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BACKGROUND: There is controversy regarding the maximum number of elements that can be included in a surgical site infection prevention bundle. In addition, it is unclear whether a bundle of this type can be implemented at a multicentre level. METHODS: A pragmatic, multicentre cohort study was designed to analyse surgical site infection rates in elective colorectal surgery after the sequential implementation of two preventive bundle protocols. Secondary outcomes were to determine compliance with individual measures and to establish their effectiveness, duration of stay, microbiology and 30-day mortality rate. RESULTS: A total of 32 205 patients were included. A 50% reduction in surgical site infection was achieved after the implementation of two sequential sets of bundles: from 18.16% in the Baseline group to 10.03% with Bundle-1 and 8.19% with Bundle-2. Bundle-2 reduced superficial-surgical site infection (OR 0.74 (95% c.i. 0.58 to 0.95); P = 0.018) and deep-surgical site infection (OR 0.66 (95% c.i. 0.46 to 0.93); P = 0.018) but not organ/space-surgical site infection (OR 0.88 (95% c.i. 0.74 to 1.06); P = 0.172). Compliance increased after the addition of four measures to Bundle-2. In the multivariable analysis, for organ/space-surgical site infection, laparoscopy, oral antibiotic prophylaxis and mechanical bowel preparation were protective factors in colonic procedures, while no protective factors were found in rectal surgery. Duration of stay fell significantly over time, from 7 in the Baseline group to 6 and 5 days for Bundle-1 and Bundle-2 respectively (P < 0.001). The mortality rate fell from 1.4% in the Baseline group to 0.59% and 0.6% for Bundle-1 and Bundle-2 respectively (P < 0.001). There was an increase in Gram-positive bacteria and yeast isolation, and reduction in Gram-negative bacteria and anaerobes in organ/space-surgical site infection. CONCLUSIONS: The addition of measures to create a final 10-measure protocol had a cumulative protective effect on reducing surgical site infection. However, organ/space-surgical site infection did not benefit from the addition. No protective measures were found for organ/space-surgical site infection in rectal surgery. Compliance with preventive measures increased from Bundle-1 to Bundle-2.
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Pacotes de Assistência ao Paciente , Infecção da Ferida Cirúrgica , Humanos , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/epidemiologia , Feminino , Masculino , Idoso , Pessoa de Meia-Idade , Tempo de Internação , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Antibioticoprofilaxia/métodos , Cirurgia Colorretal/efeitos adversos , Estudos de Coortes , Colo/cirurgia , Reto/cirurgiaRESUMO
BACKGROUND: The Catalan Cancer Plan (CCP) undertakes periodic audits of cancer treatment outcomes, including organ/space surgical site infections (O/S-SSI) rates, while the Catalan Healthcare-associated Infections Surveillance Programme (VINCat) carries out standardized prospective surveillance of surgical site infections (SSI) in colorectal surgery. This cohort study aimed to assess the concordance between these two monitoring systems for O/S-SSI following primary rectal cancer surgery. METHODS: The study compared O/S-SSI incidence data from CCP clinical audits versus the VINCat Programme in patients undergoing surgery for primary rectal cancer, in 2011-12 and 2015-16, in publicly funded centres in Spain. The main outcome variable was the incidence of O/S-SSI in the first 30 days after surgery. Concordance between the two registers was analysed using Cohen's kappa. Discordant cases were reviewed by an expert, and the main reasons for discrepancies evaluated. RESULTS: Pooling data from both databases generated a sample of 2867 patients. Of these, O/S-SSI was detected in 414 patients-235 were common to both registry systems, with satisfactory concordance (κ = 0.69, 95% confidence interval 0.65-0.73). The rate of discordance from the CCP (positive cases in VINCat and negative in CCP) was 2.7%, and from VINCat (positive in CCP and negative in VINCat) was 3.6%. External review confirmed O/S-SSI in 66.2% of the cases in the CCP registry and 52.9% in VINCat. CONCLUSIONS: This type of synergy shows the potential of pooling data from two different information sources with a satisfactory level of agreement as a means to improving O/S-SSI detection. CLINICALTRIALS: gov Identifier: NCT06104579. Registered 30 November 2023.
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Neoplasias Retais , Infecção da Ferida Cirúrgica , Humanos , Neoplasias Retais/cirurgia , Masculino , Feminino , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/etiologia , Espanha/epidemiologia , Idoso , Estudos Prospectivos , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos , Seguimentos , Prognóstico , Incidência , Vigilância da População/métodos , Bases de Dados FactuaisRESUMO
BACKGROUND: Guidelines recommend 5-7 days of antibiotic treatment in patients with surgical infection and adequate source control. This nationwide stewardship intervention aimed to reduce the duration of treatments in surgical patients to <7 days. METHODS: Prospective cohort study evaluating surgical patients receiving antibiotics ≥7 days in 32 hospitals. Indication for treatment, quality of source control, type of recommendations issued, and adherence to the recommendations were analysed. Temporal trends in the percentages of patients with treatment >7 days were evaluated using a linear regression model and Pearson's correlation coefficients. RESULTS: A total of 32 499 patients were included. Of these, 13.7% had treatments ≥7 days. In all, 3912 stewardship interventions were performed, primarily in general surgery (90.7%) and urology (8.1%). The main types of infection were intra-abdominal (73.4%), skin/soft tissues (9.8%) and urinary (9.2%). The septic focus was considered controlled in 59.9% of cases. Out of 5458 antibiotic prescriptions, the most frequently analysed drugs were piperacillin/tazobactam (21.7%), metronidazole (11.2%), amoxicillin/clavulanate (10.3%), meropenem (10.7%), ceftriaxone (9.3%) and ciprofloxacin (6.7%). The main recommendations issued were: treatment discontinuation (35.0%), maintenance (40.0%) or de-escalation (15.5%), and the overall adherence rate was 91.5%. With adequate source control, the most frequent recommendation was to terminate treatment (51.2%). Throughout the study period, a significant decrease in the percentage of prolonged treatments was observed (Pc=-0.69;P < 0.001). CONCLUSIONS: This stewardship programme reduced the duration of treatments in surgical departments. Preference was given to general surgery services, intra-abdominal infection, and beta-lactam antibiotics, including carbapenems. Adherence to the issued recommendations was high.
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Gestão de Antimicrobianos , Humanos , Estudos Prospectivos , Estudos de Coortes , Antibacterianos/uso terapêutico , Combinação Piperacilina e Tazobactam/uso terapêuticoRESUMO
Background: Cancer has been associated with an increased risk of in-hospital mortality in CDI patients. However, data on delayed mortality in cancer patients with CDI are scarce. Aim/Objective: The aim of the present study was to compare outcomes between oncological patients and the general population with Clostridioides difficile infection (CDI) after 90 days of follow-up. Methods: A multicenter prospective cohort study was conducted in 28 hospitals participating in the VINCat program. Cases were all consecutive adult patients who met the case definition of CDI. Sociodemographic, clinical, and epidemiological variables and evolution at discharge and after 90 days were recorded for each case. Findings/results: The mortality rate was higher in oncological patients (OR = 1.70, 95% CI: 1.08-2.67). In addition, oncological patients receiving chemotherapy (CT) presented higher recurrence rates (18.5% vs 9.8%, p = 0.049). Among oncological patients treated with metronidazole, those with active CT showed a higher rate of recurrence (35.3% vs 8.0% p = 0.04). Discussion: Oncological patients presented a higher risk of poor outcomes after CDI. Their early and late mortality rates were higher than in the general population, and in parallel, those undergoing chemotherapy (especially those receiving metronidazole) had higher rates of recurrence.
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BACKGROUND: Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established. MATERIALS AND METHODS: Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay. RESULTS: A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis. CONCLUSIONS: In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.
Assuntos
Neoplasias Colorretais , Infecção da Ferida Cirúrgica , Humanos , Estudos de Coortes , Estudos Prospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Neoplasias Colorretais/cirurgiaRESUMO
BACKGROUND: Colorectal surgery is associated with the highest rate of surgical site infection (SSI). This study analyses the effectiveness of an interventional surveillance program on SSI rates after elective colorectal surgery. MATERIAL AND METHODS: Cohort study showing temporal trends of SSI rates and Standardized Infection Ratio (SIR) in elective colorectal surgery over a 12-year period. Prospectively collected data of a national SSI surveillance program was analysed and the effect of specific interventions was evaluated. Patient and procedure characteristics, as well as SIR and SSI rates were stratified by risk categories and type of SSI analysed using stepwise multivariate logistic regression models. RESULTS: In a cohort of 42,330 operations, overall cumulative SSI incidence was 16.31%, and organ-space SSI (O/S-SSI) was 8.59%. There was a 61.63% relative decrease in SSI rates (rho = -0.95804). The intervention which achieved the greatest SSI reduction was a bundle of 6 measures. SSI in pre-bundle period was 19.73% vs. 11.10% in post-bundle period (OR 1.969; IC 95% 1.860-2.085; p < 0.0001). O/S-SSI were 9.08% vs. 6.06%, respectively (OR 1.547; IC 95% 1.433-1.670; p < 0.0001). Median length of stay was 7 days, with a significant decrease over the studied period (rho = -0.98414). Mortality of the series was 1.08%, ranging from 0.35% to 2.0%, but a highly significant decrease was observed (rho = -0.67133). CONCLUSIONS: Detailed analysis of risk factors and postoperative infection in colorectal surgery allows strategies for reducing SSI incidence to be designed. An interventional surveillance program has been effective in decreasing SIR and SSI rates.
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Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Estudos de Coortes , Cirurgia Colorretal/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Humanos , Fatores de Risco , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controleRESUMO
BACKGROUND: The role of oral antibiotic prophylaxis (OAP) and mechanical bowel preparation (MBP) in the prevention of surgical site infection (SSI) after colorectal surgery is still controversial. The aim of this study was to analyze the effect of a bundle including both measures in a National Infection Surveillance Network in Catalonia. METHODS: Pragmatic cohort study to assess the effect of OAP and MBP in reducing SSI rate in 65 hospitals, comparing baseline phase (BP: 2007-2015) with implementation phase (IP: 2016-2019). To compare the results, a logistic regression model was established. RESULTS: Out of 34,421 colorectal operations, 5180 had SSIs (15.05%). Overall SSI rate decreased from 18.81% to 11.10% in BP and IP, respectively (OR 0.539, CI95 0.507-0.573, p < 0.0001). Information about bundle implementation was complete in 61.7% of cases. In a univariate analysis, OAP and MBP were independent factors in decreasing overall SSI, with OR 0.555, CI95 0.483-0.638, and OR 0.686, CI95 0.589-0.798, respectively; and similarly, organ/space SSI (O/S-SSI) (OR 0.592, CI95 0.494-0.710, and OR 0.771, CI95 0.630-0.944, respectively). However, only OAP retained its protective effect at both levels at multivariate analyses. CONCLUSIONS: oral antibiotic prophylaxis decreased the rates of SSI and O/S-SSI in a large series of elective colorectal surgery.
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BACKGROUND: Organ-space surgical site infections (SSI) are the most serious and costly infections after colorectal surgery. Most previous studies of risk factors for SSI have analysed colon and rectal procedures together. The aim of the study was to determine whether colon and rectal procedures have different risk factors and outcomes for organ-space SSI. METHODS: A multicentre observational prospective cohort study of adults undergoing elective colon and rectal procedures at 10 Spanish hospitals from 2011 to 2014. Patients were followed up until 30 days post-surgery. Surgical site infection was defined according to the Centers for Disease Control and Prevention criteria. Oral antibiotic prophylaxis (OAP) was considered as the administration of oral antibiotics the day before surgery combined with systemic intravenous antibiotic prophylaxis. RESULTS: Of 3,701 patients, 2,518 (68%) underwent colon surgery and 1,183 (32%) rectal surgery. In colon surgery, the overall SSI rate was 16.4% and the organ-space SSI rate was 7.9%, while in rectal surgery the rates were 21.6% and 11.5% respectively (p < 0.001). Independent risk factors for organ-space SSI in colon surgery were male sex (Odds ratio -OR-: 1.57, 95% CI: 1.14-2.15) and ostomy creation (OR: 2.65, 95% CI: 1.8-3.92) while laparoscopy (OR: 0.5, 95% CI: 0.38-0.69) and OAP combined with intravenous antibiotic prophylaxis (OR: 0.7, 95% CI: 0.51-0.97) were protective factors. In rectal surgery, independent risk factors for organ-space SSI were male sex (OR: 2.11, 95% CI: 1.34-3.31) and longer surgery (OR: 1.49, 95% CI: 1.03-2.15), whereas OAP with intravenous antibiotic prophylaxis (OR: 0.49, 95% CI: 0.32-0.73) was a protective factor. Among patients with organ-space SSI, we found a significant difference in the overall 30-day mortality, being higher in colon surgery than in rectal surgery (11.5% vs 5.1%, p = 0.04). CONCLUSIONS: Organ-space SSI in colon and rectal surgery has some differences in terms of incidence, risk factors and outcomes. These differences could be considered for surveillance purposes and for the implementation of preventive strategies. Administration of OAP would be an important measure to reduce the OS-SSI rate in both colon and rectal surgeries.
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OBJECTIVE: To determine current outcomes and predictors of treatment failure among patients with surgical site infection (SSI) after colorectal surgery. METHODS: A multicentre observational prospective cohort study of adults undergoing elective colorectal surgery in 10 Spanish hospitals (2011-2014). Treatment failure was defined as persistence of signs/symptoms of SSI or death at 30 days post-surgery. RESULTS: Of 3701 patients, 669 (18.1%) developed SSI; 336 (9.1%) were organ-space infections. Among patients with organ-space SSI, 81.2% required source control: 60.4% reoperation and 20.8% percutaneous/transrectal drainage. Overall treatment failure rate was 21.7%: 9% in incisional SSIs and 34.2% in organ-space SSIs (p < 0.001). Median length of stay was 15 days (IQR 9-22) for incisional SSIs and 24 days (IQR 17-35) for organ-space SSIs (p < 0.001). One hundred and twenty-seven patients (19%) required readmission and 35 patients died (5.2%). Risk factors for treatment failure among patients with organ-space SSI were age ≥65 years (OR 1.83, 95% CI: 1.07-1.83), laparoscopy (OR 1.7, 95% CI: 1.06-2.77), and reoperation (OR 2.8, 95% CI: 1.7-4.6). CONCLUSIONS: Rates of SSI and treatment failure in organ-space SSI after elective colorectal surgery are notably high. Careful attention should be paid to older patients with previous laparoscopy requiring reoperation for organ-space SSI, so that treatment failure can be identified early.
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Cirurgia Colorretal/efeitos adversos , Infecção da Ferida Cirúrgica/tratamento farmacológico , Falha de Tratamento , Fatores Etários , Idoso , Antibacterianos/uso terapêutico , Estudos de Coortes , Coinfecção/tratamento farmacológico , Cirurgia Colorretal/mortalidade , Farmacorresistência Bacteriana Múltipla , Feminino , Infecções por Bactérias Gram-Negativas/complicações , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
Infections related to the health-care system are those associated with health care practices in hospitalized patients as well as in out-patients with health-care contact. Nosocomial infections affect 5% of in-patients, and carry a high morbidity, mortality and economic cost. The main types of nosocomial infections are related to invasive procedures, and include respiratory tract infection, surgical site infections, urinary tract infections, and vascular catheter bacteremia. It has been shown that the application of checklists and a bundle of measures are useful in preventing these infections. Epidemiological surveillance, defined as the gathering of information to take actions, is the basis of infection control programs. These have evolved from a global surveillance targeted at processes and indicators of nosocomial infection. The comparison of these indicators can be useful in establishing preventive measures.
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Infecção Hospitalar/epidemiologia , Infecção Hospitalar/prevenção & controle , Monitoramento Epidemiológico , Humanos , Programas Nacionais de SaúdeRESUMO
The VINCat Program is a standardized surveillance program of healthcare infections in Catalonia, Spain. This program includes monitoring of surgical site infections (SSI) of elective colorectal surgery. The aim of this study was to define SSI rates in colorectal surgery among VINCat hospitals over a period of 4 years. We included consecutive elective colorectal interventions performed in VINCat hospitals from 2007 to 2010. Follow-up visits were performed 30 days after surgery. Prospective monitoring of SSI in colorectal surgery was performed according to standardized VINCat methodology. SSI was defined according to the Centers for Disease Control (CDC) and surgical risk factors according to the National Healthcare Safety Network (NHSN) classification. From 2007 to 2010, 49 centers performed 10,104 surgical procedures. The cumulative incidence of SSI was 20.8% (95% CI: 20.03-21.63). The annual cumulative SSI incidence rate did not vary significantly over the study period; however, there were significant differences among hospital infection rates. The relative frequency of organ-space infection increased from 25% in 2007 to 40% in 2010 (p<0.001). Laparoscopic surgery also increased (28% in 2007 to 42% in 2010, p<0.001). However, no changes were observed in mean surgery duration, ASA score and degree of surgical contamination. The VINCat Program incorporated a large number of Catalan hospitals that participated in standardized monitoring of colorectal surgery. The cumulative incidence rate of SSI for colorectal surgery was 20.8%, although there were large variations between hospitals.
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Colo/cirurgia , Infecção Hospitalar/epidemiologia , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Vigilância da População , Reto/cirurgia , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Número de Leitos em Hospital/estatística & dados numéricos , Hospitais Públicos/classificação , Hospitais Públicos/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Estudos Prospectivos , Fatores de Risco , Espanha/epidemiologiaRESUMO
The VINCat Program is a system for epidemiological surveillance of healthcare-related infections in which the majority of Catalan hospitals participate. It has a specific module for surgical site infections (SSI) surveillance. Primary hip and knee arthroplasties are basic indicators of the program due to their high frequency and the important morbidity of SSI of these sites. Results are presented for surgical site infection (SSI) surveillance of primary hip and knee arthroplasties for the first three years of the VINCat Program. The program requires SSI surveillance to be performed in a standardized, prospective and continuous manner by an infection control team from the centers. With primary arthroplasties, as with all procedures involving implants, the surveillance is maintained for 1 year after the intervention. The VINCat Program uses the SSI definitions of the Centers for Disease Control (CDC) and patients are stratified by surgical risk, following the classification of the National Healthcare Safety Network (NHSN). During the period 2007-2009, 51 Catalan hospitals participated in the SSI surveillance of prosthetic orthopedic surgery. The overall SSI rate in the interventions for total primary hip prosthesis (7,804 procedures) was 3.0% (IC 95%: 2.6-3.4) and for total primary knee prosthesis (16,781 procedures) was 3.3% (IC95%: 3.0-3.6). During the period 2007-2009, the overall SSI rates for total primary hip and knee arthroplasty were higher than those published by some surveillance systems in our environment. There were significant differences in the infection rates by procedure and in those adjusted by risk among the different hospitals.