[Update of the 2013 consensus conference "Management of the preoperative risk of infection"]. / Mise à jour 2013 de la conférence de consensus « Gestion préopératoire du risque infectieux ¼

UNLABELLED: The surgical site infections (SSI) are rare adverse events that may have severe consequences in terms of morbidity, mortality and costs. Guidelines on the preparation of the patient can reduce the risk of SSI. Previous guidelines were published in 2004. MATERIAL: A steering committee and a group of experts were established after seeking professional societies that had participated in the previous guidelines. The working group has defined the objectives of revising and retained two main themes: skin preparation and nasal decolonization of patients with Staphylococcus aureus. We chose to report only the work done on the patient skin preparation. The working group relied on the method of recommendation for clinical practice of the High Authority for Health (HAS). The GRADE approach was used to analyze the articles published since 2004. RESULTS: It is recommended to perform a preoperative shower but when does not matter. The use of a simple soap seems sufficient. Shampoo does not seem essential nor removal of varnish in the field of urology. Impregnated fabrics, adhesives fields and bacteriological insulating films are of little use to reduce the risk of infection. The depilation is not routinely required. It is recommended to perform a cleansing on contaminated skin. The use of an alcohol antiseptic is preferred, the successive application of two different antiseptics range is possible. CONCLUSIONS: The updated guidelines on the patient skin preparation before urological surgery was necessary. It changed some guidelines that should appear in our daily practice.

Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital.

BACKGROUND: Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures. AIM: We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital. METHODS: We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners. FINDINGS: A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease. CONCLUSIONS: With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.

Is surgical site scrubbing before painting of value? Review and meta-analysis of clinical studies.

BACKGROUND: Surgical site infections are major surgical complications. Surgical site scrubbing before painting is controversial. AIM: To conduct a meta-analysis of clinical trials that compared pre-operative scrubbing before painting with painting alone for the prevention of surgical site infections. METHODS: A systematic review and meta-analysis of clinical trials in Pubmed, ScienceDirect and Cochrane databases that compared pre-operative scrubbing before painting with painting alone, and reported surgical site infections, skin colonization or adverse effects as an outcome, was undertaken. A fixed-effect model and a random-effect model were tested. Sensitivity analysis was conducted by removing non-randomized controlled trials. FINDINGS: The systematic review identified three studies, involving 570 patients, for surgical site infection outcomes, and four other studies, involving 1082 patients, for positive skin culture outcomes. No significant differences were observed between scrubbing before painting vs painting alone in terms of surgical site infection or positive skin culture. CONCLUSION: Further research is needed to draw conclusions. Only one study in this meta-analysis identified adverse effects, but there were too few events to compare the various methods. It is believed that there is no need to scrub the surgical site if the skin is visibly clean and/or if the patient has had a pre-operative shower.

Blunt chest trauma: a right pulmonary vein rupture.

This report describes the case of a 37-year-old man who fell from 6 m height and presented an isolated rupture of the right pulmonary vein. The patient had a low blood pressure without any sign of intrathoracic injury. An echocardiogram revealed a tamponade with hemodynamic intolerance. The repair was made using cardiopulmonary bypass which made the inspection and total repair of the lesions easier. This case is unusual because of the isolated lesion and the few articles about similar reports founded in an extended literature review. Mechanisms and generation of blunt chest trauma lesions are discussed.

[Valvular replacement with the Bicarbon mechanical valve. Results after 7 years in 104 patients]. / Remplacement valvulaire par la valve mécanique Bicarbon. Résultats à 7 ans chez 104 patients.

OBJECTIVE: Study of the medium term results of aortic and mitral valve replacement with the Bicarbon' prosthesis. METHOD: From 1990 to 1996, 109 valves were implanted (70 in aortic position, 31 in mitral position and 4 double replacements). The average age was 61 years and 75% were male. According to the NYHA, 59% of patients were stage III or IV. The average pre-operative ejection fraction was 59.6%. There was re-intervention in 21.1% of patients and 35.3% had an associated procedure during the intervention. RESULTS: The average follow up was 5.4 +/- 1.98 years in 98 patients (that is 522 patient years). One patient died post-operatively and 19 died later. The overall survival at 7 years was 69.4 +/- 6.3%. Complications, expressed in patient years, were 1.15% for thrombo-embolic complications, 2.1% for haemorrhagic complications. 0.38% for endocarditis, 1.72% for non-infectious peri-prosthetic leaks, and 0.76% for re-interventions. At 7 years, the absence of thrombo-embolic, haemorrhagic, endocarditis, and re-intervention complications was 91.8 +/- 4.2%, 85.3 +/- 4.8%, 95.8 +/- 3.2%, 93.8 +/- 3.5% respectively. According to the NYHA, 95% of patients were in stage 1 or II (p < 0.001). CONCLUSION: Valvular replacement in the aortic or mitral position with the Bicarbon' valve is satisfactory as much in terms of survival as of clinical complications.

[Gastro-duodenal perforating ulcers. Therapeutic trend in African patients (a study of 80 cases recorded in Abidjan) (author's transl)]. / Perforation des ulcères gastro-duodénaux. A propos de 80 cas observés a Abidjan.

80 perforating ulcers recorded during 7 years (1970-1976) in Abidjan hospitals are reviewed. The therapeutic tactic is discussed according to the traditional and socio-economic living patterns of african patients: the authors propose a complete surgical treatment carried out either directly or after some delay but without discharging the patient who, in most cases, would no more report to the hospital. Suture may be an emergency treatment in patients with poor condition but it must be completed later during the same confinement.

[Postoperative period in cardiac surgery: don't forget heparin induced thrombocytopenia!]. / Thrombopénie immuno-allergique postopératoire en chirurgie cardiaque: un diagnostic à ne pas oublier!

Type II heparin-induced thrombocytopenia (HIT) has a low incidence in cardiac surgery, but its mortality once declared is high. Its clinical recognition can be difficult with these patients who usually have thrombocytopenia in postoperative period and who are predisposed to develop HIT prematurely. Thromboses in this context must be specific, and treatment, which is nowadays well codified, must be begun without waiting for biologic results. Besides, specificity of Elisa's test is weakened in this population since there is a high rate of serum conversion; yet, its preoperative realization associated with pre-test probability scoring for HIT, can turn out useful.

[Fulminant myocarditis: clinical value of extracorporeal life support]. / Myocardites fulminantes : intérêt de l'assistance circulatoire temporaire.

Fulminant myocarditis is a rare cause of cardiogenic shock which usually occurs in young adults without known cardiac disease. Initial course may be complicated by a cardiogenic shock refractory to optimal medical treatment. Temporary circulatory assistance using an extracorporeal life support is of great clinical value in this setting, since myocardial systolic function usually fully recovers after a short time delay.

High prevalence of undiagnosed patients with peripheral arterial disease in patients hospitalised for non-vascular disorders.

BACKGROUND: Several studies highlight the underestimation of peripheral arterial disease (PAD) rates in general population, leading to a lack of opportunity to detect subjects at a high risk for cardiovascular events. We sought to investigate (i) the prevalence of unrecognised PAD in patients hospitalised for non-vascular diseases and (ii) the intensity of preventive drug therapies in this population. DESIGN AND METHODS: This study was of the cross-sectional design in a tertiary care hospital, which included 291 randomly selected patients of >or=40 years of age. Patients were assessed for medical history, pulse palpation and ankle-brachial index (ABI). The Edinburgh Claudication Questionnaire (ECQ) was administered. PAD was defined either by an ABIor=1.4 or in case of limb revascularisation history. RESULTS: Overall PAD prevalence was 29%; 21 patients (7.2%) with a history of PAD, while 65 (22.3%) had an unknown PAD. Among patients with unknown PAD, a typical intermittent claudication was unusual (3%). In patients without cardiovascular disease (CVD), four factors were associated with unrecognised PAD: absence of posterior tibial pulse (OR 4.49, 95% CI 1.89-10.51; p<0.001), male sex (OR 2.32, 95% CI 1.03-5.25; p=0.04), age>70 years (OR 2.44, 95% CI 1.07-5.58; p=0.04), CVD risk factors>or=2 (OR 2.63, 95% CI 1.20-5.76; p=0.02). Antiplatelet therapy and statins were each prescribed in 35.5% of the unrecognised PAD patients with ABIor=1.4. CONCLUSIONS: In a tertiary care hospital, the prevalence of unrecognised PAD among patients hospitalised for non-PAD-related causes is high and the preventive CVD therapy rates are low. Hospitalisation is a good opportunity to detect PAD.

Bacterial load of cockroaches in relation to urban environment.

Sanitation is an important problem in relation to the control of pests in urban environments. This investigation analysed the potential risk related to the presence of cockroaches and their capacity for disseminating bacteria in six different types of buildings: hospital nursing area and out-patient area, swimming-pool pool-side and toilet area, low-income flats and food-handling places. Fifty-six species of bacteria were identified from 157 samples, 14 of these have previously been reported as potentially pathogenic for man and vertebrates. Similarities were found between samples collected in (a) the hospital out-patient area and food-handling establishments and (b) the hospital nursing area and flats. Pool-sides possessed a poorer bacterial flora. There was a greater bacterial specific diversity in food-handling establishments, flats and swimming-bath toilet area. Enterobacter cloacae. Klebsiella pneumoniae and Klebsiella oxytoca were dominant species in flats and the hospital nursing area. Therefore, cockroaches can play a role in disseminating bacteria, which they can carry passively on their cuticle.

Microbial organisms carried by brown-banded cockroaches in relation to their spatial distribution in a hospital.

A simultaneous study of cockroach (Supella supellectilium) distribution and of associated carried bacterial flora has been made in the main hospital in Rennes (France). Wild cockroaches carry a high number of bacterial species that can be related to the normal environmental flora and a contaminant flora acquired from particular environments. The diversity of carried bacterial species reveals a proximity factor between continguous floors of the building which leads us to suppose that cockroaches are able to forage from one floor to the other.

Cockroaches as carriers of bacteria in multi-family dwellings.

The potential risk of bacterial dissemination due to the presence of cockroaches (Blattella germanica, Blattellidae) in low-income flats was investigated. Cockroaches can carry a great variety of bacterial species; we identified 30 different species from 52 different flats. Klebsiella oxycytoca, K. pneumoniae and Enterobacter cloacae were the most frequently found. Pathogenic and potentially pathogenic bacteria represented 54% of all the bacterial identifications. Bacteria were carried either on the cuticle or in the gut. Contamination through external contact is sufficient to insure bacterial diffusion. There was a very low level of overlap estimated by Pianka's index (a) between the bacterial flora of neighbouring blocks of flats, and (b) between bacterial flora of different flats in the same block.