Manejo cirúrgico de ferimento auto-infligido por arma de fogo em região maxilofacial / Surgical management of self-inflicted injury by gun in the maxillofacial region

INTRODUÇÃO: O manejo dos pacientes vítimas de PAF possui vertentes divergentes a respeito do tratamento cirúrgico, que pode ser realizado de forma imedata ou tardia. Em lesões auto-infligidas, a distância entre a arma e a região acometida é menor, causando consequências estéticas e funcionais mais devastadoras. Aliado ao fato desse tipo de trauma criar uma ferida suja devido à comunicação com a cavidade oral e seios paranasais, o manejo das lesões representam um desafio mesmo à cirurgiões experientes. OBJETIVO: Estre trabalho relata o manejo cirúrgico de uma ferida auto-infligida por arma de fogo que resultou em avulsão dos tecidos moles na região maxilofacial. DESCRIÇÃO DO CASO: Paciente do sexo masculino, 35 anos, vítima de projétil de arma de fogo auto-infligido em região maxilofacial, cursando com extenso ferimento em região de língua e mento. Clinicamente, o paciente não apresentava sinais de fratura em ossos da face. Ambos os ferimentos apresentavam secreção purulenta e o paciente manifestava disfonia devido a grande destruição tecidual. CONSIDERAÇÕES FINAIS: O tratamento de ferimentos por arma de fogo não só é um grande desafio para o cirurgião, como para toda a equipe multidisciplinar requerida para tais casos, visto que não há protocolos bem definidos para o tratamento dessas lesões(AU)

INTRODUCTION: The management of patients who are victims of FAP has divergent aspects regarding surgical treatment, which can be performed immediately or late. In self-inflicted injuries, the distance between the weapon and the affected region is smaller, causing more devastating aesthetic and functional consequences. Allied to the fact that this type of trauma creates a dirty wound due to the communication with the oral cavity and paranasal sinuses, the management of injuries represents a challenge even for experienced surgeons. OBJECTIVE: This paper reports the surgical management of a self-inflicted gunshot wound that resulted in soft tissue avulsion in the maxillofacial region. CASE DESCRIPTION: Male patient, 35 years old, victim of a self-inflicted firearm projectile in the maxillofacial region, coursing with extensive injury in the region of the tongue and chin. Clinically, the patient did not show signs of facial bone fractures. Both wounds had purulent secretion and the patient had dysphonia due to extensive tissue destruction. FINAL CONSIDERATIONS: The treatment of gunshot wounds is not only a great challenge for the surgeon, but also for the entire multidisciplinary team required for such cases, since there are no well-defined protocols for the treatment of these injuries(AU)

Inside-out, antimicrobial resistance mediated by efflux pumps in clinical strains of Acinetobacter baumannii isolated from burn wound infections.

Acinetobacter baumannii belongs to the ESKAPE group. It is classified as a critical priority group by the World Health Organization and a global concern on account of its capacity to acquire and develop resistance mechanisms to multiple antibiotics. Data from the United States indicates 500 deaths annually. Resistance mechanisms of this bacterium include enzymatic pathways such as ß-lactamases, carbapenemases, and aminoglycoside-modifying enzymes, decreased permeability, and overexpression of efflux pumps. A. baumannii has been demonstrated to possess efflux pumps, which are classified as members of the MATE family, RND and MFS superfamilies, and SMR transporters. The aim of our work was to assess the distribution of efflux pumps and their regulatory gene expression in clinical strains of A. baumannii isolated from burned patients. METHODS: From the Clinical Microbiology Laboratory at the Instituto Nacional de Rehabilitación Luis Guillermo Ibarra Ibarra collection in Mexico, 199 strains were selected. Antibiotics susceptibilities were performed by broth microdilutions to determine minimal inhibitory concentrations. Phenotypic assays with efflux pump inhibitors were conducted using carbonyl cyanide 3-chlorophenylhydrazone (CCCP) and phenylalanine-arginine ß-naphthylamide (PAßN) in conjunction with amikacin, ceftazidime, imipenem, meropenem and levofloxacin. A search was conducted for structural genes that are linked to efflux pumps, and the relative expression of the adeR, adeS, and adeL genes was analyzed. RESULTS: Among a total of 199 strains, 186 exhibited multidrug resistance (MDR). Fluoroquinolones demonstrated the highest resistance rates, while minocycline and amikacin displayed comparatively reduced resistance rates (1.5 and 28.1, respectively). The efflux activity of fluorquinolones exhibited the highest phenotypic detection (from 85 to 100%), while IMP demonstrated the lowest activity of 27% with PAßN and 43.3% with CCCP. Overexpression was observed in adeS and adeL, with adeR exhibiting overexpression. Concluding that clinical strains of A. baumannii from our institution exhibited efflux pumps as one of the resistance mechanisms.

Evaluating antibiotic prophylaxis adherence: Implications for surgical site infections and wound care management.

AIM: This study aimed to evaluate adherence to an antibiotic prophylaxis protocol and its impact on incidence of surgical site infection (SSI). MATERIALS AND METHOD: A prospective observational cohort study was conducted at a teaching hospital in São Paulo, Brazil, from September to November 2015. The population were adults who underwent surgery with surgical antibiotic prophylaxis. The main outcomes measured were incidence of SSI at 30-days postoperatively, protocol adherence and surgical wound complications. STROBE guidelines were followed. RESULTS: Among the 527 participants recruited, a 30-day follow-up was completed by 78.7 % (n = 415). Within this cohort, 57.6 % were females aged over 60 years (36.4 %). The incidence of SSI stood at 9.4 % (n = 39), with dehiscence being the most prevalent complication at 64.1 % (n = 25), followed by increased exudate at 51.3 % (n = 20). Notably, full adherence to the antibiotic prophylaxis protocol was low at 1.7 % (n = 7). The study observed a 60 % increased risk of SSI for every protocol mistake made. Alarmingly, 17.8 % (n = 74) of participants received antibiotic treatment exceeding the stipulated protocol duration. The overall mortality rate stood at 13.5 % (n = 56), with 1 % (n = 4) of these deaths attributed to SSI. CONCLUSION: There is a pressing global necessity to enhance antibiotic management, as underscored by this study's revelation of low adherence to the antibiotic prophylaxis protocol. This lack of adherence correlated with a notable incidence of SSI and subsequent wound complications. Nearly 20 % of participants received prolonged antibiotic treatment. Adhering strictly to the protocol could substantially impact SSI-related outcomes and enhance global antibiotic management.

Caracterización de pacientes con infección de sitio quirúrgico en post-operados de cirugía abdominal de urgencias hospitalizados

Introducción: Las infecciones de sitio quirúrgico están asociadas con infecciones relacionadas a la asistencia sanitaria (IRAS), causadas por bacterias que ingresan a través de las incisiones efectuadas durante un procedimiento quirúrgico. Objetivo: Describir la frecuencia y características de las infecciones de sitio quirúrgico en las cirugías de urgencias en pacientes pediátricos hospitalizados en el Hospital General Pediátrico. Materiales y Métodos: Estudio observacional descriptivo, retrospectivo, de corte transversal. Población: Pacientes de 0 a 18 años sometidos a intervención quirúrgica abdominal de urgencia. Variables estudiadas: Edad, Sexo, Procedencia, Comorbilidad, reingreso hospitalario, tiempo trascurrido entre la intervención quirúrgica y la aparición de la infección en sitio quirúrgico. Datos obtenidos del análisis de fichas clínicas y la base de datos del HIS en el paquete estadístico SPSv23 (IBM SPSS, DEMO) utilizando estadística descriptiva. Resultados: Fueron incluidas 440 fichas de pacientes, la mediana de edad fue de 10 años, el 60,5% fueron del sexo masculino y el 71,4% procedían del Departamento Central. Se observó que el diagnóstico más frecuente fue peritonitis de origen apendicular 53,2%. El estado nutricional de la población en estudio fue normal en 93,2%, y fueron reingresos el 3% de los pacientes intervenidos. Presentaron infección de sitio quirúrgico el 4,8%, de los cuales 11/21 fueron absceso de pared. En cuanto al tiempo trascurrido entre la cirugía y la aparición de la infección la mediana fue de 14 días. Conclusión: La frecuencia de infección del sitio quirúrgico encontrada en este estudio fue del 4,8%. La patología quirúrgica con mayor porcentaje fue la peritonitis y el tipo de infección absceso de pared. La mayoría de los pacientes eran escolares con buen estado nutricional.

Introduction: Surgical-site infections are associated with healthcare-associated infections (HAIs), caused by bacteria that enter through the incisions made during a surgical procedure. Objective: To describe the frequency and characteristics of surgical site infections in emergency surgeries in pediatric patients hospitalized at a Pediatric General Hospital. Materials and Methods: This was a descriptive, retrospective and cross-sectional observational study. Population: Patients aged 0 to 18 years undergoing emergency abdominal surgery. Variables studied: Age, Sex, Origin, Comorbidity, hospital readmission, time elapsed between the surgical intervention and the appearance of the surgical site infection. Data obtained from the analysis of clinical records and the electronic health record database in the SPSv23 statistical package (IBM SPSS, DEMO) using descriptive statistics. Results: 440 patient records were included, the median age was 10 years, 60.5% were male and 71.4% came from the Central Department. It was observed that the most frequent diagnosis was peritonitis of appendiceal origin 53.2%. The nutritional status of the study population was normal in 93.2%, and 3% of the operated patients were readmitted. 4.8% had surgical site infection, of which 11/21 were wall abscesses. Regarding the time elapsed between surgery and the appearance of the infection, the median was 14 days. Conclusion: The frequency of surgical-site infection found in this study was 4.8%. The surgical pathology with the highest percentage was peritonitis and the wall abscess type of infection. Most of the patients were schoolchildren with good nutritional status.

Surgical site infection in patients undergoing hip and knee arthroplastie / Infección del sitio quirúrgico en pacientes sometidos a artroplastias de cadera y rodilla / Infecção de sítio cirúrgico em pacientes submetidos a artroplastias de quadril e joelho

Objective: To characterize cases of Surgical Site Infections (SSI) in patients undergoing hip and knee arthroplasties. Method: A cross-sectional, retrospective, and quantitative study conducted in a public, teaching, and high-complexity hospital in the southern region of Brazil. Data collection took place between 2020 and 2022 from records contained in 91 medical records and post-discharge forms within 90 days after surgery for prosthesis implan-tation. Data were analyzed by descriptive statistics and SSI incidence rate. Results: 49 (53.8%) knee arthroplasty records and 42 (46.2%) hip arthroplasty records were analyzed. Five cases developed infection, all detected at the post-arthroplasty knee outpatient visit, resulting in an SSI incidence rate in arthroplasties of 5.5% (n=5). Infections were characterized as deep incisional (40%; n=2), organ or cavity (40%; n=2), and superficial (20%; n=1), resul-ting in readmission in 80% of cases and a corresponding average hospitalization time of 11 days (SD=4.2). Conclusion: The significant rate of SSI in clean surgeries points to the need to intensify good surgical practices. Outpatient surveillance is emphasized as a strategy for building realistic indicators and providing support for prevention efforts. (AU)

Objetivo: Caracterizar los casos de Infecciones del Sitio Quirúrgico (ISQ) en pacientes sometidos a artroplastia de cadera y rodilla. Método: Investigación transversal, retrospectiva y cuantitativa realizada en un hospital público, docente y de alta complejidad en la región sur de Brasil. La reco-lección de datos se realizó entre 2020 y 2022 en registros contenidos en 91 historias clínicas y formularios posteriores al alta hospitalaria en un período de hasta 90 días después de la cirugía destinada al implante de la prótesis. Los datos fueron analizaron mediante estadística descriptiva y tasa de incidencia de ISQ. Resultados: Se analizaron 49 (53,8%) registros de artroplastia de rodilla y 42 (46,2%) de cadera. Cinco casos evolucionaron con infección, todos detectados en el seguimiento ambulatorio después de la artroplastia de rodilla, lo que resultó en una tasa de incidencia de ISQ en artroplastias del 5,5% (n=5). Las infecciones se caracterizaron como incisionales profundas (40%; n=2), de órgano o cavidad (40%; n=2) y superficiales (20%; n=1); resultando en reingreso en el 80% de los casos y el correspondiente tiempo promedio de hospitalización de 11 días (SD=4,2). Conclusión: La tasa significativa de ISQ en cirugías limpias apunta a la necesidad de intensificar las buenas prácticas quirúrgicas. Se reitera la vigilancia ambulatoria como estrategia para la construcción realista de indicadores y apoyo a la prevención. (AU)

Objetivo: Caracterizar os casos de Infecções de Sítio Cirúrgico (ISC) em pacientes submetidos a artroplastias de quadril e joelho. Método:Pesquisa transversal, retrospectiva e quantitativa realizada em um hospital público, de ensino e de alta complexidade da região sul do Brasil. A coleta de dados ocorreu entre 2020 e 2022 em registros contidos em 91 prontuários e fichas pós alta hospitalar no período de até 90 dias após a cirurgia destinada ao implante da prótese. Os dados foram analisados por estatística descritiva e taxa de incidência de ISC. Resultados: Foram analisados 49 (53,8%) regis-tros de artroplastia de joelho e 42 (46,2%) de quadril. Cinco casos evoluíram com infecção, todos detectados no retorno ambulatorial pós artroplastia de joelho, resultando em taxa de incidência de ISC em artroplastias de 5,5% (n=5). As infecções foram caracterizadas como incisional profunda (40%; n=2), de órgão ou cavidade (40%; n=2) e superficial (20%; n=1); decorrendo em reinternação em 80% dos casos e correspondente tempo médio de hospitaliza-ção de 11 dias (DP=4,2). Conclusão: O expressivo índice de ISC em cirurgias limpas direciona para a necessidade de intensificar boas práticas cirúrgicas. Reitera-se a vigilância ambulatorial como estratégia para a construção realística de indicadores e subsídio para a prevenção. (AU)

Surgical hand scrubbing in cardiac surgery teams: a microbiological analysis / Desinfección quirúrgica de las manos en los equipos de cirugía cardíaca: un análisis microbiológico / Degermação cirúrgica das mãos da equipe de cirurgia cardíaca: uma análise microbiológica

Objective: To describe the microbiota of the hands of the cardiac surgery team after surgical hand scrubbing and glove removal at the end of the surgical procedure, and to compare this with adherence to the recommended surgical scrubbing time. Method: An observational study was car-ried out at two points: after the surgical scrubbing of the cardiac surgery team's hands and after glove removal at the end of the surgical procedure. The variables analyzed included professional identification and aspects of surgical hand scrubbing. Data were collected using an observation script based on the literature. Results: Twenty professionals were observed, resulting in 40 samples. At both collection times, microorganisms from the skin's resi-dent microbiota were identified, including coagulase-negative Staphylococcus, methicillin-sensitive Staphylococcus aureus, and Bacillus sp. in 35% (7) of the surgical team. Microorganisms potentially related to surgical site infections, such as Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis were iso-lated in 25% (5) of the population studied. The risk of pathogenic microorganisms being present when surgical hand scrubbing was not carried out in the recommended time was 14.2%. Conclusion: Strategies for ensuring adherence to proper hand scrubbing technique and periodic training should be implemented to mitigate the occurrence of surgical site infections and enhance patient safety. (AU)

Objetivo: Descrever a microbiota das mãos da equipe de cirurgia cardíaca após a degermação cirúrgica das mãos e a retirada das luvas ao tér-mino do procedimento cirúrgico, e comparar com a adesão ao tempo correto de degermação cirúrgica. Método: Estudo observacional realizado em dois momentos: após degermação cirúrgica das mãos da equipe de cirurgia cardíaca e após a retirada das luvas ao término do procedimento cirúrgico. As variáveis analisadas foram de identificação dos profissionais e aspectos da degermação cirurgica das mãos. O instrumento de coleta de dados contou com um roteiro de observação, com base na literatura. Resultados: Vinte profissionais foram observados, resultando em 40 amostras. Nos dois momen-tos de coleta, foram identificados microrganismos da microbiota residente da pele, como Staphylococcus coagulase negativa, Staphylococcus aureus sensível à meticilina, Bacillus sp em 35% (7) da equipe cirúrgica. Houve isolamento de microrganismos potencialmente relacionados à infecção de sítio cirúrgico, Escherichia coli, Klebsiella pneumoniae e Proteus mirabilis em 25% (5) da população estudada. O risco da presença de microrganismo patogênico quando a degermação cirurgica das mãos não é realizada no tempo recomendado foi de 14,2%. Conclusão: estratégias para adesão à técnica correta e ao treina-mento periódico de degermação das mãos devem ser implementadas para mitigar a ocorrência de infecção de sítio cirúrgico e segurança do paciente. (AU)

Objectivo: Describir la microbiota de las manos del equipo de cirugía cardíaca tras el desgerminado quirúrgico de las manos y la retirada de los guantes al final del procedimiento quirúrgico, y compararla con el cumplimiento del tiempo recomendado de desgerminado quirúrgico. Método: Estudio observacional realizado en dos momentos: tras el desgerminado quirúrgico de las manos del equipo de cirugía cardíaca y tras la retirada de los guantes al final del procedimiento quirúrgico. Las variables analizadas fueron la identificación profesional y los aspectos del desgerminado quirúrgico de las manos. El instrumento de recolección de datos incluyó un guion de observación basado en la literatura. Resultados: Se observó a 20 profesionales, resultando en 40 muestras. En ambos momentos de recolección, se identificaron microorganismos de la microbiota residente de la piel, como Staphylococcus coagu-lasa-negativo, Staphylococcus aureus sensible a meticilina y Bacillus sp en el 35% (7) del equipo quirúrgico. Los microorganismos potencialmente relaciona-dos con la infección del sitio quirúrgico, como Escherichia coli, Klebsiella pneumoniae y Proteus mirabilis se aislaron en el 25% (5) de la población estudiada. El riesgo de presencia de microorganismos patógenos cuando la desgerminación quirúrgica de las manos no se realiza en el tiempo recomendado fue del 14,2%. Conclusión: Se deben implementar estrategias de adherencia a la técnica correcta y entrenamientos periódicos en el desgerminado de manos para mitigar la ocurrencia de infección del sitio quirúrgico y promover la seguridad del paciente. (AU)

Estimation of antimicrobial costs in cases of surgical site infection / Estimación de los costes antimicrobianos en casos de infección del sitio quirúrgico / Estimativa dos custos com antimicrobianos em casos de infecção de sítio cirúrgico

Objective: To estimate the costs of antimicrobials in patients with surgical site infections (SSI). Method: This is a descriptive, cross-sectional study with retrospective documentary analysis conducted at a tertiary public hospital with seven surgical rooms, averaging 750 surgeries per month.The micro-costing method used was the average direct cost of antibiotics, excluding intraoperative prophylactic antibiotics. Hospital infection investi-gation records were analyzed, and the study included records of patients diagnosed with confirmed surgical site infections (n=79) in 2021. Clinical data and direct costs of antimicrobials were examined. Results: The infection rate in this study was 6.76%. The specialties with the highest representation were digestive system and urological surgeries. Vancomycin was the most used antimicrobial, resulting in a total expenditure of R$ 7,345.68. Tigecycline incurred the highest total cost, amounting to R$ 79,655.52. Antimicrobials used to treat the 79 confirmed cases of SSIs totaled R$ 211,790.21 in costs. Conclusion: The average cost of antimicrobials per patient with SSI, considering total hospitalization days, was R$ 2,680.88, a significant component of total treatment costs. It is recommended to include cost analysis in the planning of hospital infection protocols. (AU)

Objetivo: Estimar los costos de los antimicrobianos en pacientes con infecciones del sitio quirúrgico (ISQ). Método: Este es un estudio descrip-tivo, transversal con análisis documental retrospectivo realizado en un hospital público terciario con siete salas quirúrgicas, con un promedio de 750 ciru-gías por mes. Se utilizó el método de microcosteo, calculando el costo directo promedio de los antibióticos, excluyendo los utilizados como profilaxis intraoperatoria. Se analizaron registros de investigación de infecciones hospitalarias, incluyendo pacientes diagnosticados con ISQ confirmadas (n=79) en 2021. Se examinaron datos clínicos y costos directos de los antimicrobianos. Resultados: La tasa de infección en este estudio fue del 6.76%. Las espe-cialidades con mayor representación fueron cirugías del sistema digestivo y urológicas. El antimicrobiano más utilizado fue la vancomicina, con un gasto total de R$ 7,345.68. Tigeciclina tuvo el costo total más alto, alcanzando R$ 79,655.52. Los antimicrobianos utilizados para tratar los 79 casos confirma-dos de ISQ sumaron R$ 211,790.21 en costos. Conclusión: El costo promedio de los antimicrobianos por paciente con ISQ, considerando los días totales de hospitalización, fue de R$ 2,680.88, un componente significativo de los costos totales de tratamiento. Se recomienda incluir análisis de costos en la planificación de protocolos de infección hospitalaria. (AU)

Objetivo: Estimar os custos com antimicrobianos em pacientes com infecções de sítio cirúrgico. Método: Trata-se de um estudo descritivo, trans-versal, com análise documental retrospectiva, realizado em um hospital público terciário, com sete salas cirúrgicas, onde se realizam em média 750 cirur-gias mensais. O método de microcusteio utilizado foi o custo direto médio dos antibióticos, não sendo incluído antibiótico profilático no intraoperatório. Analisaram-se as fichas de investigação de infecção hospitalar e foram incluídas no estudo as fichas de pacientes que tiveram o diagnóstico de infecção de sítio cirúrgico confirmado (n=79) em 2021. Foram verificados os dados clínicos e apenas os custos diretos com os antimicrobianos. Resultados: A taxa dessas infecções neste estudo foi de 6,76%. As especialidades com maior representatividade foram cirurgias do aparelho digestivo e urológicas. O antimi-crobiano mais utilizado foi a Vancomicina, resultando no gasto total de R$ 7.345,68. O medicamento que gerou maior custo total foi a Tigeciclina, que representou R$ 79.655,52. Os antimicrobianos utilizados para tratar dos 79 casos confirmados de ISCs totalizaram o custo de R$ 211.790,21. Conclusão: A média de custo com antimicrobiano por paciente com ISC, no total de dias internados, foi de R$ 2.680,88, valor considerado representativo no custo total do tratamento. Recomenda-se a inclusão de análise de custos no planejamento de protocolos de infecção hospitalar. (AU)

Use of Antibiotics following Snakebite in the Era of Antimicrobial Stewardship.

Even though there are guidelines for the management of snakebite envenoming (SBE), the use of antibiotics in this pathology remains controversial. The aim of this study is to provide a narrative review of the literature and recommendations based on the best available evidence regarding antibiotic use in SBE. We performed a narrative review of relevant literature regarding SBE and antibiotic use as prophylaxis or treatment. A total of 26 articles were included. There is wide use of antibiotics in SBE; nevertheless, infection was not necessarily documented. The antibiotics used varied according to the study, from beta lactams to lincosamide and nitroimidazoles, and from monotherapy to combined antimicrobials. The most common recommendations were to manage skin and soft tissue infections and avoid infectious complications, but these suggestions are not necessarily based on bacteriological findings. Prophylactic use of antibiotics in SBE is discouraged in most studies. Antibiotic prescription in SBE should be based on the susceptibility of microorganisms isolated from the affected tissue or identified in snakes' oral cavities. Antibiotics should be reserved only for patients with a demonstrated infection, or those at a high risk of developing an infection, i.e., presenting severe local envenoming, local signs of infection, or those with incorrect manipulation of wounds. Prospective studies are needed to correlate microbiological findings at the wound site and the response to antibiotic use.

Preoperative antibiotic prophylaxis and the incidence of surgical site infections in elective clean soft tissue surgery of the hand and upper limb: a systematic review and meta-analysis.

BACKGROUND: Surgical site infections (SSI) are the most frequent early complications of hand surgeries. However, the indications still remain uncertain for antibiotic prophylaxis in elective clean soft tissue surgeries of the hand and upper limb. Therefore, a systematic review of the literature and a meta-analysis was conducted to investigate the impact of antibiotic prophylaxis on the prevention of SSI in these types of surgeries. METHODS: An electronic search was performed in the following databases: MEDLINE/Pubmed, PMC/Pubmed, Web of Science/Clarivate Analytics, Embase/Elsevier, Scopus/Elsevier, BVS/Lilacs, and the Cochrane Library, with no restrictions regarding publication language or date. The primary outcome of interest was the occurrence of SSI following elective clean soft tissue surgeries of the hand and upper limb according to the administration of preoperative antibiotic prophylaxis and no antibiotic prophylaxis. Surgeries involving simultaneous bone procedures or orthopedic implants were excluded. Study selection and data extraction were conducted independently by two reviewers. RoB 2.0 and ROBINS-I are Cochrane risk-of-bias tool for randomized trials and non-randomized studies of interventions. The magnitude of the intervention effect was estimated using the relative risk (RR). The meta-analysis was performed with the Review Manager and R software tools, using the Mantel-Haenszel random-effects model and a 95% confidence interval (CI). Results with p ≤ 0.05 were considered statistically significant. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS: The initial search yielded 1175 titles, from which 12 articles met the inclusion criteria for the systematic review, and 10 were included in the subsequent meta-analysis. The majority of these studies were nonrandomized intervention trials, exhibiting a moderate risk of bias. According to our review, preoperative antibiotic prophylaxis did not have a statistically significant impact on the incidence of SSI (RR = 1.13, 95% CI 0.91-1.40, p = 0.28). The overall quality of evidence for this outcome was rated as low. Moderate statistical heterogeneity was observed (I2 = 44%), and the prespecified sensitivity analysis highlighted the consistency of the results. CONCLUSIONS: While these results were consistent with the findings from individual studies included in this review, it is important to note that, given the threshold of p ≤ 0.05 for statistical significance, no definitive conclusions can be drawn from the quantitative analysis of the data obtained. LEVEL OF EVIDENCE: Level 2. TRIAL REGISTRATION: CRD42023417786.

Infecção de sítio cirúrgico e o telemonitoramento pelo enfermeiro no pós-operatório: uma revisão de escopo / Surgical site infection and nurse telemonitoring in the postoperative period: a scoping review

OBJETIVO: mapear evidências científicas sobre a prevenção e o manejo precoce de infecção de sítio cirúrgico por telemonitoramento em pacientes cirúrgicos após alta hospitalar. MÉTODO: revisão de escopo desenvolvida conforme proposto pelo Instituto Joanna Briggs (JBI). Foi realizada a pesquisa nas bases de dados PubMed, Literatura Latino-americana e do Caribe em Ciências da Saúde (LILACS), Cochrane Collaboration, Scopus, CINAHL, MEDLINE, Web of Science e Embase. Os estudos foram adicionados ao gerenciador Endnote Basic e Rayyan por três pesquisadores independentes. RESULTADOS: foram identificados 1.386 estudos e incluídos 31, os quais apresentaram relevância em relação a sinais de alerta precoce e tardio da infecção de sítio cirúrgico, complicações, fatores de risco, prevenção e utilização do telemonitoramento. CONCLUSÃO: observou-se que, embora os estudos abordem a infecção de sítio cirúrgico e o telemonitoramento, faz-se necessário a formulação dos instrumentos utilizados nas consultas telefônicas, contemplando com maior especificidade os critérios indispensáveis a serem abordados.

OBJECTIVE: This study aims to map scientific evidence regarding the prevention and early management of surgical site infection through telemonitoring in surgical patients after discharge from the hospital. METHOD: A scoping review was conducted following the guidelines proposed by the Joanna Briggs Institute (JBI). The search was performed across PubMed, Latin American and Caribbean Health Sciences Literature (LILACS), Cochrane Collaboration, Scopus, CINAHL, MEDLINE, Web of Science, and Embase databases. Three independent researchers collect the identified studies using Endnote Basic and Rayyan. RESULTS: A total of 1,386 studies were identified, of which 31 were included in the analysis. These selected studies demonstrated significance regarding early and late warning signs of surgical site infection, complications, risk factors, prevention strategies, and the utilization of telemonitoring. CONCLUSION: While the studies address surgical site infection and telemonitoring, it is imperative to formulate the instruments employed in telephonic consultations, incorporating a more specific consideration of essential criteria to be addressed.

Microbiological profile and antibiotic sensitivity of maxillofacial infections in an emergency hospital

Aim: To investigate the bacteriological profile of oral and maxillofacial infections and the pattern of sensitivity to a specific group of antibiotics in a reference emergency hospital in Brazil. Methods: This is a prospective cohort institutional study that studied patients affected by oral and/ or maxillofacial infections in a Brazilian emergency hospital, over a 12-month period, of different etiologies, through data collection, culture and antibiogram tests, and monitoring of the process of resolution of the infectious condition. The variables were analyzed using the chi-square and Mann-Whitney tests, using a significance level of 5%. Results: The sample consisted of 61 patients, 62.3% male. The mean age of participants was 34.3 years. Odontogenic infection was the most frequent etiology and the submandibular space was the most affected. The bacterial species Streptococcus viridans was isolated in 21.6% of cases. Levofloxacin, vancomycin and penicillin were the antibiotics with the highest frequency of bacterial sensitivity, while clindamycin and erythromycin showed the highest percentages of resistance. Conclusions: The results suggest that, among the most used antibiotics for the treatment of these infections, penicillin remains an excellent option of choice for empirical therapy

Digital tools for post-discharge surveillance of surgical site infection.

AIMS: Conduct a scoping review on the development and use of digital tools for post-discharge surgical site infection surveillance. DESIGN: Scoping review. DATA SOURCES: Science Direct, PubMed, Embase, Literatura Latino-Americana e do Caribe em Ciências da Saúde and Cumulative Index to Nursing and Allied Health Literature were searched from 2013 to May 2022. Six intellectual property registries were reviewed from 2013 to 2022. REVIEW METHODS: The review followed the Joanna Briggs Institute model, and included intellectual property records (applications, prototypes and software) and scientific articles published in any language on the development and/or testing of digital tools for post-discharge surveillance of surgical site infection among surgical patients aged 18 and over. RESULTS: One intellectual property record and 13 scientific articles were identified, covering 10 digital tools. The intellectual property record was developed and registered by a China educational institution in 2018. The majority of manuscripts were prospective cohort studies and randomized clinical trials, published between 2016 and 2022, and more than half were conducted in the United States. The population included adult patients undergoing cardiac, thoracic, vascular, abdominal, arthroplasty and caesarean surgery. The main functionalities of the digital tools were the previously prepared questionnaire, the attachment of a wound image, the integrated Web system and the evaluation of data by the health team, with post-discharge surgical site infection surveillance time between 14 and 30 days after surgery. CONCLUSION: Digital tools show promise for the surveillance of surgical site infection, collaborating with the early detection of wound infection. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Mobile technology was favourable for detecting surgical site infections, reducing unnecessary visits to the health service, and increasing patient satisfaction. IMPACT: Technological advances in the health area open new perspectives for post-discharge surveillance of surgical site infection. WHAT IS ALREADY KNOWN?: There is underreporting of surgical site infections due to difficulties related to traditional methods of post-discharge surveillance. The use of digital tools within surgical site infection surveillance is increasing. Benefits of using digital tools within surgical site infection surveillance have been reported. WHAT HAS THIS STUDY ADDED TO OUR KNOWLEDGE?: This scoping review is one of the first to analyse the development and use of digital tools for post-discharge surveillance of surgical site infection in different countries. The main functionalities of digital tools are: structured questionnaires; attachment of wound images; integrated web systems; and evaluation of data by professionals. The use of mobile technology is favourable for detecting surgical site infections with a reduction in costs from face-to-face consultations and increased patient satisfaction. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Healthcare providers can successfully use digital tools for surgical site infection post-discharge surveillance. Remote monitoring can reduce unnecessary patient visits to healthcare facilities. Policy makers can study how to implement digital platforms for remote patient monitoring. REPORTING METHOD: PRISMA statement for Scoping Reviews (PRISMA-ScR). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution. TRIAL AND PROTOCOL REGISTRATION: The study protocol was registered in the OSF (https://doi.org/10.17605/OSF.IO/BA8D6).

Development and validity of serious game for teaching-learning in surgical site infection prevention / Desarrollo y validación de un juego serio para la enseñanza-aprendizaje sobre la prevención de infecciones del sitio quirúrgico / Desenvolvimento e validação de serious game para ensino-aprendizagem de prevenção de infecção de sítio cirúrgico

ABSTRACT Objective: To develop and validate serious game for teaching-learning regarding surgical site infection prevention. Method: This is a methodological study conducted in stages: game content development and validity based on virtual simulation (preparation, participation and debriefing) and challenges; game development, following the concept, pre-production, prototype, production and post-production stages; and usability validity, using an instrument called Heuristic Evaluation for Digital Educational Games. To assess the game content and usability, 12 nurses and 08 experts in digital games were involved. Results: The serious game script contained three sequential pre-, intra- and post-operative periods, focusing on nursing interventions aimed at preventing surgical site infections. A Content Validity Coefficient above 0.80 was obtained for game content. Regarding gameplay assessment using the assessed heuristics, all statements present in game script were considered adequate, and adjustments were implemented regarding feedback, access to the theoretical framework on preventing surgical site infections, the inclusion of images in the study material and directing players to the debriefing session. Conclusion: The serious game developed was considered valid and a potential pedagogical tool in nursing for learning how to prevent surgical site infections.

RESUMEN Objetivo: desarrollar y validar el serious game para la enseñanza-aprendizaje sobre la prevención de infecciones del sitio quirúrgico. Método: estudio metodológico realizado por etapas: desarrollo y validación del contenido del juego, basado en simulación virtual (preparación, participación y debriefing) y desafíos; desarrollo de juegos, siguiendo las etapas de concepto, preproducción, prototipo, producción y postproducción; y validación de usabilidad mediante el instrumento Heuristic Evaluation for Digital Educational Games. Para evaluar el contenido y usabilidad del juego participaron 12 enfermeros y 08 expertos en juegos digitales. Resultados: el guión del serious game contenía tres períodos pre, intra y postoperatorios secuenciales, centrándose en intervenciones de enfermería destinadas a prevenir infecciones del sitio quirúrgico. Se obtuvo un Coeficiente de Validez de Contenido superior a 0,80 para el contenido del juego. En cuanto a la evaluación de la jugabilidad mediante las heurísticas evaluadas, todas las afirmaciones presentes en el guión del juego fueron consideradas adecuadas y se implementaron ajustes en cuanto a retroalimentación, acceso al marco teórico sobre prevención de infecciones del sitio quirúrgico, inclusión de imágenes en el material de estudio y orientación del jugador en la sesión de debriefing. Conclusión: el serious game desarrollado se consideró válido y potencial herramienta pedagógica en el área de enfermería para aprender a prevenir infecciones del sitio quirúrgico.

RESUMO Objetivo: desenvolver e validar serious game para o ensino-aprendizagem referente à prevenção de infecção de sítio cirúrgico. Método: estudo metodológico conduzido por etapas: desenvolvimento e validação do conteúdo do jogo, baseados na simulação virtual (preparação, participação e debriefing) e desafios; desenvolvimento do jogo, seguindo as etapas de conceito, pré-produção, protótipo, produção e pós-produção; e, validação da usabilidade, por meio do instrumento Heuristic Evaluation for Digital Educational Games. Para avaliação do conteúdo e usabilidade do jogo, contou-se com 12 enfermeiros e 08 especialistas em jogos digitais. Resultados: o script do serious game conteve três períodos sequenciais pré, intra e pós-operatório, com enfoque em intervenções de enfermagem voltadas para prevenção de infecção de sítio cirúrgico. Obteve-se um Coeficiente de Validade de Conteúdo acima de 0,80 para o conteúdo do jogo. Referente à avaliação da jogabilidade pelas heurísticas avaliadas, todas as afirmativas presentes no script do jogo foram consideradas adequadas e houve a implementação de ajustes no que se refere ao feedback, ao acesso ao referencial teórico sobre prevenção de infecção de sítio cirúrgico, à inclusão de imagens no material de estudo e ao direcionamento do jogador à sessão de debriefing. Conclusão: o serious game desenvolvido foi considerado válido e potencial ferramenta pedagógica na área de enfermagem para aprendizagem da prevenção de infecção de sítio cirúrgico.

Low-cost wound protector for laparoscopic surgeries / Protetor de ferida operatória de baixo custo para cirurgias laparoscópicas

ABSTRACT The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.

RESUMO O papel dos protetores de ferida operatória em cirurgias laparoscópicas é bastante controverso na literatura. Alguns estudos demonstram seu benefício na redução da taxa de infeções de sítio cirúrgico, porém esses resultados não são reprodutíveis em todos os procedimentos. Além da proteção da ferida operatória, esses dispositivos podem ser utilizados nos sítios de extração de peças cirúrgicas em procedimentos laparoscópicos. Há vários dispositivos comercialmente disponíveis para esse fim, entretanto são pouco disponíveis nos serviços com menos recursos. Um dos motivos dessa limitação é o custo do dispositivo. Nesta nota, buscamos oferecer uma opção barata que utiliza materiais amplamente disponíveis no centro cirúrgico e cuja confecção é simples.

Risk factors for the development of surgical site infection in bariatric surgery: an integrative review of literature / Fatores de risco para o desenvolvimento de infecção de sítio cirúrgico em cirurgia bariátrica: revisão integrativa / Factores de riesgo para el desarrollo de infección del sitio quirúrgico en cirugía bariátrica: una revisión integradora

Abstract Objective: to evaluate evidence on risk factors for the development of surgical site infection in bariatric surgery. Method: integrative review. The search for primary studies was performed in four databases. The sample consisted of 11 surveys. The methodological quality of the included studies was assessed using tools proposed by the Joanna Briggs Institute. Data analysis and synthesis were performed in a descriptive manner. Results: surgical site infection rates ranged from 0.4% to 7.6%, considering the results of primary studies, in which patients underwent laparoscopic surgery. In surveys of participants undergoing surgical procedures with different approaches (open, laparoscopic or robotic), infection rates ranged from 0.9% to 12%. Regarding the risk factors for the development of this type of infection, antibiotic prophylaxis, female sex, high Body Mass Index and perioperative hyperglycemia are highlighted. Conclusion: conducting the integrative review generated a body of evidence that reinforces the importance of implementing effective measures for the prevention and control of surgical site infection, by health professionals, after bariatric surgery, promoting improved care and patient safety in the perioperative period.

Resumo Objetivo: avaliar as evidências sobre os fatores de risco para o desenvolvimento de infecção de sítio cirúrgico em cirurgia bariátrica. Método: revisão integrativa. A busca dos estudos primários foi realizada em quatro bases de dados. A amostra foi composta por 11 pesquisas. A qualidade metodológica dos estudos incluídos foi avaliada por meio de ferramentas propostas pelo Joanna Briggs Institute. A análise e a síntese dos dados foram realizadas de maneira descritiva. Resultados: as taxas de infecção de sítio cirúrgico variaram de 0,4% até 7,6%, considerando os resultados dos estudos primários, cujos pacientes foram submetidos à cirurgia por via laparoscópica. Nas pesquisas com os participantes submetidos aos procedimentos cirúrgicos com diferentes abordagens (aberta, via laparoscópica ou robótica), as taxas de infecção variaram de 0,9% até 12%. Com relação aos fatores de risco para o desenvolvimento deste tipo de infecção, ressaltam-se antibioticoprofilaxia, sexo feminino, Índice de Massa Corporal elevado e hiperglicemia perioperatória. Conclusão: a condução da revisão gerou corpo de evidências que reforça a importância na implementação de medidas efetivas para prevenção e controle de infecção de sítio cirúrgico pelos profissionais de saúde após cirurgia bariátrica, promovendo a melhoria da assistência e da segurança do paciente no perioperatório.

Resumen Objetivo: evaluar las evidencias sobre los factores de riesgo para el desarrollo de infección de sitio quirúrgico en cirugía bariátrica. Método: revisión integradora. La búsqueda de estudios primarios se realizó en cuatro bases de datos. La muestra estuvo compuesta por 11 investigaciones. La calidad metodológica de los estudios incluidos se evaluó mediante herramientas propuestas por el Joanna Briggs Institute. El análisis y la síntesis de los datos se realizaron de manera descriptiva. Resultados: las tasas de infección del sitio quirúrgico oscilaron entre 0,4% y 7,6%, considerando los resultados de los estudios primarios, en los que los pacientes fueron sometidos a cirugía mediante laparoscopia. En investigaciones con participantes que se sometieron a procedimientos quirúrgicos con diferentes enfoques (abierto, laparoscópico o robótico), las tasas de infección oscilaron entre el 0,9 % y el 12 %. En cuanto a los factores de riesgo para el desarrollo de este tipo de infección, se destacan la profilaxis antibiótica, el sexo femenino, el Índice de Masa Corporal elevado y la hiperglucemia perioperatoria. Conclusión: la realización de la revisión generó un cuerpo de evidencia que refuerza la importancia de implementar medidas efectivas para la prevención y el control de la infección de sitio quirúrgico, por parte de los profesionales de la salud, después de la cirugía bariátrica, promoviendo la mejora de la atención y la seguridad del paciente en el período perioperatorio.

Fatores de Risco para Infecção da Ferida Operatória em Pacientes Submetidos à Cirurgia Cardíaca Pediátrica / Risk Factors for Surgical Site Infection in Patients Undergoing Pediatric Cardiac Surgery

Resumo Fundamento A infecção do sítio cirúrgico (ISC) é uma importante complicação no pós-operatório de cirurgia cardíaca pediátrica associada ao aumento da morbimortalidade. Objetivos Identificar fatores de risco para a ISC após cirurgias cardíacas para correção de malformações congênitas. Métodos Este estudo caso-controle incluiu 189 pacientes com um ano completo e 19 anos e 11 meses, submetidos à cirurgia cardíaca em hospital universitário terciário de cardiologia de janeiro de 2011 a dezembro de 2018. Foi realizado registro e análise de dados pré, intra e pós-operatórios. Para cada caso foram selecionados dois controles, conforme o diagnóstico da cardiopatia e cirurgia realizada em um intervalo de até 30 dias para minimizar diferenças pré e/ou intraoperatórias. Para a análise dos fatores de risco foi utilizado o modelo de regressão binária logística. Significância estatística definida como valor de p<0,05. Resultados O estudo incluiu 66 casos e 123 controles. A incidência de ISC variou de 2% a 3,8%. Fatores de risco identificados: faixa etária de lactentes (OR 3,19, IC 95% 1,26 - 8,66, p=0,014), síndrome genética (OR 6,20, IC 95% 1,70 - 21,65, p=0,004), RACHS-1 categorias 3 e 4 (OR 8,40, IC 95% 3,30 - 21,34, p<0,001), o valor da proteína C reativa (PCR) de 48 horas pós-operatórias foi demonstrado como fator protetor para esta infecção (OR 0,85, IC 95% 0,73 - 0,98, p=0,023). Conclusão Os fatores de risco identificados não são variáveis modificáveis. Vigilância e medidas preventivas contínuas são fundamentais para reduzir a infecção. O papel do PCR elevado no pós-operatório foi fator protetor e precisa ser melhor estudado.

Abstract Background Surgical site infection is an important complication after pediatric cardiac surgery, associated with increased morbidity and mortality. Objectives We sought to identify risk factors for surgical site infection after pediatric cardiac surgeries. Methods A case-control study included patients aged between 1 year and 19 years and 11 months of age, submitted to cardiac surgery performed at a tertiary cardiac center from January 1 st , 2011, through December 31, 2018. Charts were reviewed for pre-, intra, and postoperative variables. We identified two randomly selected control patients with the same pathophysiological diagnosis and underwent surgery within thirty days of each index case. Univariate and multivariate logistic regression analyses were performed to identify risk factors. Statistical significance was defined as p<0.05. Results Sixty-six cases and 123 controls were included. Surgical site infection incidence ranged from 2% to 3.8%. The following risk factors were identified: Infant age (OR 3.19, 95% CI 1.26 to 8.66, p=0.014), presence of genetic syndrome (OR 6.20, CI 95% 1.70 to 21.65, p=0.004), categories 3 and 4 of RACHS-1 (OR 8.40, CI 95% 3.30 to 21.34, p<0.001), 48 h C-reactive protein level range was detected as a protective factor for this infection (OR 0.85, 95% CI 0.73 to 0.98, p=0.023). Conclusions The risk factors defined in this study could not be modified. Therefore, additional surveillance and new preventive strategies need to be implemented to reduce the incidence of surgical site infection. The increased CRP in the postoperative period was a protective factor that needs further understanding.

Driveline dressings used in heartmate patients and local complications: A retrospective cohort.

BACKGROUND: Patients with long-term ventricular assist devices (VAD) are predisposed to infection, bleeding, and pressure injuries at the insertion of the driveline. There is no consensus on a driveline dressing protocol. Chlorhexidine is often used to clean the driveline exit site and has been associated with lower rates of infection. For driveline coverage, bacteriostatic agents and transparent film have shown good results, but are costly. The same issue was associated with anchorage devices. OBJECTIVES: The purpose of this study was to evaluate the types of dressings used in the driveline of patients using HeartMate (HM) and to describe the incidence density of local complications (infection, bleeding, and pressure injury) within 30 days postoperatively. METHODS: A retrospective cohort study was conducted and included 22 patients admitted to the Intensive Care Unit after implantation of HM II and III in a Brazilian private hospital. RESULTS: Several types of dressings were used in the drivelines. There were 22 different types of dressings. Dressing type 6 (Chlorhexidine, Excilon, Gauze and IV3000) were the most used (45.4%). Subjects using the Flexi-Trak anchoring device had a higher rate of local bleeding (50.0%) and those who used the Hollister device had more infection (61.1%) and pressure injury associated with a medical device (11.1%), compared to others. Infection was the primary complication (45.4%), followed by local bleeding (27.7%). CONCLUSION: Despite the high variability of products used in the driveline of patients using HeartMate, the dressing made with chlorhexidine, silver-impregnated absorbent foam and transparent film, and the use of anchoring devices was the most frequently used. Infection was the most common complication.

Deep Sternal Wound Infection After Beating Heart Coronary Artery Bypass Surgery with Routine Use of Skeletonized Bilateral Internal Thoracic Artery.

INTRODUCTION: Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). We observed the role of routine use of BITA and off-pump coronary artery bypass grafting (OPCABG) in the incidence of DSWI and associated risk factors. METHODS: Between January 2010 and December 2020, 1,207 patients were treated with isolated coronary artery bypass grafting. In all cases, OPCABG was attempted, and BITA was used whenever there was a need for a second arterial graft for the left coronary artery. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple linear regression analysis was employed to model the risk of DSWI. RESULTS: The incidence of DSWI was 0.58%. Mortality rate was higher in DSWI group than in no-DSWI group (28.57% vs. 1.25%; P<0.001). No significant difference in DSWI incidence was observed when BITA (70.6%) or single internal thoracic artery (29.4%) were used (P=0.680). The prevalence of diabetes (100% vs. 40.7%; P=0.001), hyperlipidemia (100% vs. 85.9%; P=0.045), and obesity (71.4% vs. 26.8%; P-0.017) was significantly elevated in DSWI group, when compared with no-DSWI group. Diabetes (P=0.0001), unstable angina (P=0.0064), previous myocardial infarction > 30 days (P=0.0009), left ventricular ejection fraction < 50% (P=0.0074), and emergency surgery (P=0.0002) were independent risk factors. CONCLUSION: The results of routine use of skeletonized BITA after OPCABG were satisfactory regarding DSWI incidence and operative mortality in a single-center experience.

The Impact of the COVID-19 Pandemic in Postoperative Neurosurgical Infections at a Reference Center in México.

The COVID-19 pandemic has had a major global impact on the treatment of hospitalized surgical patients. Our study retrospectively evaluates the impact of the COVID-19 pandemic at a neurosurgical reference center in Mexico City. We compared the number of neurosurgeries, the rate and type of postoperative infections, the causative microorganisms and in-hospital mortality rates in a 4-year period, from the pre-pandemic year 2019 until 2022. A total of 4150 neurosurgical procedures were registered. In 2020 the total number of surgeries was reduced by 36% compared to 2019 OR = 0.689 (95% CI 0.566-0.834) p ≤ 0.001, transnasal/trans sphenoidal pituitary resections decreased by 53%, and spinal surgeries by 52%. The rate of neurosurgical infections increased from 3.5% in 2019 to 5.6% in 2020 (p = 0.002). Regarding the microorganisms that caused infections, gram positive cocci accounted for 43.5% of isolates, Klebsiella spp. and Pseudomonas spp. caused one third of the infections. No significant differences were found for in-hospital mortality nor patterns of resistance to antibiotics. The number of surgeries increased in the last two years, although the infection rate has returned to pre-pandemic levels. We observed a lower impact from subsequent waves of COVID-19 and despite an increase in the number of surgeries, the surgeries have not amounted to the full pre-pandemic levels.