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Antimicrobial stewardship strategies in wound care: evidence to support the use of dialkylcarbamoyl chloride (DACC)- coated wound dressings.
Rippon, MG, Rogers, AA, Ousey, K
Journal of wound care. 2021;(4):284-296
Abstract
BACKGROUND Traditionally, infections are treated with antimicrobials (for example, antibiotics, antiseptics, etc), but antimicrobial resistance (AMR) has become one of the most serious health threats of the 21st century (before the emergence of COVID-19). Wounds can be a source of infection by allowing unconstrained entry of microorganisms into the body, including antimicrobial-resistant bacteria. The development of new antimicrobials (particularly antibiotics) is not keeping pace with the evolution of resistant microorganisms and novel ways of addressing this problem are urgently required. One such initiative has been the development of antimicrobial stewardship (AMS) programmes, which educate healthcare workers, and control the prescribing and targeting of antimicrobials to reduce the likelihood of AMR. Of great importance has been the European Wound Management Association (EWMA) in supporting AMS by providing practical recommendations for optimising antimicrobial therapy for the treatment of wound infection. The use of wound dressings that use a physical sequestration and retention approach rather than antimicrobial agents to reduce bacterial burden offers a novel approach that supports AMS. Bacterial-binding by dressings and their physical removal, rather than active killing, minimises their damage and hence prevents the release of damaging endotoxins. AIM: Our objective is to highlight AMS for the promotion of the judicious use of antimicrobials and to investigate how dialkylcarbamoyl chloride (DACC)-coated dressings can support AMS goals. METHOD MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify published articles describing data relating to AMS, and the use of a variety of wound dressings in the prevention and/or treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent and/or treat wound infection in a manner that does not kill or damage the microorganisms (for example, by actively binding and removing intact microorganisms from wounds) were then narratively reviewed. RESULTS The evidence reviewed here demonstrates that using bacterial-binding wound dressings that act in a physical manner (for example, DACC-coated dressings) as an alternative approach to preventing and/or treating infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS. CONCLUSION Some wound dressings work via a mechanism that promotes the binding and physical uptake, sequestration and removal of intact microorganisms from the wound bed (for example, a wound dressing that uses DACC technology to successfully prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS (for example, reducing the use of antimicrobials in wound treatment regimens) by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.
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Comparison of the antimicrobial efficacy of povidone-iodine-alcohol versus chlorhexidine-alcohol for surgical skin preparation on the aerobic and anaerobic skin flora of the shoulder region.
Dörfel, D, Maiwald, M, Daeschlein, G, Müller, G, Hudek, R, Assadian, O, Kampf, G, Kohlmann, T, Harnoss, JC, Kramer, A
Antimicrobial resistance and infection control. 2021;(1):17
Abstract
BACKGROUND Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery. We hypothesized that prolonged skin preparation with an agent that penetrates deeply into the skin would be beneficial. Thus, we compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times. METHODS Using a cross-over arrangement, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC) or alcohol-based povidone-iodine (PVP-I-ALC). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique. RESULTS Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55 ± 0.75 vs. 1.94 ± 0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 4 of 32 samples after CHG-ALC application. Anaerobic flora was reduced more effectively by PVP-I-ALC than CHG-ALC after standard (RF 3.96 ± 1.46 vs. 1.74 ± 1.24, p < 0.01) and prolonged (RF 3.14 ± 1.20 vs. 1.38 ± 1.16, p < 0.01) contact times and immediate sampling, but not after 3-h sampling. No adverse events were reported. CONCLUSIONS PVP-I-ALC showed marginal benefits concerning the aerobic flora, but more substantial benefits over CHG-ALC concerning the anaerobic flora of the shoulder. Standard and prolonged contact times showed superiority for PVP-I-ALC for anaerobic flora at all immediate sampling points, but missed significance at 3-h sampling. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.
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Reining in Sternal Wound Infections: The Achilles' Heel of Bilateral Internal Thoracic Artery Grafting.
Zia, A, Hasan, M, Ilyas, S, Siddiqui, HU, Tappuni, B, Marsia, S, Zubair, MM, Raza, S, Mustafa, RR, Baloch, ZQ, et al
Surgical infections. 2020;(4):323-331
Abstract
Background: Although the survival advantage of bilateral internal thoracic artery grafting (BITA) is well known in patients undergoing coronary artery bypass grafting (CABG), this technique has not been widely adopted. This is mainly because of the increased risk of deep sternal wound infections (DSWI) associated with its use. However, in recent years the overall risk of DSWI has decreased. This is mainly because of strategies that have been adopted to decrease the risk of these infections in patients undergoing CABG. Conclusion: In this review we identified DSWI preventive strategies and described them in detail so that their use by surgeons can be increased. This would minimize the risk of DSWI after BITA grafting and maximize the use of this highly effective surgical technique.
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Safety and Efficacy of Hydrogen Peroxide in Controlling Blood Loss and Surgical Site Infection After Multisegmental Lumbar Spine Surgery: A Retrospective, Case-Controlled Study.
Chen, H, Yang, JS, Zou, P, Zhao, YT, Liu, TJ, Tian, Y, Ding, KY, Liu, P, Zhang, JN, Hao, DJ
World neurosurgery. 2020;:e303-e307
Abstract
OBJECTIVE To explore the safety and efficacy of hydrogen peroxide H2O2 in controlling blood loss and surgical site infection (SSI) after multisegmental lumbar spine surgery. METHODS A total of 2626 patients who had undergone multisegmental lumbar spinal surgery from January 2015 to January 2018 were included in the present study. Stratified by the use of H2O2 irrigation, they were divided into 2 groups: the control group (n = 1345) and the experimental group (n = 1281). The demographic parameters, laboratory examination results, and surgery-related information (e.g., operative time, number of operated levels, intraoperative blood loss, postoperative drainage, postoperative SSI, extubation time), and perioperative complications were recorded. RESULTS No significant differences were seen regarding the demographic parameters, laboratory examination results, comorbidities, and surgery-related information. The extubation time and postoperative drainage collection were lower in the experimental group (3.6 ± 0.5 vs. 4.1 ± 0.6 days, P = 0.402; 251.8 ± 67.5 vs. 291.8 ± 71.3 mL, P = 0.013). In the control group, the rate of SSI was 2.4% (32 of 1345) and included 17 superficial wound infections and 15 deep wound infections. In the experimental group, the SSI rate was 1.4% (18 of 1281; 15 with a superficial wound infection and 3 with a deep wound infection). Staphylococcus aureus was the most common organism, especially in the experimental group (66.7% vs. 50%). No statistically significant difference was found between the 2 groups in the perioperative complications, including hematencephalon, deep vein thrombosis, pulmonary embolism, and myocardial infarction (P > 0.05). Pneumocephalus was not observed in either group. CONCLUSION The application of H2O2 in posterior lumbar interbody fusion can reduce the blood loss and incidence of SSI after surgery and was quite beneficial for controlling the increasing number of vancomycin-resistant bacteria.
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Prophylaxis of Wound Infections-antibiotics in Renal Donation (POWAR): A UK Multicentre Double Blind Placebo Controlled Randomised Trial.
Ahmed, Z, Uwechue, R, Chandak, P, van Dellen, D, Barwell, J, Heap, S, Szabo, L, Hemsley, C, Olsburgh, J, Kessaris, N, et al
Annals of surgery. 2020;(1):65-71
Abstract
BACKGROUND Postoperative infection after hand-assisted laparoscopic donor nephrectomy (HALDN) confers significant morbidity to a healthy patient group. Current UK guidelines cite a lack of evidence for routine antibiotic prophylaxis. This trial assessed if a single preoperative antibiotic dose could reduce post HALDN infections. METHODS Eligible donors were randomly and blindly allocated to preoperative single-dose intravenous co-amoxiclav or saline. The primary composite endpoint was clinical evidence of any postoperative infection at 30 days, including surgical site infection (SSI), urinary tract infection (UTI), and lower respiratory tract infection (LRTI). FINDINGS In all, 293 participants underwent HALDN (148 antibiotic arm and 145 placebo arm). Among them, 99% (291/293) completed follow-up. The total infection rate was 40.7% (59/145) in the placebo group and 23% (34 of 148) in the antibiotic group (P = 0.001). Superficial SSIs were 20.7% (30/145 patients) in the placebo group versus 10.1% (15/148 patients) in the antibiotic group (P = 0.012). LRTIs were 9% (13/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P = 0.046). UTIs were 4.1% (6/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P = 0.72).Antibiotic prophylaxis conferred a 17.7% (95% confidence interval 7.2%-28.1%), absolute risk reduction in developing postoperative infection, with 6 donors requiring treatment to prevent 1 infection. INTERPRETATION Single-dose preoperative antibiotic prophylaxis dramatically reduces post-HALDN infection rates, mainly impacting SSIs and LRTIs.
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Surgical site infection prevention measures in General Surgery: Position statement by the Surgical Infections Division of the Spanish Association of Surgery.
Badia, JM, Rubio Pérez, I, Manuel, A, Membrilla, E, Ruiz-Tovar, J, Muñoz-Casares, C, Arias-Díaz, J, Jimeno, J, Guirao, X, Balibrea, JM
Cirugia espanola. 2020;(4):187-203
Abstract
Surgical site infection is associated with prolonged hospital stay and increased morbidity, mortality and healthcare costs, as well as a poorer patient quality of life. Many hospitals have adopted scientifically-validated guidelines for the prevention of surgical site infection. Most of these protocols have resulted in improved postoperative results. The Surgical Infection Division of the Spanish Association of Surgery conducted a critical review of the scientific evidence and the most recent international guidelines in order to select measures with the highest degree of evidence to be applied in Spanish surgical services. The best measures are: no removal or clipping of hair from the surgical field, skin decontamination with alcohol solutions, adequate systemic antibiotic prophylaxis (administration within 30-60minutes before the incision in a single preoperative dose; intraoperative re-dosing when indicated), maintenance of normothermia and perioperative maintenance of glucose levels.
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Does an Antimicrobial Incision Drape Prevent Intraoperative Contamination? A Randomized Controlled Trial of 1187 Patients.
Hesselvig, AB, Arpi, M, Madsen, F, Bjarnsholt, T, Odgaard, A, ,
Clinical orthopaedics and related research. 2020;(5):1007-1015
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BACKGROUND The risk of periprosthetic joint infection (PJI), a serious complication after arthroplasty, has not changed for years. Interventions such as eradication of Staphylococcus aureus and antibiotic bone cement are used to diminish infection risk but despite these efforts, the percentage of infection in TKA remains constant. Antimicrobial drapes have a dual action, acting both as a physical and antimicrobial barrier to counter bacterial contamination of the surgical wound. To study the effect of antimicrobial drapes, we used intraoperative contamination as a proxy for infection in our investigation. QUESTIONS/PURPOSES (1) Do antimicrobial surgical drapes reduce the risk of intraoperative microbial contamination in patients undergoing primary knee arthroplasty? (2) Are other factors such as sex, season, age, type of arthroplasty and duration of surgery associated with an increased risk of contamination in patients undergoing primary knee arthroplasty? (3) Does loosening of the antimicrobial drape increase contamination risk? METHODS An investigator-initiated, two-arm, non-blinded, multicenter, randomized, controlled trial was performed at five different hospitals in the capital and central regions of Denmark. Twenty-four surgeons participated in the study. Participants were patients older than 18 years undergoing primary knee arthroplasty. We excluded patients with an iodine allergy, previous open knee surgery, previous septic arthritis, any antibiotics taken 4 weeks before surgery, and if they were unable to understand the implications of study participation. Patients were randomly assigned to operation with an antimicrobial drape (intervention group) or operation without (control group). We screened 1769 patients, of which 100 were ineligible and 10 declined to participate. In all, 94% (1659 of 1769) of patients consented and were randomized to the intervention group (51%, 838 of 1659) and control group (49%, 821 of 1659), respectively. In all, 36% (603 of 1659) of patients in the intervention group and 35% (584 of 1659) patients in the control group were available for final analysis. No crossover was performed, and analysis was done per-protocol. Patients were excluded due to logistic failures like lack of utensils, samples disappearing en route to the laboratory mainly caused by implementation of a new electronic patient chart (EPIC, Verona, WI, USA), and forgetful surgeons. Intraoperatively, we swabbed for bacteria at the surgical site and in a rinse from the surgeons' gloves. All samples were sent for cultivation, and colony forming units (CFUs) counts ≥ 1 were deemed contaminated. The primary outcome measure was the difference in the proportion of contaminated patients between the two randomized groups. Secondary outcome measures were the affiliation of sex, season, age, type of implant used, and duration of surgery on contamination risk. To investigate whether other factors were affiliated with contamination risk, we did a logistic regression to control for confounding variables, including sex, age, season, type of implant and duration of surgery. RESULTS Use of iodinated drapes reduced contamination, with contamination detected in 10% (60 of 603) procedures where iodinated drapes were used compared with 15% (90 of 584) when they were not (odds ratio 0.61 [95% CI 0.43 to 0.87]; p = 0.005), with a relative risk reduction of 35% (95% CI 12.3 to 52.5) and a number needed to treat of 18 patients. After controlling for confounding variables such as sex, age, type of implant, and duration of surgery, we found that not using an antimicrobial drape increased contamination risk by a factor of 1.6 (95% CI 1.08 to 2.35; p = 0.02). Female sex and undergoing surgery in the central region were associated with lower odds of contamination (OR 0.55 [95% CI 0.39 to 0.8]; p = 0.002 and OR 0.45 [95% CI 0.25 to 0.8]; p = 0.006, respectively). Patients with more than a 10-mm separation of the drape from the skin had higher odds of contamination (OR 3.54 [95% CI 1.64 to 11.05]; p = 0.0013). CONCLUSIONS The use of an antimicrobial drape resulted in lower contamination risk than operating without an antimicrobial drape. Our findings suggest that antimicrobial drapes are useful in infection prevention, but further studies are needed to investigate the effect of antimicrobial drapes on infection. LEVEL OF EVIDENCE Level I, therapeutic study.
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Medical grade honey for the treatment of paediatric abdominal wounds: a case series.
Smaropoulos, E, Cremers, NA
Journal of wound care. 2020;(2):94-99
Abstract
OBJECTIVE Children are at high risk of injuries and wounds. The application of medical grade honey is a promising approach to improving the healing of wounds of various origin and severity. However, the use of medical grade honey in young paediatric patients remains limited. The aim of this study is to show the safety, efficacy and usefulness of medical grade honey in abdominal wounds, of different causes, in paediatric patients. METHOD This was a prospective, observational case series evaluating five young infants with abdominal wounds at the General Hospital in Thessaloniki. All wounds were treated in the same manner with daily medical grade honey applied to the wound area and closely monitored. RESULTS All treated wounds rapidly presented granulation tissue formation and underwent re-epithelialisation. Peripheral oedema and inflammation decreased upon initial application. Necrotic tissue was effectively debrided when present. Slough was removed and no signs of infection were detected, irrespective of initial wound presentations. Scar formation was minimal and the full range of motion was preserved in all cases. CONCLUSION Based on this case study, medical grade honey is safe and effective in treating different abdominal wounds, including infected or dehisced wounds as well as burns. The easy application and broad applicability make medical grade honey recommendable as a first-line treatment in paediatric patients.
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Metabolic factors and post-traumatic arthritis may influence the increased rate of surgical site infection in patients with human immunodeficiency virus following total hip arthroplasty.
Lin, CA, Behrens, PH, Paiement, G, Hardy, WD, Mirocha, J, Rettig, RL, Kiziah, HL, Rudikoff, AG, Hernandez Conte, A
Journal of orthopaedic surgery and research. 2020;(1):316
Abstract
BACKGROUND The impact of CD4+ T-cell count and highly active antiretroviral therapy (HAART) on the rate of surgical site infection (SSI) in patients with human immunodeficiency virus (HIV) undergoing total hip arthroplasty is still unclear. The goals of this study were to assess the rate of perioperative infection at a large tertiary care referral center and to identify risk factors in HIV+ patients undergoing total hip arthroplasty (THA). METHODS This study was a prospective, observational study at a single medical center from 2000-2017. Patients who were HIV+ and underwent THA were followed from the preoperative assessment period, through surgery and for a 2-year follow-up period. RESULTS Sixteen of 144 HIV+ patients (11%) undergoing THA developed perioperative surgical site infections. Fourteen patients (10%) required revision THA within a range of 12 to 97 days after the initial surgery. The patients' mean age was 49.6 ± 4.5 years, and the most common diagnosis prompting THA was osteonecrosis (96%). Patients who developed SSI had a lower waist-hip ratio (0.86 vs. 0.93, p = 0.047), lower high density lipoprotein cholesterol (45.8 vs. 52.5, p = 0.015) and were more likely to have post-traumatic arthritis (12.5% vs. 0%, p = 0.008). Logistic regression analysis demonstrated that current alcohol use and higher waist-hip ratio were significant protectors against infection (p < 0.05). No other demographic, medical, immunologic parameters, or specific HAART regimens were associated with perioperative infection. CONCLUSIONS Immunologic status as measured by CD4+ cell count, HIV viral load, and medical therapy do not appear to influence the development of SSI in HIV+ patients undergoing THA. Metabolic factors and post-traumatic arthritis may influence the increased rate of infection in HIV+ patients following THA.
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Effectiveness of Iodophor vs Chlorhexidine Solutions for Surgical Site Infections and Unplanned Reoperations for Patients Who Underwent Fracture Repair: The PREP-IT Master Protocol.
, , Slobogean, GP, Sprague, S, Wells, J, Bhandari, M, Rojas, A, Garibaldi, A, Wood, A, Howe, A, Harris, AD, et al
JAMA network open. 2020;(4):e202215
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IMPORTANCE The risk of developing a surgical site infection after extremity fracture repair is nearly 5 times greater than in most elective orthopedic surgical procedures. For all surgical procedures, it is standard practice to prepare the operative site with an antiseptic solution; however, there is limited evidence to guide the choice of solution used for orthopedic fracture repair. OBJECTIVE To compare the effectiveness of iodophor vs chlorhexidine solutions to reduce surgical site infections and unplanned fracture-related reoperations for patients who underwent fracture repair. DESIGN, SETTING, AND PARTICIPANTS The PREP-IT (Program of Randomized Trials to Evaluate Pre-operative Antiseptic Skin Solutions in Orthopaedic Trauma) master protocol will be followed to conduct 2 multicenter pragmatic cluster randomized crossover trials, Aqueous-PREP (Pragmatic Randomized Trial Evaluating Pre-Operative Aqueous Antiseptic Skin Solution in Open Fractures) and PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities). The Aqueous-PREP trial will compare 4% aqueous chlorhexidine vs 10% povidone-iodine for patients with open extremity fractures. The PREPARE trial will compare 2% chlorhexidine in 70% isopropyl alcohol vs 0.7% iodine povacrylex in 74% isopropyl alcohol for patients with open extremity fractures and patients with closed lower extremity or pelvic fractures. Both trials will share key aspects of study design and trial infrastructure. The studies will follow a pragmatic cluster randomized crossover design with alternating treatment periods of approximately 2 months. The primary outcome will be surgical site infection and the secondary outcome will be unplanned fracture-related reoperations within 12 months. The Aqueous-PREP trial will enroll a minimum of 1540 patients with open extremity fractures from at least 12 hospitals; PREPARE will enroll a minimum of 1540 patients with open extremity fractures and 6280 patients with closed lower extremity and pelvic fractures from at least 18 hospitals. The primary analyses will adhere to the intention-to-treat principle and account for potential between-cluster and between-period variability. The patient-centered design, implementation, and dissemination of results are guided by a multidisciplinary team that includes 3 patients and other relevant stakeholders. DISCUSSION The PREP-IT master protocol increases efficiency through shared trial infrastructure and study design components. Because prophylactic skin antisepsis is used prior to all surgical procedures and the application, cost, and availability of all study solutions are similar, the results of the PREP-IT trials are poised to inform clinical guidelines and bring about an immediate change in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT03385304 and NCT03523962.