Barriers and facilitators for surgical site infection surveillance for adult cardiac surgery in a high-income setting: an in-depth exploration.

BACKGROUND: Surgical site infection (SSI) surveillance aims to facilitate a reduction in SSIs through identifying infection rates, benchmarking, triggering clinical review and instituting infection control measures. Participation in surveillance is, however, variable suggesting opportunities to improve wider adoption. AIM: To gain an in-depth understanding of the barriers and facilitators for SSI surveillance in a high-income European setting. METHODS: Key informant interviews with 16 surveillance staff, infection prevention staff, nurses and surgeons from nine cardiac hospitals in England. Data were analysed thematically. FINDINGS: SSI surveillance was reported to be resource intensive. Barriers to surveillance included challenges associated with data collection: data being located in numerous places, multiple SSI data reporting schemes, difficulty in finding denominator data, lack of interface between computerized systems, 'labour intensive' or 'antiquated' methods to collect data (e.g., using postal systems for patient questionnaires). Additional reported concerns included: relevance of definitions, perceived variability in data reporting, lack of surgeon engagement, unsupportive managers, low priority of SSIs among staff, and a 'blame culture' around high SSI rates. Facilitators were increased resources, better use of digital technologies (e.g., remote digital wound monitoring), integrating surveillance within routine clinical work, having champions, mandating surveillance, ensuring a closer relationship between surveillance and improved patient outcomes, increasing the focus on post-discharge surveillance, and integration with primary care data. CONCLUSION: Using novel interviews with 'front-line' staff, identified opportunities for improving participation in SSI surveillance. Translating these findings into action will increase surveillance activity and bring patient safety benefits to a larger pool of surgical patients.

Assessing the added value of group B Streptococcus maternal immunisation in preventing maternal infection and fetal harm: population surveillance study.

OBJECTIVE: To assess the incidence of maternal group B Streptococcus (GBS) infection in England. DESIGN: Population surveillance augmented through data linkage. SETTING: England. POPULATION: All pregnant women accessing the National Health Service (NHS) in England. METHODS: Invasive GBS (iGBS) infections during pregnancy or within 6 weeks of childbirth were identified by linking Public Health England (PHE) national microbiology surveillance data for 2014 to NHS hospital admission records. Capsular serotypes of GBS were determined by reference laboratory typing of clinical isolates from women aged 15-44 years. Post-caesarean section surgical site infection (SSI) caused by GBS was identified in 21 hospitals participating in PHE SSI surveillance (2009-2015). MAIN OUTCOME MEASURES: iGBS rate per 1000 maternities; risk of GBS SSI per 1000 caesarean sections. RESULTS: Of 1601 patients diagnosed with iGBS infections in England in 2014, 185 (12%) were identified as maternal infections, a rate of 0.29 (95% CI 0.25-0.33) per 1000 maternities and representing 83% of all iGBS cases in women aged 18-44 years. Seven (3.8%) were associated with miscarriage. Fetal outcome identified excess rates of stillbirth (3.4 versus 0.5%) and extreme prematurity (<28 weeks of gestation, 3.7 versus 0.5%) compared with national averages (P < 0.001). Caesarean section surveillance in 27 860 women (21 hospitals) identified 47 cases of GBS SSI, with an estimated 4.24 (3.51-5.07) per 1000 caesarean sections, a median time-to-onset of 10 days (IQR 7-13 days) and ten infections that required readmission. Capsular serotype analysis identified a diverse array of strains with serotype III as the most common (43%). CONCLUSIONS: Our assessment of maternal GBS infection in England indicates the potential additional benefit of GBS vaccination in preventing adverse maternal and fetal outcomes.

International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass.

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Prevalence and incidence of surgical site infections in the European Union/European Economic Area: how do these measures relate?

BACKGROUND: In 2011-2012, the European Centre for Disease Prevention and Control (ECDC) initiated the first European point prevalence survey (PPS) of healthcare-associated infections (HCAIs) in addition to targeted surveillance of the incidence of specific types of HCAI such as surgical site infections (SSIs). AIM: To investigate whether national and multi-country SSI incidence can be estimated from ECDC PPS data. METHODS: In all, 159 hospitals were included from 15 countries that participated in both ECDC surveillance modules, aligning surgical procedures in the incidence surveillance to corresponding specialties from the PPS. National daily prevalence of SSIs was simulated from the incidence surveillance data, the Rhame and Sudderth (R&S) formula was used to estimate national and multi-country SSI incidence from the PPS data, and national incidence per specialty was predicted using a linear model including data from the PPS. FINDINGS: The simulation of daily SSI prevalence from incidence surveillance of SSIs showed that prevalence fluctuated randomly depending on the day of measurement. The correlation between the national aggregated incidence estimated with R&S formula and observed SSI incidence was low (correlation coefficient = 0.24), but specialty-specific incidence results were more reliable, especially when the number of included patients was large (correlation coefficients ranging from 0.40 to 1.00). The linear prediction model including PPS data had low proportion of explained variance (0.40). CONCLUSION: Due to a lack of accuracy, use of PPS data to estimate SSI incidence is recommended only in situations where incidence surveillance of SSIs is not performed, and where sufficiently large samples of PPS data are available.

Differential rates of group B streptococcus (GBS) colonisation in pregnant women in a racially diverse area of London, UK: a cross-sectional study.

OBJECTIVE: To describe the epidemiology of maternal group B streptococcus (GBS) colonisation by racial group. DESIGN: Cross-sectional study. SETTING: Antenatal clinics in London North West University Healthcare NHS Trust. POPULATION: Pregnant women. METHODS: Group B streptococcus (GBS) colonisation status was recorded during a screening programme for the prevention of invasive early-onset GBS infection. Information regarding age, address, ethnicity, parity, mode of delivery, body mass index (BMI), and diabetes was routinely collected. Data were analysed by multivariable analysis. MAIN OUTCOME MEASURES: Association between GBS colonisation and putative risk factors. RESULTS: Overall, 29.1% (1836/6309) of the women were colonized with GBS. Multivariable analysis showed significantly higher colonisation among women of black African origin (39.5%; OR = 1.57) compared with white British women (27.4%), and lowest colonisation in women of South Asian origin (23.3%; OR = 0.8). Higher parity (≥2) was associated with higher colonisation (35.3%), with the odds of colonisation over 40% higher than for nulliparous women. Increasing BMI was associated with an incremental rise in colonisation from 23 to 35%. Colonisation was not associated with age, season or mode of testing. CONCLUSION: This study identified high maternal GBS colonisation rates in a racially and socially diverse population. The highest rates were seen in women of black African origin and also with higher parity and BMI. Further research is needed to understand the relationship between these factors and rectovaginal colonisation. TWEETABLE ABSTRACT: Study of group B streptococcus colonisation in pregnant women in London shows highest rates in black African women and those with high BMI and parity.

The epidemiology and management of candidemia in Northern Ireland during 2002-2011, including a 12-month enhanced case review.

In Northern Ireland there are concerns about candidaemia, with rates higher than those reported in England and Wales. Our aim was to explore the epidemiology of candidaemia during a 10 year period and the clinical management upon suspicion of cases during a one year enhanced investigation in Northern Ireland.Candidaemia reports to the Public Health Agency were validated during 2002-2011 and used to examine incidence and antifungal sensitivity trends (during 2007-2011). A clinical proforma was used to collate information for all patients with candidaemia in 2011.The majority (96%) of isolates were captured through voluntary laboratory reporting. There was a year-on-year increase in candidaemia from 2002-2011, from 80 to 131 episodes (incidence rate ratio 1.09 95% CI 1.05-1.13). Rates were highest in males under 1 year and over 75 years. 83/98 (85%) of case notes were available from candidaemia patients during 2011. The most prevalent risk factors were patients on total parenteral nutrition (26 people, 31.3%), surgery in the two months prior to the candidaemia (25 people, 30.1%), significant steroid use in the previous 3 months (24 people, 28.9%) and active neoplastic disease (23 people, 27.7%),This study confirmed an increase in candidaemia rates over time, with the observed incidence in 2011 higher than England and Wales. We identified areas for improvement around the clinical management of candidaemia. We recommend raising the awareness of guidelines for fundoscopy, echocardiography and central venous catheter removal.

Severe group A streptococcal infections in mothers and their newborns in London and the South East, 2010-2016: assessment of risk and audit of public health management.

OBJECTIVE: We describe cases of invasive group A Streptococcus (iGAS) in mothers or neonates and assess management according to national guidelines, which recommend administering antibiotics to both mother and neonate if either develops iGAS infection within 28 days of birth and investigation of clusters in maternity units. DESIGN: Cross-sectional retrospective study. SETTING AND POPULATION: Notified confirmed iGAS cases in either mothers or neonates with onset within 28 days of birth in London and the South East of England between 2010 and 2016 METHOD: Review of public health records of notified cases. MAIN OUTCOME MEASURES: Incidence and onset time of iGAS in postpartum mothers and babies, proportion given prophylaxis, maternity unit clusters within 6 months. RESULTS: We identified 134 maternal and 21 neonatal confirmed iGAS infections. The incidence (in 100 000 person years) of iGAS in women within 28 days postpartum was 109 (95% CI 90-127) compared with 1.3 in other females aged 15-44. For neonates the incidence was 1.5 (95% CI 9-23). The median onset time was 2 days postpartum [interquartile range (IQR) 0-5 days] for mothers and 12 days (IQR 7-15 days) for neonates. All eligible mothers and most (109, 89%) eligible neonates received chemoprophylaxis. Of 20 clusters (59 cases of GAS and iGAS) in maternity units, two clusters involved possible transmission. However, in 6 of 15 clusters, GAS isolates were not saved for comparison even after relevant guidance was issued. CONCLUSIONS: iGAS infection remains a potential postpartum risk. Prophylaxis among neonates and storage of isolates from maternity cases can be improved. TWEETABLE ABSTRACT: Are public health guidelines being followed in the management of mothers and their newborns to reduce the risk of iGAS infection?

Impact of participation in a surgical site infection surveillance network: results from a large international cohort study.

BACKGROUND: Surveillance of surgical site infections (SSIs) is a core component of effective infection control practices, though its impact has not been quantified on a large scale. AIM: To determine the time-trend of SSI rates in surveillance networks. METHODS: SSI surveillance networks provided procedure-specific data on numbers of SSIs and operations, stratified by hospitals' year of participation in the surveillance, to capture length of participation as an exposure. Pooled and procedure-specific random-effects Poisson regression was performed to obtain yearly rate ratios (RRs) with 95% confidence intervals (CIs), and including surveillance network as random intercept. FINDINGS: Of 36 invited networks, 17 networks from 15 high-income countries across Asia, Australia and Europe participated in the study. Aggregated data on 17 surgical procedures (cardiovascular, digestive, gynaecological-obstetrical, neurosurgical, and orthopaedic) were collected, resulting in data concerning 5,831,737 operations and 113,166 SSIs. There was a significant decrease in overall SSI rates over surveillance time, resulting in a 35% reduction at the ninth (final) included year of surveillance (RR: 0.65; 95% CI: 0.63-0.67). There were large variations across procedure-specific trends, but strong consistent decreases were observed for colorectal surgery, herniorrhaphy, caesarean section, hip prosthesis, and knee prosthesis. CONCLUSION: In this large, international cohort study, pooled SSI rates were associated with a stable and sustainable decrease after joining an SSI surveillance network; a causal relationship is possible, although unproven. There was heterogeneity in procedure-specific trends. These findings support the pivotal role of surveillance in reducing infection rates and call for widespread implementation of hospital-based SSI surveillance in high-income countries.

Future priorities of acute hospitals for surgical site infection surveillance in England.

BACKGROUND: Since the launch of the national Surgical Site Infection (SSI) Surveillance Service in 1997, successive expansions of the programme provided hospitals with increasing flexibility in procedures to target through surveillance. Ensuring that the programme continues to meet hospitals' needs remains essential. AIM: As a means to inform the future direction of the service, a survey of all acute National Health Service trusts was undertaken to assess and understand priorities for surveillance. METHODS: A web-based survey was circulated to acute NHS trust infection control teams in England, asking them to identify and rank (i) reasons for undertaking current SSI surveillance, (ii) priority surgical categories for future SSI surveillance, and (iii) reasons for prioritizing these categories. FINDINGS: Of the 161 trusts surveyed, 84 (52%) responded. Assessment of quality of care was identified as the most common driver for SSI surveillance activity. Considerable heterogeneity in priority areas was observed, with 24 different surgical categories selected as top priority. Of the procedures undertaken by 15 or more trusts, caesarean section (2.7), hip replacement (2.8) and coronary artery bypass graft (2.9) were highest ranked. All 17 categories in the current surveillance programme were selected as a top priority by one or more trusts. CONCLUSION: Whereas the majority of hospitals' priorities for SSI surveillance are included in the current programme, the top-ranked priority, caesarean section, is not included. Given the diversity of priority areas, maintaining a comprehensive spectrum of categories in the national programme is essential to assist hospitals in addressing local priorities.

Mycobacterium chimaera infection following cardiac surgery in the United Kingdom: clinical features and outcome of the first 30 cases.

OBJECTIVES: Mycobacterium chimaera infection following cardiac surgery, due to contaminated cardiopulmonary bypass heater-cooler units, has been reported worldwide. However, the spectrum of clinical disease remains poorly understood. To address this, we report the clinical and laboratory features, treatment and outcome of the first 30 UK cases. METHODS: Case note review was performed for cases identified retrospectively through outbreak investigations and prospectively through ongoing surveillance. Case definition was Mycobacterium chimaera detected in any clinical specimen, history of cardiothoracic surgery with cardiopulmonary bypass, and compatible clinical presentation. RESULTS: Thirty patients were identified (28 with prosthetic material) exhibiting a spectrum of disease including prosthetic valve endocarditis (14/30), sternal wound infection (2/30), aortic graft infection (4/30) and disseminated (non-cardiac) disease (10/30). Patients presented a median of 14 months post surgery (maximum 5 years) most commonly complaining of fever and weight loss. Investigations frequently revealed lymphopenia, thrombocytopenia, liver cholestasis and non-necrotizing granulomatous inflammation. Diagnostic sensitivity for a single mycobacterial blood culture was 68% but increased if multiple samples were sent. In all, 27 patients started macrolide-based combination treatment and 14 had further surgery. To date, 18 patients have died (60%) a median of 30 months (interquartile range 20-39 months) after initial surgery. Survival analysis identified younger age, mitral valve surgery, mechanical valve replacement, higher serum sodium concentration and lower C-reactive protein as factors associated with better survival. CONCLUSIONS: Mycobacterium chimaera infection following cardiac surgery is associated with a wide spectrum of disease. The diagnosis should be considered in all patients who develop an unexplained illness following cardiac surgery.

Have reducing tonsillectomy rates in England led to increasing incidence of invasive Group A Streptococcus infections in children?

OBJECTIVES: To determine whether there is a correlation between falling tonsillectomy numbers and increasing numbers of tonsillitis admissions and invasive Group A ß-haemolytic streptococcus (iGAS) infection in children aged 14 and under in England. DESIGN: An observational cross-sectional study was performed. SETTING: The data extracted covered the period from 1991 until 2014. PARTICIPANTS: Hospital admissions for tonsillectomies, tonsillitis/pharyngitis and all diagnoses of iGAS in children aged 14 and under who had a tonsillectomy. MAIN OUTCOME MEASURES: Correlation between trends in tonsillectomies, tonsillitis/pharyngitis and iGAS. RESULTS: Across all age groups, there was a dramatic reduction in the total number of tonsillectomies performed in England from 28 309 in 1990/1991, down to 6327 in 2013/2014 (77.7% reduction). The numbers of hospital admissions for management of acute tonsillitis and pharyngitis have risen dramatically. iGAS numbers have increased steadily over this time period and more than doubled in children aged 14 and under. There are significant negative correlations between the trend in iGAS infections and numbers of tonsillectomies in all ages. There are also strong positive correlations between the trend in numbers of tonsillitis episodes and the number of iGAS infections in all under 14-year groups; the strongest correlation was seen in the 1- to 4-year age group (+0.92 Pearson correlation coefficient). CONCLUSIONS: There appears to be a correlation between falling tonsillectomy numbers, increasing hospital admissions with tonsillitis and rising iGAS infection in England. Further studies are required to assess the aetiological role of tonsillitis in predisposing to iGAS infection and the potential societal benefit of tonsillectomies.

Estimating the risk of invasive group A Streptococcus infection in care home residents in England, 2009-2010.

Invasive group A streptococcal (iGAS) infections cause severe disease and death, especially in residents of long-term care facilities (LTCFs). In order to inform iGAS prevention, we compared the risk of iGAS in LTCF residents and community residents. We identified LTCF residents among cases of iGAS from national surveillance (2009-2010) using postcode matching, and cases of hospital-acquired infections via hospital admission records. We used Poisson regression to calculate incidence rate ratios (IRR) and logistic regression to explore factors associated with case fatality rate (CFR). A total of 2741 laboratory-confirmed iGAS cases were matched to a hospital admission: 156 (6%) were defined as hospital-acquired. Out of the total cases, 96 (3·5%) were LTCF residents. Compared with community residents, LTCF residents over 75 years of age had a higher risk of iGAS infection (IRR = 1·7; 95% CI 1·3-2·1) and CFR (OR = 2·3; 95% CI 1·3-3·8). Amongst community-acquired cases, the risk of iGAS in LTCF residents between 75 and 84 years of age doubled (IRR = 2·7; 95% CI 1·8-3·9) compared with their community counterparts. The CFR among community-acquired cases was higher in LTCF residents than community residents (21% vs. 11%). Age remained associated with death in our final model. Our study showed that, even controlling for age, LTCF residents have a higher risk of acquiring and dying from iGAS. Whilst existing co-morbidities may explain this, it is reasonable to assume that the institutional setting may facilitate transmission. Therefore, cases in LTCF require prompt investigation together with a better understanding of factors contributing to the acquisition of infection.

Microbiological problems and biofilms associated with Mycobacterium chimaera in heater-cooler units used for cardiopulmonary bypass.

The role of heater-cooler units (HCUs) in the transmission of Mycobacterium chimaera during open heart surgery has been recognized since 2013. Subsequent investigations uncovered a remarkable global outbreak reflecting the wide distribution of implicated devices. HCUs are an essential component of cardiopulmonary bypass operations and their withdrawal would severely affect capacity for life-saving cardiac surgery. However, studies have demonstrated that many HCUs are contaminated with a wide range of micro-organisms, including M. chimaera and complex biofilms. Whole genome sequencing of M. chimaera isolates recovered from one manufacturer's HCUs, worldwide, has demonstrated a high level of genetic similarity, for which the most plausible hypothesis is a point source contamination of the devices. Dissemination of bioaerosols through breaches in the HCU water tanks is the most likely route of transmission and airborne bacteria have been shown to have reached the surgical field even with the use of ultraclean theatre ventilation. Controlling the microbiological quality of the water circulating in HCUs and reducing biofilm formation has been a major challenge for many hospitals. However, enhanced decontamination strategies have been recommended by manufacturers, and, although they are not always effective in eradicating M. chimaera from HCUs, UK hospitals have not reported any new cases of M. chimaera infection since implementing these mitigation strategies. Water safety groups in hospitals should be aware that water in medical devices such as HCUs may act as a vector in the transmission of potentially fatal water-borne infections.

Outcome of a screening programme for the prevention of neonatal invasive early-onset group B Streptococcus infection in a UK maternity unit: an observational study.

BACKGROUND: Against a background of failure to prevent neonatal invasive early-onset group B Streptococcus infections (GBS) in our maternity unit using risk-based approach for intrapartum antibiotic prophylaxis, we introduced an antenatal GBS carriage screening programme to identify additional women to target for prophylaxis. OBJECTIVES: To describe the implementation and outcome of an antepartum screening programme for prevention of invasive early-onset GBS infection in a UK maternity unit. DESIGN: Observational study of outcome of screening programme (intervention) with comparison to historical controls (preintervention). SETTING: Hospital and community-based maternity services provided by Northwick Park and Central Middlesex Hospitals in North West London. PARTICIPANTS: Women who gave birth between March 2014 and December 2015 at Northwick Park Hospital. METHODS: Women were screened for GBS at 35-37 weeks and carriers offered intrapartum antibiotic prophylaxis. Screening programme was first introduced in hospital (March 2014) and then in community (August 2014). Compliance was audited by review of randomly selected case records. Invasive early-onset GBS infections were defined through GBS being cultured from neonatal blood, cerebrospinal fluid or sterile fluids within 0-6 days of birth. MAIN OUTCOME: Incidence of early-onset GBS infections. RESULTS: 6309 (69%) of the 9098 eligible women were tested. Screening rate improved progressively from 42% in 2014 to 75% in 2015. Audit showed that 98% of women accepted the offer of screening. Recto-vaginal GBS carriage rate was 29.4% (1822/6193). All strains were susceptible to penicillin but 11.3% (206/1822) were resistant to clindamycin. Early onset GBS rate fell from 0.99/1000 live births (25/25276) in the prescreening period to 0.33/1000 in the screening period (Rate Ratio=0.33; p=0.08). In the subset of mothers actually screened, the rate was 0.16/1000 live births (1/6309), (Rate Ratio=0.16; p<0.05). CONCLUSIONS: Our findings confirm that an antenatal screening programme for prevention of early-onset GBS infection can be implemented in a UK maternity setting and is associated with a fall in infection rates.

Impact of national policies on the microbial aetiology of surgical site infections in acute NHS hospitals in England: analysis of trends between 2000 and 2013 using multi-centre prospective cohort data.

Our study aimed to evaluate changes in the epidemiology of pathogens causing surgical site infections (SSIs) in England between 2000 and 2013 in the context of intensified national interventions to reduce healthcare-associated infections introduced since 2006. National prospective surveillance data on target surgical procedures were used for this study. Data on causative organism were available for 72% of inpatient-detected SSIs meeting the standard case definitions for superficial, deep and organ-space infections (9767/13 531) which were analysed for trends. A multivariable logistic linear mixed model with hospital random effects was fitted to evaluate trends by pathogen. Staphylococcus aureus was the predominant cause of SSI between 2000 (41%) and 2009 (24%), decreasing from 2006 onwards reaching 16% in 2013. Data for 2005-2013 showed that the odds of SSI caused by S. aureus decreased significantly by 14% per year [adjusted odds ratio (aOR) 0·86, 95% confidence interval (CI) 0·83-0·89] driven by significant decreases in methicillin-resistant S. aureus (MRSA) (aOR 0·71, 95% CI 0·68-0·75). However a small significant increase in methicillin-sensitive S. aureus was identified (aOR 1·06, 95% CI 1·02-1·10). Enterobacteriaceae were stable during 2000-2007 (12% of cases overall), increasing from 2008 (18%) onwards, being present in 25% of cases in 2013; the model supported these increasing trends during 2007-2013 (aOR 1·12, 95% CI 1·07-1·18). The decreasing trends in S. aureus SSIs from 2006 and the increases in Enterobacteriaceae SSIs from 2008 may be related to intensified national efforts targeted at reducing MRSA bacteraemia combined with changes in antibiotic use aimed at controlling C. difficile infections.

Impact of obesity on the risk of wound infection following surgery: results from a nationwide prospective multicentre cohort study in England.

We sought to assess the impact of body mass index on the risk of surgical site infection in a prospective cohort study of 206 National Health Service (NHS) hospitals in England between 2007 and 2011. Body mass index was available for 159,720 of 350,089 operations among patients undergoing abdominal hysterectomy, coronary artery bypass graft, hip replacement, knee replacement, or large-bowel surgery. Among these patients, the risk of surgical site infection ranged from 0.65% for knee replacement to 11.04% for large-bowel surgery. Overall, 127,512 (79.8%) patients were overweight or obese (body mass index of ≥25 kg/m(2)). Obesity was associated with a 1.1-fold to 4.4-fold increase in the adjusted odds of developing surgical site infection as compared with normal weight, depending on the type of surgery. The population-attributable fraction (PAF) for body mass index was greatest in overweight (body mass index of 25.0-29.9 kg/m(2)) patients undergoing coronary artery bypass graft, accounting for 15% of their overall risk of surgical site infection (PAF 0.15; 95% CI 0.09-0.22). Being overweight or obese substantially increased the likelihood of patients developing surgical site infection. Given the increasingly high proportion of the surgical population who are overweight, this is likely to place a considerable additional burden on the NHS. Strategies for mitigating this excess risk need to be found.

The cost of hospital care for management of invasive group A streptococcal infections in England.

The objective of this study was to estimate the direct financial costs of hospital care for management of invasive group A streptococcal (GAS) infections using hospital records for cases diagnosed in England. We linked laboratory-confirmed cases (n = 3696) identified through national surveillance to hospital episode statistics and reimbursement codes. From these codes we estimated the direct hospital costs of admissions. Almost all notified invasive GAS cases (92% of 3696) were successfully matched to a primary hospital admission. Of these, secondary admissions (within 30 days of primary admission) were further identified for 593 (17%). After exclusion of nosocomial cases (12%), the median costs of primary and secondary hospital admissions were estimated by subgroup analysis as £1984-£2212 per case, totalling £4·43-£6·34 million per year in England. With adjustment for unmatched cases this equated to £4·84-£6·93 million per year. Adults aged 16-64 years accounted for 48% of costs but only 40% of cases, largely due to an increased number of surgical procedures. The direct costs of hospital admissions for invasive GAS infection are substantial. These estimated costs will contribute to a full assessment of the total economic burden of invasive GAS infection as a means to assess potential savings through prevention measures.

Increase in scarlet fever notifications in the United Kingdom, 2013/2014.

Increases in scarlet fever above usual seasonal levels are currently being seen across the United Kingdom. Medical practitioners have been alerted to the exceptional increase in incidence. Given the potential for this to signal a population increase in invasive group A streptococcal disease, close monitoring of invasive disease is essential.