Impact of a quality improvement intervention on the incidence of surgical site infection in patients undergoing colorectal surgery: Pre-test-post-test design.

AIMS AND OBJECTIVES: The aim of this study was to measure the impact of a complex quality improvement intervention on the incidence of SSI in patients undergoing elective colorectal surgery. BACKGROUND: Surgical site infections are a major postoperative complication for patients undergoing colorectal surgery. Prevention of SSIs necessitates a complex intervention requiring many elements to be in place to ensure the successful implementation of prevention measures. DESIGN: This study was a non-equivalent pre-test post-test design where consecutive patients undergoing colorectal surgery were surveyed for surgical site infections for 30 days postoperatively and is reported using the SQUIRE 2.0. METHODS: A baseline cohort of patients was retrospectively reviewed in a single centre to ascertain the surgical site infection incidence rate in the first 6 months of 2018 (T0) and prospectively at two 6-month time periods in 2019 (T1, T2) following the introduction of a complex intervention. There were 311 patients included across three time periods. RESULTS: There was a notable decrease in surgical site infection incidence rates from baseline over the course of the study. Univariate analysis identified Body Mass Index, a wound contamination classification of dirty or contaminated, duration of surgery >75th percentile and a National Healthcare Safety Network risk index score of 3 as factors that significantly increase the probability of developing a surgical site infection. Multivariate analysis identified duration of surgery and body mass index increased the probability of an SSI. The results of the logistical regression model found that there was a significant reduction in the probability of an SSI between T0 and T2. CONCLUSIONS: The implementation of a complex intervention led to a reduction in the incidence of surgical site infections and improved implementation of evidence-based practices as part of a care bundle in relation to the prevention of surgical site infections in patients undergoing elective colorectal surgery. RELEVANCE TO CLINICAL PRACTICE: A multicomponent multidisciplinary complex intervention as part of a quality improvement project can successfully reduce the incidence rates of surgical site infections in patients who require elective colorectal surgery. Normalisation Process Theory provides guidance and support in implementing complex interventions for the prevention of surgical site infection. PATIENT OR PUBLIC CONTRIBUTION: Patients provided post-discharge information on their wound healing as part of the surveillance component of the intervention. Five patients reviewed and provided feedback on a patient information booklet which was developed from this quality improvement intervention. A multidisciplinary steering group guided all stages of the project.

Empirical treatment of urinary tract infections: how rational are our guidelines?

Objectives: This study considers susceptibility test results obtained over a 6 month period for Enterobacteriaceae that caused urinary tract infections (UTIs) in the Cork region of Ireland and uses these results to examine the suitability of Irish empirical treatment guidelines. Patients and methods: UTI-causing Enterobacteriaceae isolates were analysed using EUCAST guidelines to determine resistance to a set of commonly prescribed antimicrobial agents, i.e. ampicillin, amoxicillin/clavulanate, cefalexin, ciprofloxacin, nitrofurantoin and trimethoprim. Patients were categorized by age and patient type, based on origin (hospital inpatients, patients in long-term care facilities and all other non-hospitalized patients). In total, 8999 test results were analysed using the IBM Cognos Analytics Series 7 interrogation tool and Microsoft Office Excel. Results: A variety of resistance patterns were observed. Only one antimicrobial agent, nitrofurantoin, demonstrated a resistance rate of less than 20% for all patient categories considered. Conclusions: Previous studies determined that a resistance rate of >20% renders an antimicrobial agent unsuitable for use as an empirical treatment option. This study demonstrated that this resistance rate is exceeded in many cases, potentially rendering some antimicrobial agents unsuitable for use as empirical treatment. We suggest that the focus on susceptibility when producing surveillance data to create empirical treatment guidelines may inadvertently camouflage resistance rates. The findings of this study highlight the need for laboratory-guided treatment of UTIs and ideally a pre-emptive sample should be obtained for laboratory investigation prior to commencement of antimicrobial therapy.

Strain-specific inhibition of Helicobacter pylori by Lactobacillus salivarius and other lactobacilli.

OBJECTIVES: To investigate the anti-Helicobacter pylori activity of 28 strains of Lactobacillus salivarius and 12 other lactobacilli, isolated from different sites and from different geographical regions. METHODS: An in vitro agar plate diffusion assay was employed to assess the Lactobacillus anti-H. pylori activity. RESULTS: Nine out of 28 L. salivarius strains and 3/12 other Lactobacillus species tested inhibited H. pylori growth. There was no correlation between ecological niche/geographical location of isolation of the lactobacilli and their inhibitory capability. Further studies on strain L. salivarius UCC119 showed that this strain could inhibit growth of 6/6 clinical isolates of H. pylori, five of which were antibiotic-resistant. This inhibition was not due to acid production and was not mediated by a protein, but did require the presence of live cells. CONCLUSIONS: Growth inhibition of H. pylori by L. salivarius is strain-dependent and is not linked to any particular environmental niche or geographic location. Strains of L. salivarius showing highest anti-H. pylori activity may be useful as an adjunct in the treatment of strains that are resistant to conventional antibiotics.

Comparison of three stool antigen assays with the 13C- urea breath test for the primary diagnosis of Helicobacter pylori infection and monitoring treatment outcome.

BACKGROUND: The urea breath test (UBT) is the gold-standard non-invasive test for the detection of Helicobacter pylori infection, however, the lack of availability of the UBT due to the high cost of the test, and in particular the need for expensive analytical instrumentation, limits the usefulness of this method. Stool antigen assays may offer an alternative non-invasive method for the diagnosis of infection. OBJECTIVE: To compare the accuracy of three stool antigen assays (HpSA, IDEIA HpStAR, and ImmunoCard STAT) against the UBT for the primary diagnosis of H. pylori infection and for monitoring treatment outcome. METHODS: A total of 102 patients attending two gastroenterology day-case clinics for the investigation of dyspepsia were included. Each patient provided breath and stool samples for analysis. Patients who tested positive for H. pylori by the validated UBT were prescribed triple therapy and invited to return for repeat breath and stool sample analysis 6 weeks post-treatment. RESULTS: Of the 102 patients tested, 48 were diagnosed with H. pylori infection by the UBT. The HpSA assay interpreted 38 of these as positive (79% sensitive). Of the 54 UBT-negative patients the HpSA assay interpreted all 54 as negative (100% specific). The IDEIA HpStAR assay correctly identified 44 patients as positive (92% sensitive) and 50 as negative (92.5% specific). The ImmunoCard STAT assay interpreted 38 patients as positive (79% sensitive) and 52 as negative (96.3% specific). CONCLUSION: The findings indicate that the IDEIA HpStAR stool antigen kit is the most accurate assay of the three assays evaluated, and possibly represents a viable alternative to the UBT for the primary diagnosis of H. pylori infection and for monitoring treatment outcome.