What Is the Ideal Duration for Surgical Antibiotic Prophylaxis?

Background: Surgical antibiotic prophylaxis practice became common in the 1970s and has since become almost universal. The earliest articles used three doses over 12 hours with the first being administered before the start of the operation. Conclusions: The duration of prophylaxis has varied widely in practice over time, but an increasing body of evidence has supported shorter durations, most recently with recommendations in influential guidelines to avoid administration after the incision is closed.

Comparative Study of Histotripsy Pulse Parameters Used to Inactivate Escherichia coli in Suspension.

OBJECTIVE: Bacterial loads can be effectively reduced using cavitation-mediated focused ultrasound, or histotripsy. In this study, gram-negative bacteria (Escherichia coli) in suspension were used as model bacteria to evaluate the effectiveness of two regimens of histotripsy treatments: cavitation histotripsy (CH) and boiling histotripsy (BH). METHODS: Ten-milliliter volumes of Escherichia coli were treated at different negative focal pressure amplitudes and over time periods up to 40 min. Cavitation activity was characterized with coaxial passive cavitation detection (PCD) and synchronized plane wave B-mode imaging. RESULTS: CH treatments exhibited a threshold behavior that was consistent with PCD metrics of cavitation. Above the threshold, bacterial inactivation followed a monotonically increasing log-linear relationship that indicated an exponential inactivation rate. BH exhibited no threshold, but instead followed a different monotonically increasing inactivation rate. Inactivation rates were larger for BH at or below the CH threshold, and larger for CH substantially above the threshold. CH studies performed at different pulse lengths at the same duty cycle had similar inactivation rates, suggesting that at any given pressure amplitude, the "on time" was the most important variable for inactivating E. coli. The maximum inactivation was produced by CH at the highest pressure amplitudes used, leading to a log reduction >4.2 for a 40 min treatment. CONCLUSION: The results of this study suggest that both CH and BH can be used to inactivate E. coli in suspension, with the optimal regimen depending on the attainable peak negative focal pressure at the target.

Six Long-Standing Questions about Antibiotic Prophylaxis in Surgery.

Surgical site infections (SSIs) are the most common adverse event occurring in surgical patients. Optimal prevention of SSIs requires the bundled integration of a variety of measures before, during, and after surgery. Surgical antibiotic prophylaxis (SAP) is an effective measure for preventing SSIs. It aims to counteract the inevitable introduction of bacteria that colonize skin or mucosa into the surgical site during the intervention. This document aims to guide surgeons in appropriate administration of SAP by addressing six key questions. The expert panel identifies a list of principles in response to these questions that every surgeon around the world should always respect in administering SAP.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update.

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Early recognition and response to increases in surgical site infections using optimised statistical process control charts-The early 2RIS trial: A multicentre stepped wedge cluster randomised controlled trial.

Background: Traditional approaches for surgical site infection (SSI) surveillance have deficiencies that delay detection of SSI outbreaks and other clinically important increases in SSI rates. We investigated whether use of optimised statistical process control (SPC) methods and feedback for SSI surveillance would decrease rates of SSI in a network of US community hospitals. Methods: We conducted a stepped wedge cluster randomised trial of patients who underwent any of 13 types of common surgical procedures across 29 community hospitals in the Southeastern United States. We divided the 13 procedures into six clusters; a cluster of procedures at a single hospital was the unit of randomisation and analysis. In total, 105 clusters were randomised to 12 groups of 8-10 clusters. All participating clusters began the trial in a 12-month baseline period of control or "traditional" SSI surveillance, including prospective analysis of SSI rates and consultative support for SSI outbreaks and investigations. Thereafter, a group of clusters transitioned from control to intervention surveillance every three months until all clusters received the intervention. Electronic randomisation by the study statistician determined the sequence by which clusters crossed over from control to intervention surveillance. The intervention was the addition of weekly application of optimised SPC methods and feedback to existing traditional SSI surveillance methods. Epidemiologists were blinded to hospital identity and randomisation status while adjudicating SPC signals of increased SSI rates, but blinding was not possible during SSI investigations. The primary outcome was the overall SSI prevalence rate (PR=SSIs/100 procedures), evaluated via generalised estimating equations with a Poisson regression model. Secondary outcomes compared traditional and optimised SPC signals that identified SSI rate increases, including the number of formal SSI investigations generated and deficiencies identified in best practices for SSI prevention. This trial was registered at ClinicalTrials.gov, NCT03075813. Findings: Between Mar 1, 2016, and Feb 29, 2020, 204,233 unique patients underwent 237,704 surgical procedures. 148,365 procedures received traditional SSI surveillance and feedback alone, and 89,339 procedures additionally received the intervention of optimised SPC surveillance. The primary outcome of SSI was assessed for all procedures performed within participating clusters. SSIs occurred after 1171 procedures assigned control surveillance (prevalence rate [PR] 0.79 per 100 procedures), compared to 781 procedures that received the intervention (PR 0·87 per 100 procedures; model-based PR ratio 1.10, 95% CI 0.94-1.30, p=0.25). Traditional surveillance generated 24 formal SSI investigations that identified 120 SSIs with deficiencies in two or more perioperative best practices for SSI prevention. In comparison, optimised SPC surveillance generated 74 formal investigations that identified 458 SSIs with multiple best practice deficiencies. Interpretation: The addition of optimised SPC methods and feedback to traditional methods for SSI surveillance led to greater detection of important SSI rate increases and best practice deficiencies but did not decrease SSI rates. Additional research is needed to determine how to best utilise SPC methods and feedback to improve adherence to SSI quality measures and prevent SSIs. Funding: Agency for Healthcare Research and Quality.

It's about the patients: Practical antibiotic stewardship in outpatient settings in the United States.

Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or "smart prescribing" as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.

Paradoxical Association of Hyperglycemia and Surgical Complications Among Patients With and Without Diabetes.

Importance: Surgical complications associated with perioperative hyperglycemia are conventionally associated with diabetes, but, paradoxically, prior cohort studies have found that patients without diabetes have greater risk of complications at similar levels of hyperglycemia compared with patients with diabetes. Objective: To describe the association between perioperative hyperglycemia and surgical complications in a population of surgical patients without diabetes receiving routine blood glucose testing and insulin administration and to evaluate the potential correlation of perioperative hyperglycemia. Design, Setting, and Participants: This retrospective cohort study of National Surgical Quality Improvement Program-defined complications after operation took place at a single academic medical center hospital from January 2013 to October 2016. Consecutive patients undergoing general, vascular, and gynecologic operations who were expected to have at least a 48-hour admission were included. Hyperglycemia was defined as blood glucose level of 140 mg/dL or higher within 24 hours after surgery. Multivariate regression was used to assess the association of hyperglycemia and complications, stratified by hyperglycemia severity and adjusted for diabetes status. Analysis began in February 2022. Exposures: Routine blood glucose testing and insulin administration. Main Outcomes and Measures: The main outcomes are odds of experiencing perioperative hyperglycemia and postoperative complication, comparing patients with and without diabetes. Results: A total of 7634 patients (mean [SD] age, 53.5 [15.1] years; 6664 patients without diabetes [83.3%] and 970 patients with diabetes [17.7%]) underwent general (6204 [81.3%]), vascular (208 [2.7%]), and gynecologic (1222 [16%]) operations. Of these, 5868 (77%) had blood glucose testing (4899 individuals without diabetes [73.5%] and 969 [99.9%] with diabetes). Hyperglycemia occurred in 882 patients with diabetes (91%) and 2484 patients without diabetes (50.7%). Of those with blood glucose level more than 180 mg/dL, 1388 (72.7%) received insulin (658 patients with diabetes who had hyperglycemia [91%] and 680 patients without diabetes who had hyperglycemia [61%]). Adjusted odds of experiencing a complication were 83% greater for patients without vs with diabetes at blood glucose level of 140 to 179 mg/dL (odds ratio, 1.83 [95% CI, 0.93-3.6]), 49% greater for blood glucose level of 180 to 249 mg/dL (odds ratio, 1.49 [95% CI, 1.06-2.11]), and 88% greater for blood glucose level more than 250 mg/dL (odds ratio, 1.88 [95% CI, 1.11-3.17]). A similar trend was observed for serious complications. Insulin may mitigate the association of hyperglycemia and complications in patients without diabetes. Conclusions and Relevance: In this study, with near universal blood glucose testing and frequent insulin use, patients without diabetes paradoxically had worse outcomes than patients with diabetes at similar levels of hyperglycemia. Insulin may mitigate this effect and broader use may improve outcomes.

Gradually Increasing Surgical Site Infection Prevention Bundle with Monitoring of Potentially Preventable Infections Resulting in Decreasing Overall Surgical Site Infection Rate.

Objective: Reduction of surgical site infection. Methods: Retrospective evaluation of a surgical infection prevention program consisting of the gradual introduction of specific infection prevention methods and a surveillance system identifying and reporting on potentially preventable surgical site infections as defined by the omission of a preventive method. Setting: A university tertiary referral medical center. Results: The sequential introduction of infection prevention elements in the bundle resulted in a fluctuating rate of potentially preventable surgical site infections simultaneously with a slow, gradual reduction of the clean wound SSI rate. Conclusions: Change in a complex, multidisciplinary environment such as an inpatient surgical unit happens gradually and requires focused attention and input from all involved professionals.

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.

Aviation-Style Computerized Surgical Safety Checklist Displayed on a Large Screen and Operated by the Anesthesia Provider Improves Checklist Performance.

BACKGROUND: Many hospitals have implemented surgical safety checklists based on the World Health Organization surgical safety checklist, which was associated with improved outcomes. However, the execution of the checklists is frequently incomplete. We reasoned that aviation-style computerized checklist displayed onto large, centrally located screen and operated by the anesthesia provider would improve the performance of surgical safety checklist. METHODS: We performed a prospective before and after observational study to evaluate the effect of a computerized surgical safety checklist system on checklist performance. We created checklist software and translated our 4-part surgical safety checklist from wall poster into an aviation-style computerized format displayed onto a large, centrally located screen and operated by the anesthesia provider. Direct observers recorded performance of the first part of the surgical safety checklist that was initiated before anesthetic induction, including completion of each checklist item, provider participation and distraction level, resistance to use of the checklist, and the time required for checklist completion before and after checklist system implementation. We compared trends of the proportions of cases with 100% surgical safety checklist completion over time between pre- and postintervention periods and assessed for a jump at the start of intervention using segmented logistic regression model while controlling for potential confounding variables. RESULTS: A total of 671 cases were observed before and 547 cases were observed after implementation of the computerized surgical safety checklist system. The proportion of cases in which all of the items of the surgical safety checklist were completed significantly increased from 2.1% to 86.3% after the computerized checklist system implementation (P < .001). Before computerized checklist system implementation, 488 of 671 (72.7%) cases had <75% of checklist items completed, whereas after a computerized checklist system implementation, only 3 of 547 (0.5%) cases had <75% of checklist items completed. CONCLUSIONS: The implementation of a computerized surgical safety checklist system resulted in an improvement in checklist performance.

Patient-Directed Active Surgical Incisions Surveillance May Lead to Further Surgical Site Infection Reduction.

Background: Surgical site infections have been a concern for many years, and decades-old articles demonstrate the benefit of surveillance and reporting of these infections with resulting decrease in incidence. Comprehensive surveillance is difficult and often incomplete and is hampered when patients must travel a distance for surgical care. In recent years there has been increasing interest in patient-generated health data (PGHD) that includes patients taking photographs of their surgical incisions. Methods: A selective review of articles on PGHD and photographic images was undertaken in combination with interviews of investigators in this field. Results: There is a possibility that a well-developed system to facilitate patient-provided images of the surgical incision to surgical care providers in a Health Insurance Portability and Accountability Act (HIPAA)-compliant manner could improve surgical surveillance and reduce unnecessary post-operative visits. Conclusions: Further study is required.

Short-Course Antimicrobial Therapy Does Not Increase Treatment Failure Rate in Patients with Intra-Abdominal Infection Involving Fungal Organisms.

BACKGROUND: Fungi frequently are isolated in intra-abdominal infections (IAI). The Study to Optimize Peritoneal Infection Therapy (STOP-IT) recently suggested short-course treatment for patients with IAI. It remains unclear whether the presence of fungi in IAI affects the optimal duration of Antimicrobial therapy. We hypothesized that a shorter treatment course in IAI with fungal organisms would be associated with a higher rate of treatment failure. METHODS: Patients enrolled in the STOP-IT trial were stratified according to the presence or absence of a fungal isolate. They were analyzed as a subgroup based on original randomization to either the control group or an experimental group that received a four-day course of Antimicrobial therapy and by comparison with those without a fungal component to their infection. Descriptive comparisons were performed using a χ2, Fisher exact, or Kruskal-Wallis test as appropriate. The primary outcome was a composite of recurrent IAI, surgical site infection, and death. RESULTS: A total of 411 patients in the study (79%) had available culture data, of which 58 (14%) had positive fungal cultures. The most common organisms were Candida albicans and C. glabrata. The treatment failure rate was equivalent in the experimental and control arms (29.6% vs. 22.6%; p = 0.54). Patients with fungal isolates were more likely to have malignant disease (25.9% vs. 9.6%; p = 0.0004) and coronary artery disease (22% vs. 12%; p = 0.04), but were otherwise similar to those without fungal isolates. Patients with fungal isolates had more hospital days (median 10 vs. 7; p < 0.0001) and more days to resumption of enteral intake (median 5 vs. 3; p = 0.0006), but there was no difference in the composite outcome. CONCLUSIONS: Patients with IAI involving fungal organisms randomized to a shorter course of Antimicrobial therapy had no difference in the rate of treatment failure. These results suggest that the presence of fungi in IAI may not indicate independently the need for a longer course of Antimicrobial therapy.