Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017

IMPORTANCE: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. OBJECTIVE: To provide new and updated evidence-based recommendations for the prevention of SSI. EVIDENCE REVIEW: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. FINDINGS: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. CONCLUSIONS AND RELEVANCE: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Necrotizing pancreatitis: a surgical approach independent of documented infection.

BACKGROUND: Strategies for the management of patients with necrotizing pancreatitis remain controversial. While consensus opinion supports operative necrosectomy for the treatment of infected pancreatic necrosis, the timing for surgical intervention is not completely resolved. Further, the indication for the surgical management of sterile pancreatic necrosis is also subject to debate. METHODS: The objective of this study was to evaluate outcome measures for the surgical management of necrotizing pancreatitis, independent of documented infection. A retrospective review was undertaken between 1994 and 2002 at a single county hospital. RESULTS: Twenty-one patients with CT-documented necrotizing pancreatitis underwent operative pancreatic necrosectomy with laparostomy within 21 days of initial diagnosis and had an average of three reoperations. Average length of stay (LOS) in the ICU was 36 days and in the hospital 67 days. Ten patients had documented infected necrosis based on initial intra-operative cultures, while I I had sterile necrosis. Overall, 95% (20/21) of the patients had a complication, with an average of three complications per patient. Common complications included ARDS (71%), sepsis (33%), renal failure (24%), and pneumonia (24%). The overall mortality rate was 14% (3/21), with a mean follow-up of 469 days. DISCUSSION: The surgical management of acute necrotizing pancreatitis, independent of documented infection, can be undertaken within 3 weeks of diagnosis with an acceptable morbidity and a low mortality rate. Creation of a laparostomy to enable ready, atraumatic debridement of the retroperitoneum is a safe alternative to standard repeat laparotomies and thus represents a useful adjunct to the surgical management of necrotizing pancreatitis.

Cinematic nuclear scintigraphy reliably directs surgical intervention for patients with gastrointestinal bleeding.

HYPOTHESIS: Cinematic technetium Tc 99m red blood cell ((99m)Tc-RBC) scans, in which real-time scanning is performed and analyzed, can accurately localize gastrointestinal bleeding and thus direct selective surgical intervention. DESIGN: Retrospective medical record review with historical controls. SETTING: Large, university-affiliated public hospital in urban setting. PATIENTS: Twenty-six patients presenting with upper and lower gastrointestinal hemorrhage who underwent cinematic (99m)Tc-RBC scan examinations between 1990 and 1997 and required surgical intervention to control the bleeding. INTERVENTIONS: All patients with gastrointestinal bleeding underwent open surgical procedures to provide cessation of bleeding and resection of appropriate abnormalities. MAIN OUTCOME MEASURES: Patient outcome was based on correlation between preoperative RBC scans and intraoperative findings, surgical pathology, and postoperative clinical course. RESULTS: Twenty-five (96%) of 26 scans were interpreted as positive for gastrointestinal bleeding. In 22 of these 25 scans, the site of bleeding was correctly identified for a sensitivity of 88%. One or more additional diagnostic tests were performed on 19 (73%) of 26 patients, and included angiography and flexible endoscopy. The most common operation performed to control bleeding was a hemicolectomy (14/26). Diverticulosis was the most prevalent diagnosis (46%). Two patients (8%) experienced rebleeding after operation. The overall mortality rate was 19% (5/26). CONCLUSIONS: Cinematic (99m)Tc-RBC scintigraphy is a sensitive, noninvasive alternative to mesenteric angiography for accurately localizing the site of gastrointestinal hemorrhages. As such, this technique can be reliably used to direct selective surgical intervention.

Laparoscopic vs open adrenalectomy for the treatment of primary hyperaldosteronism.

HYPOTHESIS: That the clinical presentations, biochemical profiles, and surgical outcomes of patients treated with laparoscopic vs open adrenalectomy for primary hyperaldosteronism are different. DESIGN, SETTINGS, PATIENTS, AND INTERVENTIONS: The medical records of 80 patients with primary hyperaldosteronism who underwent open adrenalectomy between 1975 and 1986 or laparoscopic adrenalectomy between 1993 and 1998 at the University of California-San Francisco were reviewed by a single unblinded researcher (W.T.S.). MAIN OUTCOME MEASURES: Severity of hypertension and hypokalemia at diagnosis, their improvement after adrenalectomy, and operative complications. RESULTS: Thirty-eight patients underwent open adrenalectomy and 42 patients underwent laparoscopic adrenalectomy. The patients who underwent open adrenalectomy had documented hypertension for a median of 5 years before surgery; all had diastolic blood pressures greater than 100 mm Hg. Laparoscopically treated patients had documented hypertension for a median of 2.5 years preoperatively, and 20 (48%) had diastolic blood pressures greater than 100 mm Hg. The median preoperative serum potassium levels for the open and laparoscopic groups were 2.6 mmol/L and 3.3 mmol/L, respectively; the mean serum aldosterone levels were 1.47 nmol/L and 1.30 nmol/L. Thirty-two (84%) of the 38 patients who underwent open surgery and 41 (98%) of the 42 patients treated laparoscopically had adrenal adenomas. The sensitivity of preoperative computed tomographic scanning for adenomas was 83% for the patients treated with open adrenalectomy and 93% for those treated laparoscopically. There were 4 postoperative complications in the open surgery group and none in the laparoscopic group. Postoperatively, 30(81%) of 37 patients (excluding 1 patient who died of adrenocortical carcinoma) in the open surgery group and 37 (88%) of 42 patients treated laparoscopically were normotensive. Post-operative values were 3.6 to 5.0 of serum potassium per liter and 3.5 to 4.9 of serum potassium per liter in the open and laparoscopic groups, respectively. CONCLUSIONS: Patients who are treated with laparoscopic adrenalectomy for primary hyperaldosteronism are being referred with less severe hypertension and hypokalemia than patients formerly treated with open adrenalectomy. Patients treated laparoscopically had fewer postoperative complications and were equally likely to improve in blood pressure and hypokalemia. Laparoscopic adrenalectomy has become the treatment of choice for patients with primary hyperaldosteronism because of lower morbidity.

Leukocytosis and free fluid are important indicators of isolated intestinal injury after blunt trauma.

BACKGROUND: The detection of isolated intestinal injuries after blunt trauma can be difficult because of subtle signs and symptoms, often leading to delayed diagnosis. We hypothesized that specific clinical indicators could be identified to assist in the diagnosis of these injuries. METHODS: Medical records of all patients with such injuries from 1988 to 1996 were reviewed. The patients were stratified into those operated on within 6 hours of presentation (apparent injury) and those operated on after 6 hours (occult injury), and the data were compared. RESULTS: Forty-six patients with isolated intestinal injuries were identified. There were no differences in the rate of peritonitis or free fluid on abdominal computed tomography, blood loss, intraoperative findings, or morbidity and mortality between groups. Leukocytosis (sensitivity, 84.8%; specificity, 55.2%; p = 0.01) and free fluid on computed tomography were frequently present, however, and their significance was underappreciated in the occult injury group. CONCLUSION: After blunt abdominal trauma in patients without obvious indications for invasive evaluation of the abdomen (e.g., peritoneal lavage, laparoscopy, laparotomy), leukocytosis can indicate an intestinal injury. Additionally, unexplained free fluid on abdominal computed tomography must be aggressively evaluated.

Necrotizing soft tissue infection masquerading as cutaneous abcess following illicit drug injection.

OBJECTIVE: To assess factors that might predict serious necrotizing soft tissue infections following illicit drug injection. DESIGN: A retrospective review of a consecutive case series. SETTING: An urban municipal hospital. PATIENTS: Thirty patients presenting with cutaneous abscesses resulting from illicit drug injections during a 5-year period. All cases presented clinically with fluctuance, erythema, or induration but required extensive debridement at the time of incision and drainage. INTERVENTIONS: Operative treatment employed wide incision, routine subfascial examination, and aggressive debridement. Clinical management included broad-spectrum antibiotics, critical care support, and reconstructive procedures. MAIN OUTCOME MEASURES: Mortality, extent of debridement, preoperative vital signs and laboratory values, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, bacteriologic and pathologic test results. RESULTS: Postoperatively, all patients were housed in the intensive care unit for 8.4 +/- 14.5 days. Six patients died (20%). On arrival at the intensive care unit, systolic blood pressure was 80 mm Hg or less in 2 patients, 1 of whom died. White blood cell count on hospital admission was elevated in 27 of 30 patients (mean, 27.2 +/- 15.3 x 10(9)/L) and 2 patients were identified as having human immunodeficiency virus infection. All patients underwent initial surgery less than 24 hours after admission; following debridement, the average wound size was 276 +/- 238 cm2 (range, 15-783 cm2). Five patients required extremity amputation, and all other survivors underwent reconstruction with skin grafts and/or myocutaneous flaps. All but 1 patient were reexamined in the operating room within 12 hours and underwent an average of 3.1 +/- 1.6 operative procedures. Of those wound cultures obtained in the operating room, there was no pattern to the bacteriologic isolates. Seventeen patients had mixed isolates and 11 had single organisms. Pathologic findings in 20 patients included panniculitis (3 patients), necrotizing fasciitis (11 patients), myositis (6 patients), and osteomyelitis (1 patient). We failed to identify any clinical factor, including temperature, heart rate, systolic blood pressure, white blood cell count, base deficit, albumin level, PO2, or APACHE II score that could predict mortality or the requirement for extensive debridement. CONCLUSIONS: Parenteral injections of illicit drugs can produce infections that present with signs of simple cutaneous abscess and yet unpredictably become extensive necrotizing soft tissue infections. Treatment requires a high index of suspicion along with an inquisitive operative approach to avoid missing these potentially serious infections.

Recurrent pyogenic cholangitis.

BACKGROUND: Recurrent pyogenic cholangitis is a complex biliary tract disease characterized by intrahepatic pigment stones, endemic to Southeast Asia and seen with increasing frequency in the United States. The purpose of this study was to review the management of this disorder in a county hospital. METHODS: A retrospective review of 45 patients with recurrent pyogenic cholangitis evaluated between 1984 and 1995. The clinical and surgical management of patients with localized versus bilateral hepatolithiasis were compared. RESULTS: The prevalence of recurrent pyogenic cholangitis at our hospital has more than doubled since 1983. Fourteen of 45 patients (31%) had bilateral disease and required more abdominal computed tomography scans (P < 0.01), percutaneous cholangiograms (P < 0.05), endoscopies (P < 0.01), clinic visits (P < 0.05), and hospital admissions (P < 0.02) as compared with patients with localized disease. CONCLUSIONS: The effective treatment of recurrent pyogenic cholangitis requires definition of the patients' intrahepatic distribution of disease, prior to surgical intervention, and the coordinated efforts of gastroenterologists, radiologists, and surgeons.

[Perioperative therapy of HIV infections]. / Perioperative Therapie bei HIV-Infektionen.

A meta-analysis of the literature demonstrates high operation complication rates in HIV-positive patients. Own experience connected with a general hospital in San Francisco, University of California, indicates that such an analysis provides the surgeon with the possibility of optimizing the treatment of HIV-positive patients in the perioperative phase.

Surgical risk assessment and management in patients with HIV disease.

Determining the perioperative risks associated with surgical procedures performed in patients with HIV disease is a difficult and complex task. Because HIV is a contagious, blood-borne pathogen, it threatens the health and well-being of both patient and health care provider. Despite poor early results, there is now convincing evidence that HIV infection is not a significant, independent risk factor for major surgical procedures. In practice, the authors evaluate the risk of surgery in patients with HIV infection using the same basic tools and guidelines applied to the uninfected, with the best predictors of surgical morbidity and mortality stemming from a careful and accurate assessment of the patient's cardiopulmonary, renal, endocrine, and nutritional reserve. Although HIV disease provides a unique constellation of diagnoses and challenges to the health care provider, the risk of major surgery in this population is not unlike that for other immunocompromised or malnourished patients. The authors believe that members of the surgical team have a professional, moral, and ethical responsibility to provide the highest possible quality of care for their patients, regardless of their HIV status. If after weighing the risks and benefits to the patient the surgeon believes the procedure will have a positive effect on the patient's life, the surgeon must offer surgical treatment. To do less does a disservice to the patient, the provider, and the profession as a whole.

Laparoscopic adrenalectomy. Comparison of the lateral and posterior approaches.

OBJECTIVE: To compare the lateral transabdominal and posterior retroperitoneal laparoscopic methods for performing adrenalectomy. DESIGN: Nonrandomized. SETTING: Hospitals affiliated with the University of California, San Francisco. PATIENTS: Thirty-six patients (15 men and 21 women), aged 5 to 78 years (mean age, 49 years), were treated for the following conditions: aldosteronoma, 18 patients; pheochromocytoma, 4 patients; Cushing syndrome, 6 patients; androgen-secreting tumor, 1 patient; nonfunctioning adenoma, 3 patients; adrenal hemorrhage, 1 patient; metastatic neoplasm, 2 patients; and myelolipoma, 1 patient. INTERVENTIONS: Twenty-three lateral and 14 posterior laparoscopic adrenalectomies. MAIN OUTCOME MEASURES: Success rate, operating time, complications, and length of hospital stay. RESULTS: The tumors, which ranged in size from 1 to 13 cm (mean, 4.2 cm; median, 2.5 cm), were all successfully resected laparoscopically. All 8 tumors larger than 6 cm were resected by the lateral approach. One critically ill patient died. No patient required blood transfusions or conversion to laparotomy. Mean operating time was 3.8 hours vs 3.4 hours (median, 3.5 hours vs 3 hours) and mean hospital stay was 2.2 days vs 1.5 days (median, 2 days vs 1 day) for the lateral and posterior approaches, respectively. All patients without concomitant procedures were ready to be discharged within 48 hours. CONCLUSIONS: Both approaches were effective and safe. We prefer the lateral approach for tumors larger than 6 cm and the posterior approach for bilateral tumors.

Are universal precautions realistic?

In concluding whether universal precautions are necessary, it certainly appears that we need something to reduce the significant problem of HIV transmission to health-care providers. As occupational risk goes, it exceeds the occupational risk of a number of other high-risk professions. Unfortunately, we do not know if universal precautions are effective. We also do not know the true compliance rate in use of universal precautions, nor whether they have an impact on transmission even if effectively used. What are the alternatives? They are not great, but some have not been adequately explored or implemented. Re-engineering around needle use in the hospital is clearly the most likely area to produce concrete results, because needlesticks are overwhelmingly the greatest source of infection, but this has not been encouraged to the degree it could be, even with systems already developed. Universal testing does not appear to be a viable alternative, for numerous reasons already discussed. Finally, are universal precautions more important for other pathogens than HIV? I would say yes. Hepatitis B, hepatitis C, and nosocomial infections are more important both as public health issues and as health-care provider prevention issues. If universal precautions are effective in reducing any of these, they are worthwhile.

Trauma centers in a managed care environment.

Health care reform will affect the relationship of trauma centers to health maintenance organizations and other managed care plans. We studied Kaiser Permanente Medical Center (Kaiser) members admitted to the Trauma Center at San Francisco General Hospital (SFGH) to determine: (1) variables predicting transfer from SFGH to a Kaiser Hospital (repatriation), (2) the length of hospital stay (LOS), and (3) the cost of their care. The SFGH trauma registry provided data on 7,794 patients admitted before 1994. To investigate LOS, 89 Kaiser patients over 1 year were matched with non-Kaiser patients on age, maximum Abbreviated Injury Scale score (MAIS) by body region, Injury Severity Score (ISS), head injury severity, and blunt or penetrating injury and disposition. Kaiser patients were significantly younger, more likely to have blunt injury, and had a lower death rate. Significant predictors of repatriation were an MAIS score > or = 3, abdominal or extremity injury, and an ISS score of 26 to 40. The mean LOS for all Kaiser patients was 7.6 days, compared with 4.8 for controls (p = 0.20). However, mean LOS was significantly longer in repatriated Kaiser patients compared with controls (16 vs. 7.8 days, p < 0.0005). Kaiser reimbursement rates were comparable with commercial payors, but higher than others. A relatively small number of severely injured patients account for a large percentage of costly trauma care. Analyses of patient subsets are necessary for trauma centers to negotiate suitable relationships with managed care plans. A prospective study is needed to examine the cost efficiency of early transfer of managed care patients.

Volunteer low-risk outpatient surgery for uninsured patients in San Francisco. The Ambulatory Surgery Access Coalition.

OBJECTIVE: To provide uncompensated elective low-risk outpatient surgery for uninsured patients through a coalition of volunteer physicians, nurses, and hospitals. DESIGN: Description of the process of establishing the Ambulatory Surgery Access Coalition (ASAC), the political and administrative obstacles encountered, and the clinical results of treatment of the first 25 patients in the pilot project. SETTING: The ASAC includes the Kaiser Foundation Hospital, San Francisco, Calif, the University of California, San Francisco, the San Francisco General Hospital (SFGH), the San Francisco Department of Public Health, the San Francisco Consortium of Community Clinics, the Northern California Chapter of the American College of Surgeons, and the San Francisco Medical Society. A pilot program of uncompensated outpatient surgery was performed at the Kaiser Foundation Hospital. PATIENTS: Twenty-nine patients were referred to the ASAC between January 1 and November 1, 1994. Twenty-six patients were judged to be candidates for surgery, and 25 patients met the criteria for the ASAC program. One patient was referred to SFGH for treatment because of a perceived increased risk for hospitalization after surgery. RESULTS: Twenty-one patients underwent herniorrhaphy; three, excision of large inclusion cysts; and one, anal fistulotomy. Seventeen procedures were done under local anesthesia, seven under general anesthesia, and one under spinal anesthesia. None of the patients required hospital admission. No wound infections occurred. CONCLUSION: The ASAC successfully provided uncompensated low-risk outpatient surgery to 25 low-income uninsured patients in San Francisco. The coalition hopes, first, to include other San Francisco hospitals and surgical specialties, and second, to serve as a model for other communities throughout the country.

Emergent abdominal surgery in AIDS: experience in San Francisco.

Several recent reviews have suggested that aggressive surgical intervention can reduce morbidity and mortality associated with intra-abdominal crises in AIDS patients. We reviewed our experience with 57 AIDS patients with 63 emergent laparotomies performed at 4 hospitals affiliated with the University of California in San Francisco. Fifty-five patients (96%) were homosexual men. Thirty-nine (68%) had been treated for an opportunistic infection. Indications for exploration included right lower quadrant pain consistent with appendicitis in 24 patients (38%), visceral perforation or obstruction in 11 (17%), right upper quadrant pain in 9 (14%), diffuse peritonitis in 8 (13%), and uncontrollable hemorrhage in 8 (13%). Perioperative mortality was 12% (7/57). Fifteen patients (26%) suffered major complications including pneumonia, sepsis, multi-organ failure, and intra-abdominal abscess. Forty-five of 50 survivors (90%) were receiving some type of chronic antimicrobial or antineoplastic chemotherapy, compared to only 2 of the 7 patients who died (28.6%) (P < 0.001). Lack of ongoing prophylactic treatment for AIDS-related disease, active opportunistic infections, Walter Reed VI classification, and ongoing sepsis at the time of exploration were noted to be associated with increased morbidity and mortality.

Withdrawing and withholding life support in geriatric surgical patients. Ethical considerations.

Geriatric patients often require prolonged postoperative intensive care after complex surgery. These patients frequently are intubated, sedated or confused, and unable to participate in therapeutic decisions. There is much controversy surrounding the use of critical care in the elderly as well as prognostic uncertainty. This article reviews the medical, ethical, and legal issues that define the clinical principles involved in the decision to limit life support in geriatric patients.

Transfusion significantly increases the risk for infection after splenic injury.

OBJECTIVES: To determine if splenectomy results in an increased risk for perioperative infection when analyzed against splenic repair and to identify factors associated with perioperative infection, respiratory complication, and admission to the intensive care unit following surgery for splenic trauma. DESIGN: Data were collected retrospectively from hospital records and analyzed using stepwise multiple logistic regression. SETTING: San Francisco (Calif) General Hospital, an urban level 1 trauma center. PATIENTS: All patients (n = 252) undergoing operation for traumatic splenic injury at San Francisco General Hospital from 1984 through 1990. Patients who died within 24 hours of presentation were excluded from the study. MAIN OUTCOME MEASURES: Perioperative infection, respiratory complications, and admission to the intensive care unit. RESULTS: Infection rates and the types of organisms yielded in cultures were similar between patients who underwent splenectomy and repair. Gram-negative and gram-positive organisms were found in equal numbers, and in no group did encapsulated organisms predominate. Splenectomy had no independent impact on any of the three outcome measures. Total blood transfusion was found to be the only independently significant variable associated with perioperative infection and respiratory complication. Total blood transfusion of more than 2 U and Injury Severity Score of greater than 25 were independently significantly associated with admission to the intensive care unit. CONCLUSIONS: The choice between splenectomy and splenic repair does not affect the risk for perioperative infection following injury, whereas blood transfusion significantly increases the risk for perioperative infection, respiratory complication, and admission to the intensive care unit.

Cardiac stapling in the management of penetrating injuries of the heart: rapid control of hemorrhage and decreased risk of personal contamination.

The resuscitation of patients with cardiopulmonary arrest from a penetrating injury of the heart requires emergency thoracotomy and control of hemorrhage. Suture control may be technically difficult in patients with large or multiple lacerations. Emergency cardiac suturing techniques expose the surgeon to the risk of a contaminated needle stick. After we determined that rapid control of hemorrhage from cardiac lacerations could be achieved in anesthetized sheep with the use of a standard skin stapler, the technique was applied in the clinical setting. Twenty-eight patients underwent emergency stapling of 33 cardiac lacerations at our institution from September 1987 to December 1991. Seventy-nine percent (22) of the patients sustained stab wounds, and 21% (6) were injured by gunshots. Fifty-eight percent (19) of the injuries involved the right ventricle, 27% (9) involved the left ventricle, 9% (3) involved the right atrium, and 6% (2) involved the left atrium. In 93% (26) of the patients, control of hemorrhage was achieved within 2 minutes of exposure of the injuries. Both patients in whom control could not be achieved had sustained large-caliber gunshot injuries. Fifteen (54%) of the patients survived, including one patient with two cardiac lacerations and another with three lacerations. Of the surviving patients, two had mild neurologic deficits. No personal contamination occurred related to the use of the stapler. We conclude (1) cardiac stapling is highly effective in the management of hemorrhage from penetrating injury, particularly in the setting of multiple cardiac lacerations; (2) the technique may not be effective with certain types of gunshot wounds; and (3) the use of the stapler for emergency cardiorrhaphy eliminates the risk of personal contamination from a needle stick.