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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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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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Extraocular and Intraocular Infections Following Strabismus Surgery: A Review.
Ing, MR, Shortell, J, Golez, J
Journal of pediatric ophthalmology and strabismus. 2019;(4):214-221
Abstract
An extensive literature review of various types of infections following strabismus surgery was facilitated by using the search engines PubMed and Google Scholar. In both search engines, the phrases "infection following strabismus surgery," "infection strabismus surgery," "complications of strabismus surgery," "endophthalmitis strabismus surgery," and "strabismus scleral perforation" were used for the review. The type of infection, surface involved, and site of the infection determined the type of therapy. Infections involving deeper tissues, such as periocular infection or orbital cellulitis, required systemic therapy. Sub-Tenon's abscesses required incision and drainage, as well as systemic antibiotics. The development of endophthalmitis following strabismus surgery was rare, but was usually devastating to the visual result. Symptoms of an adverse intraocular condition began by mean postoperative day 3, but the definitive diagnosis and treatment of endophthalmitis was not made until mean postoperative day 6. Despite early detection of this latter type of infection and early surgical intervention with vitreous paracentesis and intraocular injection of antibiotics, the visual result was extremely poor in more than two-thirds of the reported cases. Although there is no known way to truly prevent all infections following strabismus surgery, several techniques may be prudent for the strabismus surgeon to adopt to decrease the bacterial load and minimize the risk of infection. The surgeon should be encouraged to consider preoperative use of povidone-iodine on the operative field and avoid scleral perforation during surgery. [J Pediatr Ophthalmol Strabismus. 2019;56(4):214-221.].
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Prophylaxis of surgical site infection in adult spine surgery: A systematic review.
Yao, R, Tan, T, Tee, JW, Street, J
Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2018;:5-25
Abstract
INTRODUCTION Surgical site infection (SSI) remains a significant source of morbidity in spine surgery, with reported rates varying from 0.7 to 16%. OBJECTIVE To systematically review and evaluate the evidence for strategies for prophylaxis of SSI in adult spine surgery in the last twenty years. METHODS Two independent systematic searches were conducted, at two international spine centers, encompassing PubMed, ClinicalTrials.gov, Cochrane Database, EBSCO Medline, ScienceDirect, Ovid Medline, EMBASE (Ovid), and MEDLINE. References were combined and screened, then distilled to 69 independent studies for final review. RESULTS 11 randomized controlled trials (RCTs), 51 case-controlled studies (CCS), and 7 case series were identified. Wide variation exists in surgical indications, approaches, procedures, and even definitions of SSI. Intra-wound vancomycin powder was the most widely studied intervention (19 studies, 1 RCT). Multiple studies examined perioperative antibiotic protocols, closed-suction drainage, povidone-iodine solution irrigation, and 2-octyl-cyanoacrylate skin closure. 18 interventions were examined by a single study only. There is limited evidence for the efficacy of intra-wound vancomycin. There is strong evidence that closed-suction drainage does not affect SSI rates, while there is moderate evidence for the efficacy of povidone-iodine irrigation and that single-dose preoperative antibiotics is as effective as multiple doses. Few conclusions can be drawn about other interventions given the paucity and poor quality of studies. CONCLUSIONS While a small body of evidence underscores a select few interventions for SSI prophylaxis in adult spine surgery, most proposed measures have not been investigated beyond a single study. Further high level evidence is required to justify SSI preventative treatments.
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Probiotics in Prevention of Surgical Site Infections.
Siddharthan, R, Chapek, M, Warren, M, Martindale, R
Surgical infections. 2018;(8):781-784
Abstract
Despite significant improvements in peri-operative care, surgical site infections (SSIs) remain an important contributor to morbidity, cost, and death. The human gastrointestinal tract is a complex microenvironment linking host cells and the indigenous microflora or "microbiome," creating a "super-organism" that engages in macro-nutrient and micro-nutrient extraction for the host while serving as a barrier to toxins and other detrimental bacterial end-products. Maintaining a healthy microbiome in the peri-operative period may enable control of multi-drug resistance (MDR) organisms, whereas use of antibiotics simply resets the dysbiotic relation by eliminating multiple strains of bacteria. Such loss of microbial diversity or abundance can slow wound healing. Use of pro-biotics to prevent infection has been evaluated in several studies, but their utility is not yet clear. There is a clear need for randomized trials to draw firm conclusions about their efficacy and to make clinical recommendations.
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Alternatives to antibiotics for prevention of surgical infection.
Ploegmakers, IB, Olde Damink, SW, Breukink, SO
The British journal of surgery. 2017;(2):e24-e33
Abstract
BACKGROUND Surgical-site infection (SSI) is still the second most common healthcare-associated infection, after respiratory tract infection. SSIs are associated with higher morbidity and mortality rates, and result in enormous healthcare costs. In the past decade, several guidelines have been developed that aim to reduce the incidence of SSI. Unfortunately, there is no consensus amongst the guidelines, and some are already outdated. This review discusses the recent literature regarding alternatives to antibiotics for prevention of SSI. METHODS A literature search of PubMed/MEDLINE was performed to retrieve data on the prevention of SSI. The focus was on literature published in the past decade. RESULTS Prevention of SSI can be divided into preoperative, perioperative and postoperative measures. Preoperative measures consist of showering, surgical scrubbing and cleansing of the operation area with antiseptics. Perioperative factors can be subdivided as: environmental factors, such as surgical attire; patient-related factors, such as plasma glucose control; and surgical factors, such as the duration and invasiveness of surgery. Postoperative measures consist mainly of wound care. CONCLUSION There is a general lack of evidence on the preventive effectiveness of perioperative measures to reduce the incidence of SSI. Most measures are based on common practice and perceived effectiveness. The lack of clinical evidence, together with the stability of the high incidence of SSI (10 per cent for colorectal procedures) in recent decades, highlights the need for future research.
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Perioperative infections in congenital heart disease.
Murni, IK, MacLaren, G, Morrow, D, Iyer, P, Duke, T
Cardiology in the young. 2017;(S6):S14-S21
Abstract
BACKGROUND Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality. METHODS A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed. RESULTS Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition. CONCLUSIONS The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.
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Povidone iodine in wound healing: A review of current concepts and practices.
Bigliardi, PL, Alsagoff, SAL, El-Kafrawi, HY, Pyon, JK, Wa, CTC, Villa, MA
International journal of surgery (London, England). 2017;:260-268
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Abstract
BACKGROUND Of the many antimicrobial agents available, iodophore-based formulations such as povidone iodine have remained popular after decades of use for antisepsis and wound healing applications due to their favorable efficacy and tolerability. Povidone iodine's broad spectrum of activity, ability to penetrate biofilms, lack of associated resistance, anti-inflammatory properties, low cytotoxicity and good tolerability have been cited as important factors, and no negative effect on wound healing has been observed in clinical practice. Over the past few decades, numerous reports on the use of povidone iodine have been published, however, many of these studies are of differing design, endpoints, and quality. More recent data clearly supports its use in wound healing. METHODS Based on data collected through PubMed using specified search criteria based on above topics and clinical experience of the authors, this article will review preclinical and clinical safety and efficacy data on the use of povidone iodine in wound healing and its implications for the control of infection and inflammation, together with the authors' advice for the successful treatment of acute and chronic wounds. RESULTS AND CONCLUSION Povidone iodine has many characteristics that position it extraordinarily well for wound healing, including its broad antimicrobial spectrum, lack of resistance, efficacy against biofilms, good tolerability and its effect on excessive inflammation. Due to its rapid, potent, broad-spectrum antimicrobial properties, and favorable risk/benefit profile, povidone iodine is expected to remain a highly effective treatment for acute and chronic wounds in the foreseeable future.
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Blurred Lines: Dysbiosis and Probiotics in the ICU.
Morrow, LE, Wischmeyer, P
Chest. 2017;(2):492-499
Abstract
Clinicians have traditionally dichotomized bacteria as friendly commensals or harmful pathogens. However, the line separating the two has become blurred with the recognition that the intestinal microbiome is a complex entity in which species can shift sides-from friend to foe and back again-based on crucial factors in their local environment. Significant disruptions in the homeostasis of the microbiome, a phenomenon called dysbiosis, is increasingly associated with a host of untoward effects. Patients in the ICU are at high risk for dysbiosis given the high rate of antibiotic use, acute changes in diet, and the stress of critical illness. Probiotics are living microbes of human origin that when ingested in sufficient quantities, can colonize sites such as the oropharynx and GI tract and provide benefits to the host. In recent years, we have increasingly explored the utility of using probiotics to reverse the intestinal dysbiosis associated with critical illness, thereby reducing select ICU complications associated with increased morbidity and mortality. Although these preliminary efforts have demonstrated varying degrees of success, our present studies suffer from a host of limitations that hinder the strength of their conclusions and the generalizability of their results. Probiotic investigations have been further hobbled by current regulatory requirements, which were designed to serve as the framework for pharmaceutical research. Although such measures are intended to ensure patient safety, they inadvertently impose barriers that stifle innovation regarding nutraceuticals. This review strives to summarize the current evidence regarding the efficacy and safety of probiotics in the ICU as well as to provide an overview of the obstacles probiotic researchers face going forward.
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Nasal decontamination for the prevention of surgical site infection in Staphylococcus aureus carriers.
Liu, Z, Norman, G, Iheozor-Ejiofor, Z, Wong, JK, Crosbie, EJ, Wilson, P
The Cochrane database of systematic reviews. 2017;(5):CD012462
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Abstract
BACKGROUND Surgical site infection rates in the month following surgery vary from 1% to 5%. Due to the large number of surgical procedures conducted annually, the costs of these surgical site infections (SSIs) can be considerable in financial and social terms. Nasal decontamination using antibiotics or antiseptics is performed to reduce the risk of SSIs by preventing organisms from the nasal cavity being transferred to the skin where a surgical incision will be made. Staphylococcus aureus (S aureus) colonises the nasal cavity and skin of carriers and can cause infection in open or unhealed surgical wounds. S aureus is the leading nosocomial (hospital-acquired) pathogen in hospitals worldwide. The potential effectiveness of nasal decontamination of S aureus is thought to be dependent on both the antibiotic/antiseptic used and the dose of application; however, it is unclear whether nasal decontamination actually reduces postoperative wound infection in S aureus carriers. OBJECTIVES To assess the effects of nasal decontamination on preventing surgical site infections (SSIs) in people who are S aureus carriers undergoing surgery. SEARCH METHODS In September 2016 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus. We also searched three clinical trial registries and the references of included studies and relevant systematic reviews. There were no restrictions based on language, date of publication or study setting. SELECTION CRITERIA Randomised controlled trials (RCTs) which enrolled S aureus carriers with any type of surgery and assessed the use of nasal decontamination with antiseptic/antibiotic properties were included in the review. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, risk of bias assessment and GRADE assessment. MAIN RESULTS We located two studies (291 participants) for inclusion in this review. The trials were clinically heterogeneous with differences in duration of follow-up, and nasal decontamination regimens. One study compared mupirocin (2% contained in a base of polyethylene glycol 400 and polyethylene glycol 3350) with a placebo in elective cardiac surgery patients; and one study compared Anerdian (iodine 0.45% to 0.57% (W/V), chlorhexidine acetate 0.09% to 0.11% (W/V)) with no treatment also in cardiac surgery patients. The trials reported limited outcome data on SSI, adverse events and secondary outcomes (e.g. S aureus SSI, mortality). Mupirocin compared with placeboThis study found no clear difference in SSI risk following use of mupirocin compared with placebo (1 trial, 257 participants); risk ratio (RR) 1.60, 95% confidence interval (CI) 0.79 to 3.25 based on 18/130 events in the mupirocin group and 11/127 in the control group; low-certainty evidence (downgraded twice due to imprecision). Anerdian compared with no treatmentIt is uncertain whether there is a difference in SSI risk following treatment with Anerdian compared with no treatment (1 trial, 34 participants); RR 0.89, 95% CI 0.06 to 13.08 based on 1/18 events in the Anerdian group and 1/16 in the control group; very low certainty evidence (downgraded twice due to imprecision and once due to risk of bias). AUTHORS' CONCLUSIONS There is currently limited rigorous RCT evidence available regarding the clinical effectiveness of nasal decontamination in the prevention of SSI. This limitation is specific to the focused question our review addresses, looking at nasal decontamination as a single intervention in participants undergoing surgery who are known S aureus carriers. We were only able to identify two studies that met the inclusion criteria for this review and one of these was very small and poorly reported. The potential benefits and harms of using decontamination for the prevention of SSI in this group of people remain uncertain.