Ojan Assadian

Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients.

BACKGROUND Care bundles are a strategy that can be used to reduce the risk of surgical site infection (SSI), but individual studies of care bundles report conflicting outcomes. This study assesses the effectiveness of care bundles to reduce SSI among patients undergoing colorectal surgery. METHODS We performed a systematic review and meta-analysis of randomized controlled trials, quasi-experimental studies, and cohort studies of care bundles to reduce SSI. The search strategy included database and clinical trials register searches from 2012 until June 2014, searching reference lists of retrieved studies and contacting study authors to obtain missing data. The Downs and Black checklist was used to assess the quality of all studies. Raw data were used to calculate pooled relative risk (RR) estimates using Cochrane Review Manager. The I(2) statistic and funnel plots were performed to identify publication bias. Sensitivity analysis was carried out to examine the influence of individual data sets on pooled RRs. RESULTS Sixteen studies were included in the analysis, with 13 providing sufficient data for a meta-analysis. Most study bundles included core interventions such as antibiotic administration, appropriate hair removal, glycemic control, and normothermia. The SSI rate in the bundle group was 7.0% (328/4,649) compared with 15.1% (585/3,866) in a standard care group. The pooled effect of 13 studies with a total sample of 8,515 patients shows that surgical care bundles have a clinically important impact on reducing the risk of SSI compared to standard care with a CI of 0.55 (0.39-0.77; P = .0005). CONCLUSION The systematic review and meta-analysis documents that use of an evidence-based, surgical care bundle in patients undergoing colorectal surgery significantly reduced the risk of SSI.

Reliability of Nested PCR for Detection of Chlamydia pneumoniae DNA in Atheromas: Results from a Multicenter Study Applying Standardized Protocols

ABSTRACT The present multicenter study was designed to find explanations for the discrepancies in the reported rates of detection of Chlamydia pneumoniae DNA in endarterectomy specimens. Coded identical sets of (i) a C. pneumoniae DNA dilution series (panel 1; n = 10), (ii) spiked control tissue specimens (panel 2; n = 10 specimens, including 5 negative controls), and (iii) endarterectomy specimens (panel 3; 15 atheromas, 5 negative controls) were analyzed at four laboratories by three standardized DNA extraction methods in each laboratory and a nested touchdown PCR protocol targeting the ompA gene of C. pneumoniae. Panel 1 samples were correctly identified as positive to levels of 0.3 inclusion-forming units (IFU)/PCR mixture (100%) and 0.03 IFU/PCR mixture (50%). All negative controls were correctly reported as negative. Panel 2 samples were identified as C. pneumoniae positive to levels of 0.01 IFU/PCR mixture (100%) and 0.005 IFU/PCR mixture (91%), independent of the DNA extraction method used, and only one false-positive result was reported. For panel 3 samples, 5 of 240 (2%) analyses (in which DNA extractions and PCR were performed at the same laboratory) were positive; the positive specimens were from three endarterectomy specimens and two negative controls. After exchange of DNA extracts between laboratories, 13 of 15 atheroma samples were C. pneumoniae DNA positive in at least 1 of a series of 48 analyses per atheroma sample; however, the overall positivity rate did not exceed 5% (33 of 720 analyses) and therefore was lower than that for the negative controls (8%; 19 of 240 analyses). Not a single positive result could be achieved when all panel 3 extracts (n = 240 analyses) were reamplified by a 16S rRNA PCR followed by hybridization with a C. pneumoniae-specific probe. Statistical analyses demonstrated that positive results did not occur in an independent and random fashion and could most likely be explained by amplicon carryover at the nested PCR level as well as amplicon introduction during DNA extraction, but not by the patterns of distribution of very low target levels or a certain DNA extraction protocol. The results of studies by nested PCR for detection of the prevalence of C. pneumoniae will always be questionable.

Feasibility and Clinical Applicability of Polihexanide for Treatment of Second-Degree Burn Wounds

Objectives: Due to a partial rejection of mesh split-thickness skin grafts (mesh grafts) after application of povidone-iodine and silver nitrate and due to its better in vitro tolerance, polihexanide was investigated as an alternative and its applicability in the treatment of second-degree burn wounds. Methods: In 4 patients with poorly healing decubitus ulcers the mesh grafts were each divided into three areas which were pre-treated with either undiluted povidone-iodine solution, 1% silver nitrate solution or 0.04% polihexanide solution. After 7 days of application the wound areas were compared clinically and histologically. Thereafter 14 patients (average extent of burns 28% TBSA) were treated in the same way. Results: Clinically and histologically the mesh grafts treated with polihexanide showed by far the best re-epithelialization compared with the deep tissue necrosis and marked fibrin discharge observed for application of povidone-iodine and silver nitrate. The second-degree burn wounds treated with polihexanide epithelialized without any further débridement after an average of 10 days with remarkable freedom from pain. Compared with silver nitrate treatment, no fibrin film was observed on the wound. Conclusion: Polihexanide proved clinically and histologically superior to povidone-iodine and silver nitrate. For the treatment of second-degree burns, which cannot primarily be covered by plastic surgery, polihexanide is suitable because in addition to its antiseptic efficacy it does not inhibit the re-epithelialization process.

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections.

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices. Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of up to 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria. The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.

Successful Treatment of Disseminated Acanthamoeba sp. Infection with Miltefosine

We report on an HIV-negative but immunocompromised patient with disseminated acanthamoebiasis, granulomatous amoebic encephalitis, and underlying miliary tuberculosis and tuberculous meningitis. The patient responded favorably to treatment with miltefosine, an alkylphosphocholine. The patient remained well with no signs of infection 2 years after treatment cessation.

In vitro Antibacterial Activity of Lucilia sericata Maggot Secretions

Maggots of the green blowfly, Lucilia sericata, are used as an alternative to surgical intervention and long-term antiseptic therapy for the treatment of chronic wounds. The secretions of maggots are known to have antibacterial properties. To quantify the bactericidal effect of secretions from larvae of L. sericata, an in vitro test model based on the modified European quantitative suspension test (EN 1040) was developed, in which a co-culture of maggots and bacteria (Micrococcus luteus,Escherichia coli, methicillin-sensitive Staphylo-coccus aureus) in tryptic soy broth was tested. The numbers of bacterial colonies with and without maggot exposure were compared after 24, 48 and 72 h of exposure. The mean log10 reduction factor (RF) for bacterial elimination per maggot was >4 at all examined times for all tested bacteria. Thus, maggot secretion fulfilled the required definitions of an antiseptic. In addition, the maggots’ ability to ingest bacteria was also evaluated. Maggots contained viable bacteria after 48 h of contact with the respective organisms. These maggots also continued excreting bacteria. Therefore, maggots should be disposed of after use as they must be regarded as medical waste.

Concentration of bacteria passing through puncture holes in surgical gloves

BACKGROUND The reasons for gloving-up for surgery are to protect the surgical field from microorganisms on the surgeons hands and protect the surgeon from the patients microorganisms. This study measured the concentration of bacteria passing through glove punctures under surgical conditions. METHODS Double-layered surgical gloves were worn during visceral surgeries over a 4-month period. The study included 128 outer gloves and 122 inner gloves from 20 septic laparotomies. To measure bacterial passage though punctures, intraoperative swabs were made, yielding microorganisms that were compared with microorganisms retrieved from the inner glove layer using a modified Gaschen bag method. RESULTS Depending on the duration of glove wear, the microperforation rate of the outer layer averaged 15%. Approximately 82% of the perforations went unnoticed by the surgical team. Some 86% of perforations occurred in the nondominant hand, with the index finger being the most frequently punctured location (36%). Bacterial passage from the surgical site through punctures was detected in 4.7% of the investigated gloves. CONCLUSION Depending on the duration of wear, surgical gloves develop microperforations not immediately recognized by staff. During surgery, such perforations allow passage of bacteria from the surgical site through the punctures. Possible strategies for preventing passage of bacteria include strengthening of glove areas prone to punctures and strict glove changing every 90 minutes.

Quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans

BackgroundDespite the increasing promotion of alcohol-based hand rubs and the worldwide use of ethanol-based hand rubs in hospitals only few studies have specifically addressed the issue of ethanol absorption when repeatedly applied to human skin. The aim of this study was to assess if ethanol absorption occurs during hygienic and surgical hand disinfection using three different alcohol-based hand-rubs, and to quantify absorption levels in humans.MethodsTwelve volunteers applied three hand-rubs containing 95% (hand-rub A), 85% (hand-rub B) and 55% ethanol (hand-rub C; all w/w). For hygienic hand disinfection, 4 mL were applied 20 times for 30 s, with 1 minute break between applications. For surgical hand disinfection, 20 mL of each hand rub was applied to hands and arms up to the level of the elbow 10 times for 3 minutes, with a break of 5 minutes between applications. Blood concentrations of ethanol and acetaldehyde were determined immediately prior and up to 90 minutes after application using head space gas chromatography.ResultsThe median of absorbed ethanol after hygienic hand disinfection was 1365 mg (A), 630 mg (B), and 358 mg (C). The proportion of absorbed ethanol was 2.3% (A), 1.1% (B), and 0.9% (C). After surgical hand disinfection, the median of absorbed ethanol was 1067 mg (A), 1542 mg (B), and 477 mg (C). The proportion of absorbed ethanol was 0.7% (A), 1.1% (B), and 0.5% (C). The highest median acetaldehyde concentration after 20 hygienic hand disinfections was 0.57 mg/L (hand-rub C, after 30 min), after 10 surgical hand disinfections 3.99 mg/L (hand-rub A, after 20 minutes).ConclusionThe overall dermal and pulmonary absorption of ethanol was below toxic levels in humans and allows the conclusion that the use of the evaluated ethanol-based hand-rubs is safe.

Diagnosis, treatment, and prognosis of Mycoplasma pneumoniae childhood encephalitis: systematic review of 58 cases.

Most of the knowledge on Mycoplasma pneumoniae encephalitis in children is based on case reports or small case series. The aim of this study was to assess the important features of the disease by a systematic review of previously published cases. Overall, 58 cases (22 female, 36 male; median age 10 years, range: 2—17 years), derived from 38 reports, were reviewed. Forty-five patients (76%) had flulike or respiratory symptoms prior to the onset of neurologic disease, and 23 patients (40%) presented with pulmonary infiltrates. Cerebrospinal fluid (CSF) pleocytosis (mostly mononuclear cells) and elevated cerebrospinal fluid protein counts were present in 34 (59%) and 21 (36%) patients, respectively. Cranial computed tomography (CT) or magnetic resonance imaging (MRI) abnormalities were seen in 18 (31%) and 17 (29%) patients, respectively, whereby various different presentations were observed. Forty-four patients (76%) received antimicrobial therapy active against mycoplasmas, most frequently erythromycin (n = 29) or minocycline (n = 6). Only in one patient, cure was directly attributed to antimicrobial therapy (with chloramphenicol) by the respective authors. Thirty-three patients (57%) recovered without sequelae, 20 patients (34%) had minor to major sequelae, and 5 patients (9%) died. A high cerebrospinal fluid cell count, cerebrospinal fluid protein elevation, and higher age were associated with an unfavorable outcome. (J Child Neurol 2004;19:865—871).

Metatarsal reconstruction with use of free vascularized osteomyocutaneous fibular grafts following resection of malignant tumors of the midfoot. A series of six cases.

BACKGROUND Bone and soft-tissue sarcomas are uncommon, and their location in the foot is extremely rare. While limb salvage has become the standard of care in the treatment of sarcoma in an extremity, the unique anatomy of the foot presents challenges in reconstructing a viable and functional limb. METHODS Between 1998 and 2005, we used free microvascularized osteomyocutaneous fibular grafts to reconstruct the defects created after extensive midfoot resection in six consecutive patients with a primary malignant tumor. In all but one patient, the extent of the resection involved at least two metatarsals. The mean age (and standard deviation) at the time of the operation was 30+/-13 years. At the final follow-up examination, clinical and radiographic evaluations were performed on all patients, and functional outcome and quality of life were assessed with use of the Musculoskeletal Tumor Society score, the American Orthopaedic Foot and Ankle Society Score, and the Toronto Extremity Salvage Score. RESULTS The median duration of follow-up was 52.2 months. Limb salvage was achieved in five patients. In the remaining patient, amputation was necessary because of flap failure. Revision surgery was necessary in all patients because of complications (skin ulcerations in three patients; hematoma in two patients; and infection, necrosis of the second toe, and flap necrosis in one patient each). At the time of final follow-up, five patients had satisfactory function and reported good quality of life. The average Musculoskeletal Tumor Society, American Orthopaedic Foot and Ankle Society, and Toronto Extremity Salvage scores were 82%, 75 points, and 92%, respectively. At the time of the final follow-up, five patients had no evidence of disease and one patient had disease. CONCLUSIONS Following the resection of a malignant tumor in the midfoot, the use of microvascularized osteomyocutaneous fibular grafts has proven to be a successful surgical technique, offering an alternative to ablative surgery with functional restoration of the salvaged limb.