Interventions for preventing or controlling health care-associated infection among health care workers or patients within primary care facilities: A scoping review.

BACKGROUND: This review aimed to synthesize the evidence on infection prevention and control interventions for the prevention of health care-associated infection among health care workers or patients within primary care facilities. METHODS: PubMed, CINAHL, EMBASE, and CENTRAL databases were searched for quantitative studies published between 2011 and 2022. Study selection, data extraction, and quality assessment using Cochrane and Joanna Briggs tools, were conducted by independent review with additional sensitivity checking performed on study selection. RESULTS: Four studies were included. A randomized trial and a cross-sectional survey, respectively, found no statistical difference in laboratory-confirmed influenza in health care workers wearing N95 versus medical masks (P = .18) and a significant inverse association between the implementation of tuberculosis control measures and tuberculosis incidence (P = .02). For the prevention of surgical site infections following minor surgery, randomized trials found nonsterile gloves (8.7%; 95% confidence interval, 4.9%-12.6%) to be noninferior to sterile gloves (9.3%; 95% confidence interval, 7.4%-11.1%) and no significant difference between prophylactic antibiotics compared to placebo (P = .064). All studies had a high risk of bias. CONCLUSIONS: Evidence for infection prevention and control interventions for the prevention of health care-associated infection in primary care is very limited and insufficient to make practice recommendations. Nevertheless, the findings highlight the need for future research.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials.

INTRODUCTION: The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers. METHODS AND ANALYSIS: Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour). ETHICS AND DISSEMINATION: Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal. PROSPERO REGISTRATION NUMBER: CRD42018090261.

Effect of postoperative continuation of antibiotic prophylaxis on the incidence of surgical site infection: a systematic review and meta-analysis.

BACKGROUND: Antibiotic prophylaxis is frequently continued for 1 day or more after surgery to prevent surgical site infection. Continuing antibiotic prophylaxis after an operation might have no advantage compared with its immediate discontinuation, and it unnecessarily exposes patients to risks associated with antibiotic use. In 2016, WHO recommended discontinuation of antibiotic prophylaxis after surgery. We aimed to update the evidence that formed the basis for that recommendation. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, CENTRAL, and WHO regional medical databases for randomised controlled trials (RCTs) on postoperative antibiotic prophylaxis that were published from Jan 1, 1990, to July 24, 2018. RCTs comparing the effect of postoperative continuation versus discontinuation of antibiotic prophylaxis on the incidence of surgical site infection in patients undergoing any surgical procedure with an indication for antibiotic prophylaxis were eligible. The primary outcome was the effect of postoperative surgical antibiotic prophylaxis continuation versus its immediate discontinuation on the occurrence of surgical site infection, with a prespecified subgroup analysis for studies that did and did not adhere to current best practice standards for surgical antibiotic prophylaxis. We calculated summary relative risks (RRs) with corresponding 95% CIs using a random effects model (DerSimonian and Laird). We evaluated heterogeneity with the χ2 test, I2, and τ2, and visually assesed publication bias with a contour-enhanced funnel plot. This study is registered with PROSPERO, CRD42017060829. FINDINGS: We identified 83 relevant RCTs, of which 52 RCTs with 19 273 participants were included in the primary meta-analysis. The pooled RR of surgical site infection with postoperative continuation of antibiotic prophylaxis versus its immediate discontinuation was 0·89 (95% CI 0·79-1·00), with low heterogeneity in effect size between studies (τ2=0·001, χ2 p=0·46, I2=0·7%). Our prespecified subgroup analysis showed a significant association between the effect estimate and adherence to best practice standards of surgical antibiotic prophylaxis: the RR of surgical site infection was reduced with continued antibiotic prophylaxis after surgery compared with its immediate discontinuation in trials that did not meet best practice standards (0·79 [95% CI 0·67-0·94]) but not in trials that did (1·04 [0·85-1·27]; p=0·048). Whether studies adhered to best practice standards explained all variance in the pooled estimate from the primary meta-analysis. INTERPRETATION: Overall, we identified no conclusive evidence for a benefit of postoperative continuation of antibiotic prophylaxis over its discontinuation. When best practice standards were followed, postoperative continuation of antibiotic prophylaxis did not yield any additional benefit in reducing the incidence of surgical site infection. These findings support WHO recommendations against this practice. FUNDING: None.

Safety of 80% vs 30-35% fraction of inspired oxygen in patients undergoing surgery: a systematic review and meta-analysis.

BACKGROUND: Evidence-based guidelines from the World Health Organization (WHO) have recommended a high (80%) fraction of inspired oxygen (FiO2) to reduce surgical site infection in adult surgical patients undergoing general anaesthesia with tracheal intubation. However, there is ongoing debate over the safety of high FiO2. We performed a systematic review to define the relative risk of clinically relevant adverse events (AE) associated with high FiO2. METHODS: We reviewed potentially relevant articles from the WHO review supporting the recommendation, including an updated (July 2018) search of EMBASE and PubMed for randomised and non-randomised controlled studies reporting AE in surgical patients receiving 80% FiO2 compared with 30-35% FiO2. We assessed study quality and performed meta-analyses of risk ratios (RR) comparing 80% FiO2 against 30-35% for major complications, mortality, and intensive care admission. RESULTS: We included 17 moderate-good quality trials and two non-randomised studies with serious-critical risk of bias. No evidence of harm with high FiO2 was found for major AE in the meta-analysis of randomised trials: atelectasis RR 0.91 [95% confidence interval (CI) 0.59-1.42); cardiovascular events RR 0.90 (95% CI 0.32-2.54); intensive care admission RR 0.93 (95% CI 0.7-1.12); and death during the trial RR 0.49 (95% CI 0.17-1.37). One non-randomised study reported that high FiO2 was associated with major respiratory AE [RR 1.99 (95% CI 1.72-2.31)]. CONCLUSIONS: No definite signal of harm with 80% FiO2 in adult surgical patients undergoing general anaesthesia was demonstrated and there is little evidence on safety-related issues to discourage its use in this population.

Effectiveness of 80% vs 30-35% fraction of inspired oxygen in patients undergoing surgery: an updated systematic review and meta-analysis.

BACKGROUND: In 2016, the World Health Organization (WHO) strongly recommended the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anaesthesia to reduce the risk of surgical site infection (SSI). Since then, further trials have been published, trials included previously have come under scrutiny, and one article was retracted. We updated the systematic review on which the recommendation was based. METHODS: We performed a systematic literature search from January 1990 to April 2018 for RCTs comparing the effect of high (80%) vs standard (30-35%) FiO2 on the incidence of SSI. Studies retracted or under investigation were excluded. A random effects model was used for meta-analyses; the sources of heterogeneity were explored using meta-regression. RESULTS: Of 21 RCTs included, six were newly identified since the publication of the WHO guideline review; 17 could be included in the final analyses. Overall, no evidence for a reduction of SSI after the use of high FiO2 was found [relative risk (RR): 0.89; 95% confidence interval (CI): 0.73-1.07]. There was evidence that high FiO2 was beneficial in intubated patients [RR: 0.80 (95% CI: 0.64-0.99)], but not in non-intubated patients [RR: 1.20 (95% CI: 0.91-1.58); test of interaction; P=0.048]. CONCLUSIONS: The WHO updated analyses did not show definite beneficial effect of the use of high perioperative FiO2, overall, but there was evidence of effect of reducing the SSI risk in surgical patients under general anaesthesia with tracheal intubation. However, the evidence for this beneficial effect has become weaker and the strength of the recommendation needs to be reconsidered.

A multimodal infection control and patient safety intervention to reduce surgical site infections in Africa: a multicentre, before-after, cohort study.

BACKGROUND: Surgical site infections (SSIs) are the most frequent health-care-associated infections in developing countries. Specific prevention measures are highly effective, but are often poorly implemented. We aimed to establish the effect of a multimodal intervention on SSIs in Africa. METHODS: We did a before-after cohort study, between July 1, 2013, and Dec 31, 2015, at five African hospitals. The multimodal intervention consisted of the implementation or strengthening of multiple SSI prevention measures, combined with an adaptive approach aimed at the improvement of teamwork and the safety climate. The primary outcome was the first occurrence of SSI, and the secondary outcome was death within 30 days post surgery. Data on adherence to SSI prevention measures were prospectively collected. The intervention effect on SSI risk and death within 30 days post surgery was assessed in a mixed-effects logistic regression model, after adjustment for key confounders. FINDINGS: Four hospitals completed the baseline and follow-up; three provided suitable (ie, sufficient number and quality) data for the sustainability period. 4322 operations were followed up (1604 at baseline, 1827 at follow-up, and 891 in the sustainability period). SSI cumulative incidence significantly decreased post intervention, from 8·0% (95% CI 6·8-9·5; n=129) to 3·8% (3·0-4·8; n=70; p<0·0001), and this decrease persisted in the sustainability period (3·9%, 2·8-5·4; n=35). A substantial improvement in compliance with prevention measures was consistently observed in the follow-up and sustainability periods. The likelihood of SSI during follow-up was significantly lower than pre-intervention (odds ratio [OR] 0·40, 95% CI 0·29-0·54; p<0·0001), but the likelihood of death was not significantly reduced (0·72, 0·42-1·24; p=0·2360). INTERPRETATION: Implementation of our intervention is feasible in African hospitals. Improvement was observed across all perioperative prevention practices. A significant effect on the overall SSI risk was observed, but with some heterogeneity between sites. Further large-scale experimental studies are needed to confirm these results and to improve the sustainability and long-term effect of such complex programmes. FUNDING: US Agency for Healthcare Research and Quality, WHO.

Effect of laminar airflow ventilation on surgical site infections: a systematic review and meta-analysis.

BACKGROUND: The role of the operating room's ventilation system in the prevention of surgical site infections (SSIs) is widely discussed, and existing guidelines do not reflect current evidence. In this context, laminar airflow ventilation was compared with conventional ventilation to assess their effectiveness in reducing the risk of SSIs. METHODS: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and WHO regional medical databases from Jan 1, 1990, to Jan 31, 2014. We updated the search for MEDLINE for the period between Feb 1, 2014, and May 25, 2016. We included studies most relevant to our predefined question: is the use of laminar airflow in the operating room associated with the reduction of overall or deep SSI as outcomes in patients of any age undergoing surgical operations? We excluded studies not relevant to the study question, studies not in the selected languages, studies published before Jan 1, 1990, or after May 25, 2016, meeting or conference abstracts, and studies of which the full text was not available. Data were extracted by two independent investigators, with disagreements resolved through further discussion. Authors were contacted if the full-text article was not available, or if important data or information on the paper's content was absent. Studies were assessed for publication bias. Grading of recommendations assessment, development, and evaluation was used to assess the quality of the identified evidence. Meta-analyses were done with RevMan (version 5.3). FINDINGS: We identified 1947 records of which 12 observational studies were comparing laminar airflow ventilation with conventional turbulent ventilation in orthopaedic, abdominal, and vascular surgery. The meta-analysis of eight cohort studies showed no difference in risk for deep SSIs following total hip arthroplasty (330 146 procedures, odds ratio [OR] 1·29, 95% CI 0·98-1·71; p=0·07, I2=83%). For total knee arthroplasty, the meta-analysis of six cohort studies showed no difference in risk for deep SSIs (134 368 procedures, OR 1·08, 95% CI 0·77-1·52; p=0·65, I2=71%). For abdominal and open vascular surgery, the meta-analysis of three cohort studies found no difference in risk for overall SSIs (63 472 procedures, OR 0·75, 95% CI 0·43-1·33; p=0·33, I2=95%). INTERPRETATION: The available evidence shows no benefit for laminar airflow compared with conventional turbulent ventilation of the operating room in reducing the risk of SSIs in total hip and knee arthroplasties, and abdominal surgery. Decision makers, medical and administrative, should not regard laminar airflow as a preventive measure to reduce the risk of SSIs. Consequently, this equipment should not be installed in new operating rooms. FUNDING: None.

New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective.

Surgical site infections (SSIs) are among the most preventable health-care-associated infections and are a substantial burden to health-care systems and service payers worldwide in terms of patient morbidity, mortality, and additional costs. SSI prevention is complex and requires the integration of a range of measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations of national guidelines have been identified. Given the burden of SSIs worldwide, the numerous gaps in evidence-based guidance, and the need for standardisation and a global approach, WHO decided to prioritise the development of evidence-based recommendations for the prevention of SSIs. The guidelines take into account the balance between benefits and harms, the evidence quality, cost and resource use implications, and patient values and preferences. On the basis of systematic literature reviews and expert consensus, we present 13 recommendations on preoperative preventive measures.

New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective.

Surgical site infections (SSIs) are the most common health-care-associated infections in developing countries, but they also represent a substantial epidemiological burden in high-income countries. The prevention of these infections is complex and requires the integration of a range of preventive measures before, during, and after surgery. No international guidelines are available and inconsistencies in the interpretation of evidence and recommendations in national guidelines have been identified. Considering the prevention of SSIs as a priority for patient safety, WHO has developed evidence-based and expert consensus-based recommendations on the basis of an extensive list of preventive measures. We present in this Review 16 recommendations specific to the intraoperative and postoperative periods. The WHO recommendations were developed with a global perspective and they take into account the balance between benefits and harms, the evidence quality level, cost and resource use implications, and patient values and preferences.

A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery.

OBJECTIVE: Systematically review and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) studies on prophylactic negative pressure wound therapy (pNPWT) to prevent surgical site infections (SSIs). INTRODUCTION: pNPWT has been suggested as a new method to prevent wound complications, specifically SSIs, by its application on closed incisional wounds. METHODS: This review was conducted as part of the development of the Global Guidelines for prevention of SSIs commissioned by World Health Organization in Geneva. PubMed, Embase, CENTRAL, CINAHL, and the World Health Organization database between January 1, 1990 and October 7, 2015 were searched. Inclusion criteria were randomized controlled trials and observational studies comparing pNPWT with conventional wound dressings and reporting on the incidence of SSI. Meta-analyses were performed with a random effect model. GRADE Pro software was used to qualify the evidence. RESULTS: Nineteen articles describing 21 studies (6 randomized controlled trials and 15 observational) were included in the review. Summary estimate showed a significant benefit of pNPWT over conventional wound dressings in reducing SSIs in both randomized controlled trials and observational studies, odds ratio of 0.56 (95% confidence interval, 0.32-0.96; P = 0.04) and odds ratio of 0.30 (95% confidence interval, 0.22-0.42; P < 0.00001), respectively. This translates into lowering the SSI rate from 140 to 83 (49-135) per 1000 patients and from 106 to 34 (25-47) per 1000 patients, respectively. In stratified analyses, these results were consistent in both clean and clean-contaminated procedures and in different types of surgery, however results were no longer significant for orthopaedic/trauma surgery. The level of evidence as qualified with GRADE was however low. CONCLUSIONS: Low-quality evidence indicates that prophylactic NPWT significantly reduces the risk of SSIs.

Penetration of orally administered prulifloxacin into human lung tissue.

OBJECTIVE: To evaluate the distribution in lung tissue of ulifloxacin, the active metabolite of prulifloxacin, a new once-daily fluoroquinolone administered orally in a single 600mg dose. DESIGN: Open-label, randomised study. PATIENTS: Twenty-seven patients (25 males, 2 females; mean age 65.7 years [range 49-79 years]) with a lung neoplasm requiring lobectomy or pneumonectomy. METHODS: Patients were randomly assigned to five treatment groups and received a single oral dose of prulifloxacin 600mg at 2, 4, 6, 12 or 24 hours preoperatively. During surgery, blood and healthy lung (based on macroscopic appearance) samples were collected at the same time. Ulifloxacin concentrations in plasma and lung tissue were determined by a validated reversed-phase high-performance liquid chromatography assay. Lung tissue ulifloxacin concentrations were adjusted for blood contamination, by measuring haemoglobin in the supernatant of each tissue sample and applying a corrective equation. RESULTS: Ulifloxacin concentration in lung tissue exceeded plasma concentration at every timepoint. Following administration of prulifloxacin 600mg, the overall mean corrected lung/plasma ratio over the 24-hour period was 6.9 (range 1.2-14.1). When sampling intervals were assessed, the corrected lung/plasma ratios were 7.5 (2 hours after dosing), 6.3 (4 hours), 4.3 (6 hours), 7.0 (12 hours) and 9.2 (24 hours). The mean corrected lung/plasma area under the concentration-time curve ratio was 6.3, demonstrating the ability of the drug to penetrate lung tissue and confirming the high exposure of this target tissue to ulifloxacin. However, the limitation of the lung tissue sampling method and the high interpatient variability should be considered. Over the 24-hour period, the concentrations of ulifloxacin in lung tissue were higher than the minimum inhibitory concentration (MIC) values for pathogens frequently involved in community-acquired respiratory tract infections. CONCLUSION: Lung tissue penetration data may have a supportive value when considered jointly with MICs and efficacy results. The findings from this lung penetration study could explain the efficacy of once-daily prulifloxacin 600mg observed in clinical trials conducted in patients with exacerbation of chronic bronchitis.