Journal of Wound CareVol. 34, No. 1 CommentarySurgical site infection prevention care bundles: evidence and guidelinesMarja Boermeester, Giles Bond-Smith, David LeaperMarja BoermeesterProfessor of Surgery; Clinical Epidemiologist, Department of Surgery, Amsterdam University Medical Center, the Netherlands, Giles Bond-SmithConsultant HPB and Emergency Surgeon, Oxford University Hospitals NHS Foundation Trust, UK, David LeaperConsultant HPB and Emergency Surgeon, Oxford University Hospitals NHS Foundation Trust, UKMarja Boermeester; Giles Bond-Smith; David LeaperPublished Online:11 Jan 2025https://doi.org/10.12968/jowc.2024.0415AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookXLinkedInEmail View article References 1 World Health Organization. Global guidelines for the prevention of surgical site infection. 2nd edition. 2018. https://tinyurl.com/27vzpdvx (accessed 3 December 2024) Google Scholar2 National Institute for Health and Care Excellence. Surgical site infections: prevention and treatment. NICE guideline NG125. 2020. https://www.nice.org.uk/guidance/ng125 (accessed 3 December 2024) Google Scholar3 Page MJ, McKenzie JE, Bossuyt PM et al.. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021; 29:372. https://doi.org/10.1136/bmj.n71 Google Scholar4 Ching PR. Care bundles in surgical site infection prevention: a narrative review. Curr Infect Dis Rep 2024; 1:1–0. https://doi.org/10.1007/s11908-024-00837-9 Google Scholar5 Wolfhagen N, Boldingh QJJ, Boermeester MA, de Jonge SW. Perioperative care bundles for the prevention of surgical-site infections: meta-analysis. Br J Surg 2022; 109(10):933–942. https://doi.org/10.1093/bjs/znac196 Crossref, Medline, Google Scholar6 Tanner J, Padley W, Assadian O et al.. 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. Surgery 2015; 158(1):66–77. https://doi.org/10.1016/j.surg.2015.03.009 Crossref, Medline, Google Scholar7 Zywot A, Lau CSM, Stephen Fletcher H, Paul S. Bundles prevent surgical site infections after colorectal surgery: meta-analysis and systematic review. J Gastrointest Surg 2017; 21(11):1915–1930. https://doi.org/10.1007/s11605-017-3465-3 Crossref, Medline, Google Scholar8 Bond-Smith G, Butcher L, Soonawalla Z, Leaper D. How to reduce SSI: a new infection reduction bundle for HPB surgery. J Wound Care 2021; 30(4):254–255. https://doi.org/10.12968/jowc.2021.30.4.254 Link, Google Scholar9 Gilhooly D, Green SA, McCann C et al.. Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review. Implement Sci 2019; 14(1):47. https://doi.org/10.1186/s13012-019-0894-2 Crossref, Medline, Google Scholar10 Rochon M, Bond-Smith G, Leaper D. Preoperative surgical skin preparation. J Wound Care 2024; 33(9):676–677. https://doi.org/10.12968/jowc.2024.0237 Link, Google Scholar FiguresReferencesRelatedDetails 2 January 2025Volume 34Issue 1ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics History Published online 11 January 2025 Published in print 2 January 2025 Information© MA Healthcare LimitedPDF download

Introduction: Cleaning and reduction of microbial load on the skin is necessary before injections because of the colonization of the skin with resident flora and the presence of transient flora. Even after optimal skin antisepsis, there is a risk of infection, albeit a very low one. The World Health Organisation (WHO) based on a systematic review on the infection risk after injections and skin antisepsis, does not recommend, alcohol-based skin antisepsis as being necessary before intradermal, subcutaneous and intramuscular injections and that washing the skin with soap and water alone is sufficient. As there is no clear evidence for the benefit of using alcohol over soap washing prior to injection, this study compared the efficacy of alcohol and soap on volunteers. Method: Liquid washing emulsion or potash soap (Sapo Kalinus, German Pharmacopoeia) or propan-2-ol 70%v/v, was applied to test areas on the upper arms of 23 volunteers. To test the soap, in trial 1 after 15-second swabbing, and a further 15 seconds of air-drying, the swabbed areas were rinsed, dabbed dry, and microbiological samples taken with sterile swabs. In trial 2, after 15 seconds of swabbing, samples were taken in the same manner. The comparator alcohol was rubbed in for 15 seconds in trial 1 and for 30 seconds in trial 2 without rinsing. Swabs were transferred into tryptic soy broth and suspensions plated onto agar. Results: The reduction of bacteria was around 1x lg and did not differ significantly between the soaps and propan-2-ol. There was also no difference when comparing the two trials. Discussion: One reason for the equivalent efficacy of both methods is probably the low colonization density of the skin of the arms. Conclusion: Both methods are acceptable for legal reasons. However, if no live vaccines are applied, alcohol-based antiseptics are preferable because they are more user-friendly.

OBJECTIVE:Delayed or stalled healing in open wounds can result from persisting chronic inflammation related to infection and/or persistent bacterial colonisation and biofilm. Treatment of hard-to-heal wounds focuses on debridement and exudate management, but also on infection prevention and control. Silver dressings have been evaluated in randomised clinical trials (RCTs); this meta-analysis evaluated the efficacy and safety of a silver ion-releasing foam dressing (Biatain Ag; Coloplast A/S, Denmark) to treat hard-to-heal wounds. METHOD:Literature databases (PubMed and Cochrane Library) were searched for studies on silver ion-releasing foam dressings in the treatment of hard-to-heal wounds. Individual patient data from four RCTs were obtained and included in the meta-analysis. RESULTS:Findings showed that treatment with the silver ion-releasing foam dressing was associated with a significantly higher relative reduction in wound area after four (least squares-mean difference (LS-MD): -12.55%, 95% confidence interval (CI): (-15.95, -9.16); p<0.01) and six weeks of treatment (LS-MD: -11.94%, 95%CI: (-17.21, -6.68); p<0.01) compared with controls. Significant benefits were also observed for time to disappearance of odour (hazard ratio: 1.61, 95%CI: (1.31, 1.98); p<0.01), relative reduction of exudate (LS-MD: -5.15, 95%CI: (-7.36, -2.94); p<0.01), proportion of patients with periwound erythema (relative risk (RR): 0.81, 95%CI: (0.69; 0.94); p<0.01), and less pain at dressing removal (LS-MD: -0.35, 95%CI: (-0.63, -0.06); p=0.02). No differences regarding safety outcomes were identified. CONCLUSION:This meta-analysis has demonstrated beneficial outcomes and a good tolerability profile for silver ion-releasing foam dressings in the treatment of moderate-to-highly exuding wounds with delayed healing compared with control dressings.

AbstractBackground:Spinal fusion surgery (SFS) is one of the most common operations in the United States, >450,000 SFSs are performed annually, incurring annual costs >$10 billion.Objectives:We used a nationwide longitudinal database to accurately assess incidence and payments associated with management of postoperative infection following SFS.Methods:We conducted a retrospective, observational cohort analysis of 210,019 patients undergoing SFS from 2014 to 2018 using IBM MarketScan commercial and Medicaid–Medicare databases. We assessed rates of superficial/deep incisional SSIs, from 3 to 180 days after surgery using Cox proportional hazard regression models. To evaluate adjusted payments for patients with/without SSIs, adjusted for inflation to 2019 Consumer Price Index, we used generalized linear regression models with log-link and γ distribution.Results:Overall, 6.6% of patients experienced an SSI, 1.7% superficial SSIs and 4.9% deep-incisional SSIs, with a median of 44 days to presentation for superficial SSIs and 28 days for deep-incisional SSIs. Selective risk factors included surgical approach, admission type, payer, and higher comorbidity score. Postoperative incremental commercial payments for patients with superficial SSI were $20,800 at 6 months, $26,937 at 12 months, and $32,821 at 24 months; incremental payments for patients with deep-incisional SSI were $59,766 at 6 months, $74,875 at 12 months, and $93,741 at 24 months. Corresponding incremental Medicare payments for patients with superficial incisional at 6, 12, 24-months were $11,044, $17,967, and $24,096; while payments for patients with deep-infection were: $48,662, $53,757, and $73,803 at 6, 12, 24-months.Conclusions:We identified a 4.9% rate of deep infection following SFS, with substantial payer burden. The findings suggest that the implementation of robust evidence-based surgical-care bundles to mitigate postoperative SFS infection is warranted.

Background/Introduction: Tumour invasion and metastasis involves complex interactions between many different biological factors including proteinases, proteinase inhibitors and growth factors. The balance in the levels of these different factors will influence colorectal cancer progression.

Background: Longitudinal rates, risk factors, and costs of superficial and deep incisional surgical site infection (SSI) were evaluated six months after primary total hip arthroplasty (pTHA) and revision total hip replacement (rTHA). Patients and Methods: Patients who had pTHA or rTHA between January 1, 2016 and March 31, 2018 were identified using the IBM® MarketScan® administrative claims databases. Kaplan-Meier survival curves evaluated time to SSI over six months. Cox proportional hazard models evaluated SSI risk factors. Generalized linear models estimated SSI costs up to 12 months. Results: The total cohort included 17,514 pTHA patients (mean [standard deviation] age 59.6 [10.1] years, 50.2% female; 66.4% commercial insurance), and 2,954 rTHA patients (61.2 [12.0] years, 52.0% female; 48.6% commercial insurance). Deep and superficial post-operative SSI at six months affected 0.30% (95% confidence interval [CI], 0.22%-0.39%) and 0.67% (95% CI, 0.55%-0.79% of patients in the pTHA, and 8.9% (95%CI: 7.8%-10.0%) and 4.8% (95% CI, 4.0%-5.6%) of patients in the rTHA cohorts. Hazards for SSI were related to patient comorbidities that included diabetes mellitus, obesity, renal failure, pulmonary or circulatory disorders, and depression. The adjusted average all-cause incremental commercial costs associated with post-operative infection ranged from $21,434 to $42,879 for superficial incisional SSI and $53,884 to $76,472 for deep incisional SSI, over a 12-month post-operative assessment period. Conclusions: The SSI rate after revision total hip arthroplasty (rTHA) was nearly 9% compared with 1.0% after pTHA. The risk of infection was influenced by several comorbid risk factors. The incremental cost associated with SSIs was substantial.

Objective:We evaluated longitudinal rates, risk factors, and costs of superficial and deep incisional surgical-site infection (SSI) 6 months after primary total knee arthroplasty (pTKA) and revision total knee arthroplasty (rTKA). Methods:Patients were identified from January 1, 2016 through March 31, 2018, in the IBM MarketScan administrative claims databases. Kaplan-Meier survival curves evaluated time to SSI over 6 months. Cox proportional hazard models evaluated SSI risk factors. Generalized linear models estimated SSI costs up to 12 months. Results:Of the 26,097 pTKA patients analyzed (mean age, 61.6 years; SD, 9.2; 61.4% female; 60.4% commercial insurance), 0.65% (95% CI, 0.56%-0.75%) presented with a deep incisional SSI and 0.82% (95% CI, 0.71%-0.93%) with a superficial incisional SSI. Also, 3,663 patients who had rTKA (mean age, 60.9 years; SD, 10.1; 60.6% female; 53.0% commercial insurance), 10.44% (95% CI, 9.36%-11.51%) presented with a deep incisional SSI and 2.60% (95% CI, 2.07%-3.13%) presented with a superficial incisional SSI. Infections were associated with male sex and multiple patient comorbidities including chronic pulmonary disease, pulmonary circulatory disorders, fluid and electrolyte disorders, malnutrition, drug abuse, and depression. Adjusted average all-cause incremental commercial cost ranged from $14,298 to $29,176 and from $41,381 to 59,491 for superficial and deep incisional SSI, respectively. Conclusions:SSI occurred most frequently following rTKA and among patients with pulmonary comorbidities and depression. The incremental costs associated with SSI following TKA were substantial.

Background Surgical site infections (SSI) present a substantial burden to patients and healthcare systems. This study aimed to elucidate the prevalence of SSIs in German hospitals and to quantify their clinical and economic burden based on German hospital reimbursement data (G-DRG). Methods This retrospective, cross-sectional study used a 2010–2016 G-DRG dataset to determine the prevalence of SSIs in hospital, using ICD-10-GM codes, after surgical procedures. The captured economic and clinical outcomes were used to quantify and compare resource use, reimbursement and clinical parameters for patients who had or did not have an SSI. Findings Of the 4,830,083 patients from 79 hospitals, 221,113 were eligible. The overall SSI prevalence for the study period was 4.9%. After propensity-score matching, procedure type, immunosuppression and BMI ≥30 were found to significantly affect the risk of SSI (p<0.001). Mortality and length of stay (LOS) were significantly higher in patients who had an SSI (mortality: 9.3% compared with 4.5% [p<0.001]; LOS (median [interquartile range, IQR]): 28 [27] days compared with 12 [8] days [p<0.001]). Case costs were significantly higher for the SSI group (median [IQR]) €19,008 [25,162] compared with € 9,040 [7,376] [p<0.001]). A median underfunding of SSI was identified at €1,534 per patient. Interpretation The dataset offers robust information about the “real-world” clinical and economic burden of SSI in hospitals in Germany. The significantly increased mortality of patients with SSI, and their underfunding, calls for a maximization of efforts to prevent SSI through the use of evidence-based SSI-reduction care bundles.

BACKGROUND: Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS). STUDY DESIGN: In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement. RESULTS: In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds. CONCLUSIONS: Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.

Background: The number of primary/revision total joint replacements (TJR) are expected to increase substantially with an aging population and increasing prevalence of comorbid conditions. The 30-day re-admission rate, in all orthopedic specialties, is 5.4% (range, 4.8%-6.0%). A recent publication has documented that the surgical site infection (SSI) infection rate associated with revision total knee (rTKR, 15.6%) and revision total hip (rTHR, 8.6%) arthroplasties are four to seven times the rate of the primary procedures (2.1%-2.2%). These orthopedic infections prolong hospital stays, double re-admissions, and increase healthcare costs by a factor of 300%.Methods: A search of PubMed/MEDLINE, EMBASE and the Cochrane Library publications, which reported the infection risk after TKR and THR, was undertaken (January 1, 1995 to December 31, 2021). The search also included documentation of evidence-based practices that lead to improved post-operative outcomes.Results: The evidence-based approach to reducing the risk of SSI was grouped into pre-operative, peri-operative, and post-operative periods. Surgical care bundles have existed within other surgical disciplines for more than 20 years, although their use is relatively new in peri-operative orthopedic surgical care. Pre-admission chlorhexidine gluconate (CHG) showers/cleansing, staphylococcal decolonization, maintenance of normothermia, wound irrigation, antimicrobial suture wound closure, and post-operative wound care has been shown to improve clinical outcome in randomized controlled studies and meta-analyses.Conclusions: Evidence-based infection prevention care bundles have improved clinical outcomes in all surgical disciplines. The significant post-operative morbidity, mortality, and healthcare cost, associated with SSIs after TJR can be reduced by introduction of evidence-based pre-operative, intra-operative, and post-operative interventions.

Background: Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database. Methods: IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24 month postoperative period. Results: Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy. Conclusions: Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and co morbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted. (C) 2021 Elsevier Inc. All rights reserved.

Stijn de Jonge and colleagues have raised several important points regarding our meta-analysis.1National Institute of Health Research Unit on Global SurgeryAlcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials.Lancet Infect Dis. 2022; 22: 1242-1251Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar In recent years, several systematic reviews have been published that provide a comprehensive overview of existing data, including low-quality randomised trials. However, a meta-analysis of studies at high risk of bias merely amplifies bias.2Khan KS Daya S Jadad A The importance of quality of primary studies in producing unbiased systematic reviews.Arch Intern Med. 1996; 156: 661-666Crossref PubMed Google Scholar Rather than duplicating previous reviews, we preplanned to restrict our analysis to high-quality studies that would provide a rigorous basis for clinical practice recommendations. We used the PRISMA reporting guideline to ensure that we transparently described and justified our methods. The Cochrane Handbook recognises that masking is not possible in some contexts. Given the need to maintain suture sterility and the complex global supply chains that distribute sutures, it is not feasible to provide sutures in masked packaging. Therefore, masking would not be a meaningful marker of study quality since it would not be practical to implement this in multicentre, international trial settings. However, our quality criteria did stipulate that outcome assessors should be masked, to minimise detection bias. The use of standardised, validated outcome measures ensures internal and external validity. Surgical site infection detection rates are lower in studies that do not use validated outcome measures than in those that do.3Matthews JH Bhanderi S Chapman SJ Nepogodiev D Pinkney T Bhangu A Underreporting of secondary endpoints in randomized trials: cross-sectional, observational study.Ann Surg. 2016; 264: 982-986Crossref PubMed Scopus (23) Google Scholar Given that this potential source of bias can be readily addressed in any setting, it is an important marker of study quality. We sought to minimise potential researcher bias in our study. The protocol for this study was prospectively registered in PROSPERO. As for the FALCON trial,4National Institute of Health Research Unit on Global SurgeryReducing surgical site infections in low-income and middle-income countries (FALCON): a pragmatic, multicentre, stratified, randomised controlled trial.Lancet. 2021; 398: 1687-1699Summary Full Text Full Text PDF Scopus (29) Google Scholar this research was supported by a government research grant. Whereas de Jonge and colleagues have reported receiving funding from a manufacturer of triclosan-coated sutures in previous publications, our research was independent of industry interests. In the post-pandemic era, many health systems worldwide are under financial stress. We hope that surgeons and patients will use our meta-analysis to inform their decision making regarding the use of triclosan-coated sutures, which incur additional costs. We look forward to further research that better characterises whether there are specific patient groups who have a clear benefit in using triclosan-coated sutures. We declare no competing interests. Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trialsContrary to previous meta-analyses, this study did not show a benefit from either alcoholic chlorhexidine skin preparation or triclosan-coated sutures, both of which are more expensive than other readily available alternatives. Global and national guidance should be reconsidered to remove recommendations for their routine use. Full-Text PDF Open AccessConcerns on the evidence used to challenge established guidelinesThe systematic review by the National Institute for Health Research Unit on Global Surgery, who also conducted the related FALCON trial, showed no benefit for 2% alcoholic chlorhexidine skin preparation or antimicrobial sutures to prevent surgical site infections, and the authors suggested that global and national guidance should remove recommendations for their routine use.1 We have major concerns with this research. Full-Text PDF