Risk Factors for Surgical Site Infection after Minor Dermatologic Surgery.

BACKGROUND: Surgical site infection (SSI) after dermatologic surgery is associated with poor outcomes including increased recovery time, poor cosmesis, and repeat visits to doctors. Prophylactic antibiotics are prescribed to reduce these adverse outcomes. Identifying risk factors for SSI will facilitate judicious antibiotic prophylaxis. OBJECTIVE: To identify risk factors for SSI after minor dermatologic surgery. METHODS: Individual patient data from four large randomized controlled trials were combined to increase statistical power. A total of 3,819 adult patients requiring minor skin procedures at a single facility were recruited over a 10-year period. The main outcome measure was SSI. MAIN RESULTS: A total of 298 infections occurred, resulting in an overall incidence of 7.8% (95% confidence interval [CI], 5.8-9.6), although the incidence varied across the four studies (P = .042). Significant risk factors identified were age (relative risk [RR], 1.01; 95% CI, 1.001-1.020; P = .008), excisions from the upper limbs (RR, 3.03; 95% CI, 1.76-5.22; P = .007) or lower limbs (RR, 3.99; 95% CI, 1.93-8.23; P = .009), and flap/two-layer procedures (RR, 3.23; 95% CI, 1.79-5.85; P = .008). Histology of the excised lesion was not a significant independent risk factor for infection. CONCLUSIONS: This study demonstrated that patients who were older, underwent complex excisions, or had excisions on an extremity were at higher risk of developing an SSI. An awareness of such risk factors will guide evidence-based and targeted antibiotic prophylaxis.

Risk Factors for Surgical Site Infection in Minor Dermatological Surgery: A Systematic Review.

OBJECTIVE: To identify patient- and procedure-related risk factors for surgical site infection following minor dermatological surgery. DATA SOURCES: The MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Informit, and Scopus databases were searched for relevant literature on patient populations receiving minor surgery, where risk factors for surgical site infection were explicitly stated. STUDY SELECTION: Studies involving major dermatological surgery were excluded. The preliminary search yielded 820 studies after removing duplicates; 210 abstracts were screened, and 42 full texts were assessed for eligibility. A total of 13 articles were included. Studies were appraised using the Newcastle-Ottawa Quality Assessment Scale. DATA EXTRACTION: An electronic data collection tool was constructed to extract information from the eligible studies, and this information was distributed to participating authors. DATA SYNTHESIS: Risk factors identified included age, sex, diabetes mellitus, chronic obstructive pulmonary disease, use of antihypertensive or corticosteroid medications, smoking, surgery on the lower or upper extremities, excision of nonmelanocytic skin cancers, large skin excisions, and complex surgical techniques. No more than two studies agreed on any given risk factor, and there were insufficient studies for meta-analysis. CONCLUSIONS: Re-excision of skin cancer, below-knee excisions, and intraoperative hemorrhagic complications were predictive for infection in more than one study. More high-quality studies are required to accurately identify risk factors so they can be reliably used in clinical guidelines.

Alcoholic versus aqueous chlorhexidine for skin antisepsis: the AVALANCHE trial.

BACKGROUND: Preoperative skin antisepsis is routine practice. We compared alcoholic chlorhexidine with aqueous chlorhexidine for skin antisepsis to prevent surgical site infection after minor skin excisions in general practice. METHODS: We conducted this prospective, multicentre, randomized controlled trial in 4 private general practices in North Queensland, Australia, from October 2015 to August 2016. Consecutive adult patients presenting for minor skin excisions were randomly assigned to undergo preoperative skin antisepsis with 0.5% chlorhexidine in 70% ethanol (intervention) or 0.5% chlorhexidine aqueous solution (control). Our primary outcome was surgical site infection within 30 days of excision. We also measured the incidence of adverse reactions. RESULTS: A total of 916 patients were included in the study: 454 underwent antisepsis with alcoholic chlorhexidine and 462 with aqueous chlorhexidine. Of these, 909 completed follow-up. In the intention-to-treat analysis of cases available at follow-up, there was no significant difference in the incidence of surgical site infection between the alcoholic chlorhexidine arm (5.8%, 95% confidence interval [CI] 3.6% to 7.9%) and the aqueous chlorhexidine arm (6.8%, 95% CI 4.5% to 9.1%). The attributable risk reduction was 0.010 (95% CI -0.021 to 0.042), the relative risk was 0.85 (95% CI 0.51 to 1.41), and the number needed to treat to benefit was 100. Per protocol and sensitivity analyses produced similar results. The incidence of adverse reactions was low, with no difference between groups (p = 0.6). INTERPRETATION: There was no significant difference in efficacy between alcoholic and aqueous chlorhexidine for the prevention of surgical site infection after minor skin excisions in general practice. Trial registration: https://www.anzctr.org.au, no. ACTRN12615001045505.

A Case-Control Analysis of Postoperative Fluid Balance and Mortality After Pediatric Cardiac Surgery.

OBJECTIVES: A positive fluid balance after cardiac surgery may be associated with poor outcomes; however, previous studies looking at this association have been limited by the number of deaths in the study population. Our primary aim was to determine the relationship between postoperative cumulative fluid balance and mortality in cardiac surgical patients. Secondary aims were to study the association between fluid balance and duration of mechanical ventilation, intensive care and hospital length of stay. DESIGN: Case-control study. SETTING: A 30-bed multidisciplinary PICU. PATIENTS: All patients admitted to the PICU following cardiac surgery from 2010 to 2014. INTERVENTIONS: Deaths during PICU admission following cardiac surgery (cases) were matched 1:3 with children who survived to PICU discharge (controls) using the following criteria: age at surgery (within a 20% age range), Risk Adjusted Congenital Heart Surgery (RACHS-1) category, and year of admission. MEASUREMENTS AND MAIN RESULTS: Of 1,996 eligible children, 46 died (2.3%) of whom 45 (98%) were successfully matched. Cumulative fluid balance on days 2 and 7 was not associated with PICU mortality. On multivariable analysis, factors associated with mortality were cardiopulmonary bypass time (per 10-min increase, odds ratio [95% CI], 1.06 [1.00-1.12]; p = 0.03), extracorporeal membrane oxygenation requirement within 3 days (46.6 [9.47-230.11]; p < 0.001), peak serum chloride (mmol/L) in the first 48 hours (1.12 [1.01-1.23]), and time to start peritoneal dialysis after surgery (in comparison to no peritoneal dialysis, odds ratio [95% CI] in those started on early peritoneal dialysis was 1.07 [0.33-3.41]; p = 0.90 and in late peritoneal dialysis 3.65 [1.21-10.99]; p = 0.02). Children with cumulative fluid balance greater than or equal to 5% by day 2 spent longer on mechanical ventilation (median [interquartile range], 211 hr [97-539] vs 93 hr [34-225]; p <0.001), in PICU (11 d [8-26] vs 6 [3-13]; p < 0.001) and in hospital (22 d [13-39] vs 14 d [8-30]; p = 0.001). CONCLUSIONS: Early fluid overload is not associated with mortality. However, it is associated with increased duration of mechanical ventilation and PICU length of stay. Early peritoneal dialysis commencement (compared with late peritoneal dialysis) after surgery was associated with decreased mortality.