Standardized Infection Ratio for Surgical Site Infection after Colon Surgery: Discord in Models Measuring Healthcare Quality.

The government publishes 3 different public report surgical site infection (SSI) metrics, all called standardized infection ratios (SIRs), that impact perceived hospital quality. We conducted a non-random cross-sectional observational pilot study of 20 California hospitals that voluntarily submitted colon surgery and SSI data. Discordant SIR values, leading to contradictory conclusions, occurred in 35% of these hospitals. Infect Control Hosp Epidemiol 2016;1-5.

Periprosthetic joint infection.

Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.

Patient Compliance with Preoperative Disinfection Protocols for Lower Extremity Total Joint Arthroplasty.

INTRODUCTION: Infection after total joint arthroplasty has been most attributed to bacterial wound contamination from skin flora. To address this, the CDC recommends bathing with an antiseptic agent the night prior to the operative day. However, despite these measures, the incidence of infections has not been reduced markedly. It is important to have measures in place to ensure proper patient education about infections and disinfection protocols to optimize compliance. Our purpose was to evaluate compliance with preoperative disinfection protocols at our institution and to identify measures which may improve adherence. MATERIALS AND METHODS: Between 2007 and 2011, we reviewed a database at our institution for all patients who underwent primary or revision total hip (n=2,458) and knee (n=2,293) arthroplasty. All of these patients were instructed to follow a chlorhexidine cloth disinfection protocol at the time of surgical scheduling or during their preoperative evaluation. To verify compliance, patients were instructed to remove adhesive stickers from the cloth packages at the time of disinfection and to affix them to the instruction sheet presented on the day of surgery. This was documented in the patient medical records. A database was generated to identify those patients who were compliant (n=1,035) or non-compliant (n=3,716). Following this period, if patients did not use chlorhexidine as instructed, the staff ensured one application was received pre-operatively. RESULTS: Approximately 78% of patients (3,716 out of 4,751 patients) were noncompliant. When evaluating the demographic between the two groups, we found that age and gender distributions were not significantly different. DISCUSSION: While preoperative decolonization protocols may reduce surgical site infections, their efficacy is limited by patient compliance and comprehension. Providing patients with thorough instructions about preoperative disinfection protocols and information about the importance of infection burden is more likely to improve patient adherence.

Infection prevention methodologies for lower extremity total joint arthroplasty.

Despite advances in our understanding of surgical site infections following total joint arthroplasty, this serious surgical complication continues to represent a substantial economic burden for the patient, the treating institution and the healthcare system. After increasing for the past decade, infection rates have stabilized at 1.6%; however, the total cost is projected to increase with the total number of revision procedures performed. A systematic review of the literature was performed to identify studies that assess the efficacy of pre-, peri- and post-operative infection prevention strategies in the setting of total hip or knee arthroplasty. Preference was given to randomized-controlled trials, data from national registries and meta-analyses within the past 5 years; however, all relevant articles were included in this analysis. The results of the literature search returned 549 articles that addressed infection in total joint arthroplasty, of which 71 specifically addressed infection prevention. Topics that were addressed included the CDC recommendations, skin preparation techniques, hair removal techniques, surgical draping techniques, operative dress, operating room ventilation, operating room traffic and antibiotic utilization. Newer infection prevention techniques, such as preoperative antiseptic scrubbing, are affected and may help reduce the infection rate, while traditionally accepted methods of prophylaxis such as laminar-flow operating rooms and body exhaust suits may raise the infection rate.

Chlorhexidine reduces infections in knee arthroplasty.

The purpose of this study was to evaluate the incidence of surgical site infections in total knee arthroplasty patients using a preadmission cutaneous skin preparation protocol compared with a cohort of patients undergoing standard in-hospital perioperative preparation only. Records between 2007 and 2010 were reviewed to identify deep incisional and periprosthetic infections among patients using the chlorhexidine protocol (478 patients) and patients who did not use the protocol (1,735 patients). Patients using the chlorhexidine cloths were given two packets of six chlorhexidine gluconate-impregnated cloths, with instructions for use, the evening before and morning of surgery. A statistically lower incidence of surgical site infection was found in patients using the chlorhexidine cloths (0.6%) compared with patients undergoing in-hospital perioperative skin preparation only (2.2%). On the basis of the results of this study, a preadmission chlorhexidine protocol seems to be an effective method to prevent surgical site infections in total knee arthroplasty procedures.

Pre-admission cutaneous chlorhexidine preparation reduces surgical site infections in total hip arthroplasty.

The purpose of this study was to evaluate the incidence of surgical site infections in total hip arthroplasty patients who used an advance pre-admission cutaneous surgical preparation protocol and to compare these results to a cohort of patients who did not use the protocol. Between 2007 and 2010, 557 patients used the chlorhexidine cloths and 1901 patients did not use the cloths. Patient records were reviewed to determine the incidence of deep incisional and periprosthetic infections. A statistically significant lower incidence of infections occurred in patients who used the chlorhexidine cloths (0.5%) when compared to patients undergoing in-hospital perioperative skin preparation only (1.7%). These results confirm prior studies suggesting this as an effective method to prevent periprosthetic hip arthroplasty infections.

Advance pre-operative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty.

Surgical site infections following elective knee arthroplasties occur most commonly as a result of colonisation by the patient's native skin flora. The purpose of this study was to evaluate the incidence of deep surgical site infections in knee arthroplasty patients who used an advance cutaneous disinfection protocol and who were compared to patients who had peri-operative preparation only. All adult reconstruction surgeons at a single institution were approached to voluntarily provide patients with chlorhexidine gluconate-impregnated cloths and a printed sheet instructing their use the night before and morning of surgery. Records for all knee arthroplasties performed between January 2007 and December 2008 were reviewed to determine the incidence of deep incisional and periprosthetic surgical site infections. Overall, the advance pre-operative protocol was used in 136 of 912 total knee arthroplasties (15%). A lower incidence of surgical site infection was found in patients who used the advance cutaneous preparation protocol as compared to patients who used the in-hospital protocol alone. These findings were maintained when patients were stratified by surgical infection risk category. No surgical site infections occurred in the 136 patients who completed the protocol as compared to 21 infections in 711 procedures (3.0%) performed in patients who did not. Patient-directed skin disinfection using chlorhexidine gluconate-impregnated cloths the evening before, and the morning of, elective knee arthroplasty appeared to effectively reduce the incidence of surgical site infection when compared to patients who underwent in-hospital skin preparation only.

Preoperative chlorhexidine preparation and the incidence of surgical site infections after hip arthroplasty.

The purpose of this study was to evaluate effectiveness of an advance, at-home chlorhexidine-impregnated skin preparation cloth in decreasing the incidence of deep periprosthetic hip arthroplasty infections. Arthroplasty surgeons at the senior author's institution provided their patients with chlorhexidine-impregnated single-use cloths for use at home the night before and the morning of surgery. Between January 2007 and December 2009, the compliance of this practice, as well as the incidence of periprosthetic infections, was monitored for all patients who underwent hip arthroplasty. Of the 1134 patients who underwent hip arthroplasty, 157 patients completely complied with the preoperative chlorhexidine preparation protocol. There were 14 infections in the group that was not compliant (1.6% infection rate), and there were no infections in the compliant patient population. Based on the results of this study, at-home preoperative patient skin preparation appears to be a simple and cost-effective method to reduce periprosthetic hip infection rates.

Bloodborne pathogen exposures and prevention in the perioperative environment.

The fear of exposure to bloodborne pathogens and disease transmission from patients to health care professionals or health care professional to patients is real. Perioperative nurses and other surgical personnel should be aware of the dangers and risks of exposure to these viruses. Patients may be infected with one of the currently recognized bloodborne viruses including Hepatitis B (HBV), Hepatitis C (HCV) and the Human Immunodeficiency Virus (HIV). It is imperative that accidental exposure during surgical procedures be avoided. The most common means of exposure are percutaneous and mucous membrane routes. The persistence of HBV, HCV and HIV infections, long incubation periods, and the likelihood of frequent asymptomatic carrier states remain continuing threats to the surgical team and makes it difficult to rely on a diagnosis. Infection prevention and control strategies to reduce the risk of exposures and prevent transmission are based on a number of approaches including engineering, administrative and works practice controls and the proper selection and use of personal protective equipment.