventions: One hundred thirty patients were randomized to receive prophylaxis with either cefazolin alone (control arm) or vancomycin and cefazolin (experimental arm) from presentation to the emergency department until 24 hours after the surgical intervention. Screening for S. aureus carriage was performed with nares swabs and predebridement and postdebridement open fracture wound swabs. Patients underwent prospective assessment for the development of SSI for no less than 30 days and up to 12 months. Results: Nasal colonization of methicillin-sensitive S. aureus and MRSA among the sample was 20% and 3%, respectively. No significant difference in the rates of SSI was observed between the study arms (15% vs 19%, respectively, P = 0.62). Staphylococcus aureus caused 55% of the deep incisional/organ space SSI, with 18% attributed to MRSA. A significantly higher rate of MRSA SSIs was observed among MRSA carriers compared with noncarriers (33% vs 1%, respectively, P = 0.003). Conclusions: Staphylococcus aureus nasal colonization in trauma patients with open fractures is similar to that of the general community. In this pilot study, the addition of vancomycin to standard antibiotic prophylaxis was found safe, but its efficacy should be evaluated in a larger multiinstitutional trial. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for drug-resistant Streptococcus pneumoniae and antibiotic prescribing practices in outpatient community-acquired pneumonia.

OBJECTIVES Due to antimicrobial resistance in Streptococcus pneumoniae, national guidelines recommend a respiratory fluoroquinolone or combination antimicrobial therapy for outpatient treatment of community-acquired pneumonia (CAP) associated with risk factors for drug-resistant S. pneumoniae (DRSP). The objectives of this study were to assess the prevalence of these risk factors and antibiotic prescribing practices in cases of outpatient CAP treated in the acute care setting. METHODS This was a retrospective cohort study of adult outpatients treated for CAP in the emergency department (ED) or urgent care center of an urban, academic medical center from May 1, 2009, through October 31, 2009, and comparison of antibiotic therapy in cases with and without DRSP risk factors. RESULTS Of 175 patients, 90 (51%) had at least one DRSP risk factor, most commonly asthma (n = 28, 16%), alcohol abuse (n = 24, 14%), diabetes mellitus (n = 18, 10%), chronic obstructive pulmonary disease (n = 16, 9%), age > 65 years (n = 16, 9%), and use of antibiotics within 3 months (15, 9%). Antibiotic prescriptions were similar among cases with and without DRSP risk factors: a macrolide (62% vs. 59%, respectively, p = 0.65), doxycycline (27% vs. 28%, p = 0.82), or a respiratory fluoroquinolone (9% vs. 9%, p = 0.90). Concordance with national guideline treatment recommendations was significantly lower in cases with DRSP risk factors (9% vs. 87%, p < 0.0001). CONCLUSIONS DRSP risk factors were present in approximately half of outpatient CAP cases treated in the acute care setting; however, guideline-concordant antibiotic therapy was infrequent. Strict adherence to current guidelines would substantially increase use of fluoroquinolones or combination therapy. Whether the potential risks associated with these broad-spectrum regimens are justified by improved clinical outcomes requires further study.

Sustained Reduction in Surgical Site Infection after Abdominal Hysterectomy

BACKGROUND During a period of five years, the rate of surgical site infection (SSI) after abdominal hysterectomy at our institution was >10%. With the implementation of a multifaceted intervention designed to reduce this, the rate of SSI fell to <2% in the post-intervention period. The pre- and post-intervention periods were compared to determine which of the interventions in the multifaceted array of interventions was most valuable in decreasing SSI. METHODS A retrospective chart review was done to identify: (1) Parameters associated with SSI, and (2) parameters that differed in the pre- and post-intervention periods. The intervention included providing departmental SSI rates to the gynecology faculty, re-educating operating room (OR) staff personnel about appropriate perioperative antibiotic choice and timing, and changing the preferred sterile preparation for abdominal surgery from 10% povidone-iodine (PI) to 4% chlorhexidine gluconate (CHG). The preliminary results of our review also led to the suggestion that surgeons use blood products sparingly, although an absolute threshold for transfusion was not specified. RESULTS Twenty-one of 192 patients (10.7%) developed an SSI in the pre-intervention period, whereas 1 of 84 patients (1.2%) developed an SSI in the post-intervention period (p=0.006). Surgical site infection was associated with obesity (a body mass index [BMI] ≥30) (11.5% vs. 4.8%, p=0.04), receipt of a blood transfusion (18.2% vs. 6.6%, p=0.03), and abdominal skin preparation with PI as opposed to CHG (10.1% vs. 2.0%, p=0.07). Chlorhexidine gluconate was used more commonly for abdominal skin preparation in the post- than in the pre-intervention period (6.6% pre-intervention vs. 50.7% post-intervention, p <0.0001). CONCLUSIONS A multifaceted intervention decreased dramatically the rate of SSI after abdominal hysterectomy at our institution. No single component of the intervention could be identified as most responsible for the improvement.

Clinical Characteristics and Antibiotic Utilization in Pediatric Patients Hospitalized with Acute Bacterial Skin and Skin Structure Infection

Background: Hospitalizations for acute bacterial skin and skin structure infection (ABSSSI) in children are increasingly frequent, but little is known about antibiotic utilization. In adults, recent studies suggest substantial opportunity to reduce broad-spectrum antibiotic use and shorten therapy. We sought to determine whether similar opportunity exists in children. Methods: This was a planned secondary analysis of a pediatric cohort taken from a multicenter, retrospective cohort of patients hospitalized for ABSSSI between June 1, 2010, and May 31, 2012. The prespecified primary endpoint was a composite of 2 prescribing practices: (1) use of antibiotics with broad Gram-negative activity or (2) treatment duration >10 days. Results: One-hundred and two patients ⩽18 years old were included: 43 had non-purulent cellulitis, 19 had wound infection or purulent cellulitis and 40 had cutaneous abscess. The median age was 5 years (range 45 days to 18 years). Clindamycin was the most frequently prescribed antibiotic during hospitalization (67% of cases) and at discharge (66% of cases). The median duration of therapy was 11 days (interquartile range 10–12) and was similar for all 3 types of ABSSSI. The primary endpoint occurred in 67% of cases, including broad Gram-negative therapy in 25% and treatment duration >10 days in 61%. By multivariate logistic regression, admission through an emergency department and management by a medical (vs. surgical) service were independently associated with the primary endpoint. Conclusions: Children hospitalized for ABSSSI are frequently exposed to antibiotics with broad Gram-negative activity or treated longer than 10 days suggesting opportunity to reduce antibiotic use.

Statewide Collaboration to Evaluate the Effects of Blood Loss and Transfusion on Surgical Site Infection after Hysterectomy

We used mandatory public reporting as an impetus to perform a statewide study to define risk factors for surgical site infection. Among women who underwent abdominal hysterectomy, blood transfusion was a significant risk factor for surgical site infection in patients who experienced blood loss of less than 500 mL.

The Effect of Preoperative Skin Preparation Products on Surgical Site Infection

Skin preparation products contribute to surgical site infection (SSI) prevention. In a case-control study, diabetes was associated with increased SSI (adjusted odds ratio [OR], 5.74 [95% confidence interval (CI), 1.22-27.0]), while the use of chlorhexidine gluconate (CHG) plus isopropyl alcohol versus CHG alone was found to be protective (adjusted OR, 2.64 [95% CI, 1.12-6.20]).

Identifying colon and open reduction of fracture surgical site infections using a partially automated electronic algorithm

BACKGROUND Algorithms leveraging electronic data may reduce manual review burden for surgical site infection (SSI) surveillance with little to no reduction in sensitivity. We developed an algorithm to identify colon and open reduction of fracture (FX) SSIs to reduce manual chart review. METHODS A retrospective cohort of colon and FX procedures and associated SSIs was constructed. Potential SSIs were identified by positive microbiologic cultures or administrative data for diagnosis or treatment of wound infection. Sensitivity and specificity of the algorithm were assessed. The number of charts needing review to identify 1 SSI, and the potential time-savings from the algorithm, were calculated. RESULTS Four hundred seventy-three colon (SSI rate = 7%) and 1081 FX (SSI rate = 3%) procedures were identified. The algorithm was 91% and 97% sensitive and 76% and 93% specific for colon and FX procedures, respectively. Overall, chart review would have been reduced by 24.3 hours per 100 procedures, decreasing the number of charts to review to identify 1 SSI from 23.9 for manual review to 3.9 with the algorithm. CONCLUSIONS The algorithm identified SSIs with excellent sensitivity and specificity, resulting in substantial reductions in manual chart review. This algorithm could be tailored and applied to other hospitals.

An Evaluation of Surgical Site Infection Surveillance Methods for Colon Surgery and Hysterectomy in Colorado Hospitals

Surgical site infection (SSI) surveillance techniques for colon surgery and hysterectomy among Colorado infection preventionists were characterized through an online survey. Considerable variation was found in SSI surveillance practices, specifically varying use of triggers for SSI review, including laboratory values, healthcare personnel communication, and postoperative visits.