Decreasing Trend of Surgical Site Infections among Surgical Patients in a University Hospital in Thailand after an Active Surveillance Program.

Background: Reports from high-quality healthcare systems have shown that active surveillance and management of factors associated with surgical site infection (SSI) decreased the incidence and improved overall outcomes. Methods: This study aimed to appraise the incidence trend of SSIs during the 10-year period between 2007 and 2016 in a university hospital in a middle-income country, focusing on six high-risk and high-volume procedures. The study also examined factors associated with SSIs and their impact on surgical outcomes. Results: A total of 10,139 procedures in 9,661 cases were reviewed. The overall incidence of SSI was 2.98%. The incidence increased substantially with increasing risk score according to the National Nosocomial Infection Surveillance (NNIS) system risk score. The incidence trend decreased over time during the 10-year period studied. The procedures with the highest SSI incidence were craniotomy, colonic surgery, and cholecystectomy, which were also the three procedures that had standardized infection ratios (SIR) higher than 1.0 in all risk score categories. Univariable analysis found that diabetes mellitus was the only risk factor associated with SSI (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.2-2.73). The majority of the positive cultures were gram-negative bacteria (45%) and 49% of all reported organisms were drug resistant. There were two important consequences of the infections: length of hospitalization increased substantially from 13 days to 24 days (p < 0.01) and patients with SSI had more than three times higher mortality rate (7% compared with 1.9%, p < 0.001). Conclusion: With active surveillance, the incidence of SSIs decreased to less than 2.0% over the 10-year study period. More intensive surveillance should implemented for operations with high SIR and cases with diabetes mellitus.

An outbreak of imipenem-resistant Acinetobacter baumannii at Songklanagarind Hospital: the risk factors and patient prognosis.

OBJECTIVE: To investigate for the factors associated with acquisition of imipenem-resistant Acinetobacter baumannii (IRAB) at Songklanagarind Hospital and the subsequent patient mortality outcome. DESIGN: A case-control study was conducted to evaluate the risk factors for IRAB acquisition using imipenem-sensitive A. baumannii (ISAB) as controls. A retrospective cohort study was employed to assess the factors associated with mortality in the hospital. SETTING: An 850-bed university hospital served as a medical school, training hospital, tertiary care, and referral center for the southern part of Thailand. PATIENTS: The patients who acquired A. baumannii during their stay in the hospital. RESULTS: Between July 2003 and September 2005, there were 2,130 isolates of A. baumannii from clinical specimens of 1,237 hospitalized patients. The medical records of 899 admissions to the hospital were available for review. The significant risk factors associated with IRAB acquisition, identified from a case-control study and multiple logistic regression analysis included previous admission to medical-surgical intensive care unit (ICU), respiratory care unit (RCU), previous use of multiple classes of antibiotics, and previous use of imipenem. The cohort study revealed that the mortality rate in the patients with IRAB compared to ISAB were 33.8% and 24.1% respectively, yielding an unadjusted odds ratio of 1.6 (95% CI = 1.2-2.2). However, after controlling for confounding factors by multivariate analysis IRAB did not show the increased mortality. CONCLUSION: The outbreak of IRAB at Songklanagarind Hospital is associated with increasing antibiotic pressure particularly imipenem and the admission to the ICU and RCU. The excess patient mortality rate attributable to IRAB is not significantly different from that attributable to ISAB.

Extra charge and extra length of postoperative stay attributable to surgical site infection in six selected operations.

BACKGROUND: Information concerning the economic impact of surgical site infection (SSI) is very rare in Thailand. As the national health care financial system has been changing, the need for such data is critical. OBJECTIVE: The purpose of this study is to estimate the extra charge and excess postoperative hospitalization attributable to SSI in six surgical operative procedures comprising appendectomy, herniorrhaphy, mastectomy, cholecystectomy, colectomy, and craniotomy. MATERIAL AND METHOD: The study population consisted of patients undergoing major operations admitted to Songklanagarind Hospital from January, 1998 to December, 2003. Data were prospectively collected to identify demographic data, surgical operations, development of SSI, and outcomes of SSI. The study used one-to-one matched-pair strategy to compare case (patient with SSI) and controls (patient without SSI). The matching criteria were same final diagnosis, same operative procedure, and same American Society of Anesthesiologists (ASA) score. Data were calculated for mean difference, median difference, and 95% confidence intervals (95% C.I) of hospital charge and postoperative stay. RESULTS: The study could identify 140 matched-pairs of case and control. When compared to matched controls, cases had higher hospital charge and greater postoperative length of stay. Mean of extra hospital charge attributable to SSI was 43,658 (95% C.I; 30,228-57,088) baht and mean of excess postoperative stay was 21.3 (95% C.I; 16.6-26.0) days. Median of extra expenditure was 31,140 (95% CI; 17,327-49,081) baht and median of prolongation of postoperative stay was 14 (95% C.I, 12-18) days. CONCLUSION: This study supports the findings of the previous published reports that patients who have SSI incur enormous excess cost and hospital stay.

Device-associated infections and patterns of antimicrobial resistance in a medical-surgical intensive care unit in a university hospital in Thailand.

BACKGROUND: Surveillance of nosocomial infection in the intensive care unit (ICU) received a high level of attention and outcome indicators are now used in benchmarking the quality of patient care. Since 1999 the surveillance has targeted three site-specific, device-associated infections, including ventilator-associated pneumonia (VAP), central-line-related bloodstream infection (CR-BSI), and catheter-related urinary tract infection (CR-UTI). The authors conducted a two-year prospective study on the incidences of these infections acquired in an ICU and report herein, together with the antibiotic susceptibility patterns of the microorganisms isolated in an ICU. PATIENTS AND METHOD: Continuous prospective data collection was conducted on patients admitted to an adult medical-surgical ICU of a university hospital in Thailand from June 2000 to May 2002. RESULTS: A total 1422 patients with a total of 9370 patient-days were enrolled in the study. The incidence of VAP, CR-BSI, and CR-UTI were 10.8/1000 ventilator-days (95% C.I: 8.5-13.6), 2.6/1000 central-line-days (95%C.I. 1.5-4.4), and 13.8/1000 urinary-catheter-days (95%C.I: 10.7-17.5) respectively. The most common causative pathogens were Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. The proportion of methicillin-resistant Staphylococcus aureus, imipenem-resistant P. aeruginosa, ceftazidime-resistant A. baumannii, third-generation-cephalosporin-resistant K. pneumoniae, and quinolone-resistant E. coli were 68.8%, 30.9%, 68.5%, 44.6%, 38.3% respectively. CONCLUSION: The incidences of VAP and CR-BSI were comparable to the National Nosocomial Infection Surveillance (NNIS) report. But the incidence of CR-UTI was over the 90th percentile. The antibiotic resistance had become a serious problem.