Sternal surgical site infection prevention - is there any room for improvement?

OBJECTIVE: The objectives of this multicenter study are to evaluate current clinical practices in cardiac surgery concerning the prevention and management of sternal wound infections, to identify room for improvement, and to support implementation of systematic measures. METHODS: As a part of a campaign for infection prevention in cardiac surgery in Germany, a multiple-choice questionnaire with two main sections was developed and submitted to all cardiac surgery units in Germany (79). The project was realized in cooperation with the German Society for Thoracic and Cardiovascular Surgery, the BQS Institute for Quality and Patient Safety, and the National Reference Center for Nosocomial Infection Surveillance. RESULTS: A representative number (54 of 79 or 68%) of German cardiac surgery centers participated in the survey, in which heterogeneous procedures and various standards for prevention were observed. Surveillance, standards, and advanced training regarding hygiene measures are present in almost all participating hospitals. Methicillin-resistant Streptococcus aureus (MRSA) screening is performed in 81.5% (44/54) of all participating departments. A little less than one-tenth (7.4%) perform decolonization measures on all patients, while 85.2% perform decolonization measures only on MRSA-positive patients. Application of perioperative antibiotic prophylaxis ranges from single-shot application to 3 days of treatment. Longer treatment is expensive and time-intensive, and also increases the risk of Clostridium difficile-associated diarrhea. Nearly three-quarters (70.4%) of all participating hospitals perform preoperative hair removal 1 day before surgery. Common techniques are clipping machines (53.7%), razors (40.7%), clipping machines and depilatory cream (1.9%), or depilatory cream only (1.9%). Remanent (37.0%) and non-remanent disinfectants (55.6%) are used for preoperative skin disinfection. The time of the first wound-dressing change varies from the day of surgery (1.9%) over the first (42.6%) or second (46.3%) day after surgery to up to 3 or more days after surgery (9.3%). CONCLUSIONS: The results of the evaluation show that basic measures for infection prevention in cardiac surgery in Germany are well implemented. Nevertheless, a relevant heterogeneity in the use of special measures was observed, although research-based guidelines for infection prevention in surgery do exist and many studies have demonstrated the usefulness and feasibility of these measures.

Spondyloenchondrodysplasia with spasticity, cerebral calcifications, and immune dysregulation: clinical and radiographic delineation of a pleiotropic disorder.

Enchondromas are a feature of several constitutional disorders of bone, and the classification of different nosologic entities is still provisional. Among these disorders, spondyloenchondrodysplasia (SPENCD), as outlined by Schorr et al. [1976], is defined by the presence of radiolucent spondylar and metaphyseal lesions that represent persistence of islands of chondroid tissue within bone. Careful review of radiographic findings is needed to distinguish SPENCD from the many other disorders combining enchondromas with spinal lesions. Even when strict criteria are applied, it appears that SPENCD is clinically heterogeneous, as some SPENCD patients are neurologically intact while others present with spasticity, mental retardation, and cerebral calcifications in different combinations, and it has been suggested that SPENCD should be divided in two types. We herein report ten individuals from six families with SPENCD and illustrate the radiographic changes. Seven individuals had CNS manifestations including spasticity, developmental delay, and late-onset cerebral calcifications. We also noted that six individuals had clinical manifestations of autoimmunity (auto-immune thrombocytopenic purpura, auto-immune hemolytic anemia, auto-immune thyroiditis, and SLE) and one had been diagnosed with immune deficiency. Neurological and autoimmune manifestations were seen in different combinations within one single family. These observations suggest that SPENCD may be a single entity defined by specific radiographic features, but with remarkably pleiotropic manifestations that include CNS disease (spasticity, mental retardation, and calcifications), as well as immune dysregulation ranging from autoimmunity to immunodeficiency. The notion of recessive inheritance hitherto assumed is challenged by the observation of two apparently dominant pedigrees.