Does a Care Bundle Reduce Racial Disparities in Postcesarean Surgical Site Infections?

OBJECTIVE: To examine the effect of a care bundle on racial disparities in surgical site infections (SSIs). STUDY DESIGN: This was a retrospective cohort study of women undergoing cesarean delivery at ≥23 weeks' gestation. The care bundle included routine antibiotics (both cefazolin and azithromycin), chlorhexidine skin preparation, clippers, vaginal cleansing, placental removal by cord traction, subcutaneous tissue closure, suture skin closure, dressing removal in 24 to 48 hours, and postoperative chlorhexidine soap. Our primary outcome was SSI (superficial incisional, deep incisional, and organ/space) occurring up to 6 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (95% CI) were calculated, adjusting for predefined covariates. RESULTS: Of 2,696 women, 1,947 were black (1,014 in the preimplementation period and 933 in the postimplementation period) and 749 were nonblack (370 in the preimplementation period and 379 in the postimplementation period). Regardless of race, women in the postimplementation period had lower rates of SSI compared with those in the preimplementation period (black: 2.9 vs. 5.2%, aOR: 0.53 [95% CI: 0.33-0.85]; nonblack: 1.1 vs. 3.5%, aOR: 0.28 [95% CI: 0.09-0.89]). There was no interaction by race (p for interaction = 0.94). CONCLUSION: The care bundle decreased SSI in both black and nonblack women but did not reduce racial disparities.

Racial and Ethnic Postoperative Outcomes After Surgery: The Hispanic Paradox.

BACKGROUND: The Hispanic population in the United States have previously been shown to have, in some cases, better health outcomes than non-Hispanic whites (NHWs) despite having lower socioeconomic status and higher frequency of comorbidities. This epidemiologic finding is coined as the Hispanic Paradox (HP). Few studies have evaluated if the HP exists in surgical patients. Our study aimed to examine postoperative complications between Hispanic and NHW patients undergoing low- to high-risk procedures. MATERIALS AND METHODS: We conducted a retrospective cohort study analyzing adult patients who underwent high-, intermediate-, and low-risk procedures. The Healthcare Cost and Utilization Project California State Inpatient Database between 2006 and 2011 was used to identify the patient cohort. Candidate variables for the adjusted model were determined a priori and included patient demographics with the ethnic group as the exposure of interest. RESULTS: The median age for Hispanics was 52 (SD 19.3) y, and 38.8% were male (n = 87,837). A higher proportion of Hispanics had Medicaid insurance (23.9% versus 3.8%) or were self-pay (14.2% versus 4.5%) compared with NHWs. In adjusted analysis, Hispanics had a higher odds risk for postoperative complications across all risk categories combined (OR 1.06, 95% CI 1.04-1.09). They also had an increased in-hospital (OR 1.38, 95% CI 1.14-1.30) and 30-d mortality in high-risk procedures (OR 1.34, 95% CI 1.19-1.51). CONCLUSIONS: Hispanics undergoing low- to high-risk surgery have worse outcomes compared with NHWs. These results do not support the hypothesis of an HP in surgical outcomes.

Caesarean section wound infection surveillance: Information for action.

Surgical site infection (SSI) following caesarean section is common, resulting in significant morbidity. Several factors are known to contribute to wound infection, including maternal, procedural and antibiotic factors. We sought to clarify these issues and sought opportunities to make improvements. A retrospective cohort study was performed assessing all women who underwent caesarean section in 2014 and 2015 at Wellington Hospital. Any women with culture-positive wound samples within 30 days of surgery were identified, and clinical notes reviewed. Odds ratios (OR) were calculated for available maternal, procedural and antibiotic risk factors. Two simplified surveillance techniques were also tested for their abilities to identify significant trends. The study included 2231 women, of whom 116 (5.2%) were identified as having SSI. Maternal obesity (body mass index (BMI) ≥ 30) was associated with significant SSI risk (OR 4.1, P < 0.001). The pathogen distribution was significantly different between women with BMI < 30 and BMI ≥ 30 (P < 0.001). Increased cefazolin dose based on BMI (3 g dose for BMI ≥ 30) was associated with a significant reduction in SSI (OR 0.309, P < 0.001) and was administered in 74.1% of obese women receiving cefazolin. Maori women had an increased SSI risk (OR 2.1, P = 0.019), as did Samoan women (OR 3.0, P = 0.002). The study reinforces other studies showing that raised BMI is the single biggest risk factor for surgical site infection post-caesarean section. Surveillance using simplified techniques appears to be adequate to identify trends. We believe that concentrating on appropriate antibiotic dosing and targeting special wound care measures will be pivotal interventions in improving outcomes in high-risk groups.

Prevention of ventriculoperitoneal shunt complications after intraperitoneal urological surgeries.

PURPOSE: To evaluate perioperative management for the prevention of postoperative shunt infection and malfunction after intraperitoneal urological surgery in patients with myelodysplasia and a ventriculoperitoneal shunt. METHODS: From 2005 to 2015, 20 consecutive patients with myelodysplasia and a ventriculoperitoneal shunt who underwent intraperitoneal urological surgeries were managed with the same perioperative regimen. Intraperitoneal surgeries involved opening gastrointestinal tracts, including bladder augmentation by enterocystoplasty, creating continent catheterizable channels and Malone antegrade continent enema. We compared results with those from seven previous reports regarding postoperative shunt complications, surgical histories of previous shunt revisions, management of bacteriuria before surgery preoperative bowel preparation, antibiotic regimens, and duration of indwelling drain. RESULTS: Of 20 patients, 18 received prior shunt revisions, and 14 had positive urine culture before surgery that was managed with oral antibiotics. Thirteen patients underwent bladder augmentation with ileum, and one underwent augmentation with sigmoid colon. Nineteen patients underwent Malone antegrade continent enema using the appendix. All parenteral antibiotics were stopped on postoperative day 2.5. Mean duration of indwelling peritoneal drain was 2.7days. Mean follow-up period was 59.8months. Neither postoperative shunt infections nor intraperitoneal shunt malfunctions were recognized during follow-up period. CONCLUSIONS: This is the first study to evaluate postoperative ventriculoperitoneal shunt complications in patients with myelodysplasia who underwent intraperitoneal urological surgeries with a specific perioperative regimen. Shunt complications are greatly reduced by rigorous perioperative management, including preoperative control of bacteriuria, appropriate administration of prophylactic antibiotics, and early removal of intraperitoneal drains. LEVELS OF EVIDENCE: The type of study: Case series with no comparison group, IV.

African Americans and Short-Term Outcomes after Surgery for Crohn's Disease: An ACS-NSQIP Analysis.

BACKGROUND: Previous reports on racial disparities in the treatment of Crohn's disease [CD] in African American [AA] patients have shown differences in both medical and surgical treatments in this population. No study thus far has examined the effect of AA race on outcomes after surgery for CD. METHODS: Utilizing the National Surgical Quality Improvement Program [NSQIP] Participant User File [PUF] for the years 2005-2013, we examined the effect of AA race on postoperative complications in patients with CD undergoing intestinal surgery. RESULTS: AA patients had a significantly higher rate of complications overall compared to non-AA patients [23.5% vs 18.9%, p = 0.002]. Postoperative sepsis [10.9% vs 6.6%, p < 0.001] and surgical site infection [17.6% vs 14.8%, p = 0.037] were most significant. After adjustment for age, sex, preoperative disease severity and lifestyle factors [smoking], race remained a statistically significant factor in postoperative complication rate. Only after additional adjustment was made for comorbidities and American Society of Anesthesiologists class did race lose significance within our model. CONCLUSION: African Americans experience a greater amount of postoperative complications following surgery for Crohn's disease. Preoperative disease management, addressing smoking status and control of comorbid disease are important factors in addressing the racial disparities in the surgical treatment of Crohn's disease.

Identification of Risk Factors for Acute Surgical Site Infections in Musculoskeletal Tumor Patients Using CDC/NHSN Criteria.

BACKGROUND: Acute surgical site infections (SSI) are well-recognized postoperative complications, representing a significant source of patient morbidity and cost to the healthcare system. This study is among the first to use standardized criteria for the diagnosis of acute SSI in orthopaedic oncology. METHODS: The medical records of 165 patients were retrospectively reviewed for the occurrence of superficial or deep SSI as defined by the Center for Disease Control's National Healthcare Safety Network (CDC/NHSN) criteria. Patient, disease, and procedure-specific variables were evaluated as potential risk factors for infection. RESULTS: The overall rate of acute SSI was 10.3%. Univariate analysis demonstrated the significance of malignant pathology (p < 0.001), ASA classification (p = 0.009), operative duration (p < 0.001), intraoperative RBC transfusions (p = 0.03), the performance of an amputation (p = 0.016), and race (p = 0.008) on the incidence of SSI. Prolonged operative duration (p = 0.014) and race (p = 0.005) were found to be independent risk factors with odds ratios of 1.89 (95%, CI: 1.14 to 3.14) and 0.047 (95%, CI: 0.006 to 0.387), respectively. CONCLUSIONS: By using the CDC/NHSN guidelines for the diagnosis of acute SSI, we identified prolonged operative time and non-Caucasian race as independent risk factors for infection in musculoskeletal tumor patients.

Risk Factors for Developing Staphylococcus aureus Nasal Colonization in Spine and Arthroplasty Surgery.

Staphylococcus aureus nasal colonization is a risk factor for surgical site infection. We conducted a retrospective case-control study of 1,708 consecutively enrolled patients to identify criteria that places orthopaedic surgery patients undergoing spine and total joint arthroplasty surgery at risk for nasal colonization by MRSA and MSSA. Multivariate analysis showed obesity and asthma as significant risk factors for MRSA colonization. The identification of these two risk factors for MRSA colonization may help decolonization programs target patients with these factors for treatment prior to surgery, which could potentially lead to reductions in the rates of surgical site infections.

Changing glucose control target and risk of surgical site infection in a Southeast Asian population.

OBJECTIVE: Hyperglycemia is associated with surgical site infection and mortality in cardiac surgical patients. There is overriding evidence that glycemic control improves morbidity and mortality. However, the optimal glucose range in these patients remains controversial. Intensive glucose control can lead to mortality among critically ill adults because of episodic, moderate hypoglycemia. Therefore, we examined the effect of different glucose target control on the incidence of surgical site infection in our prospective cohort of diabetic and nondiabetic patients undergoing coronary artery bypass grafting. METHODS: Data from 1442 patients who underwent elective coronary artery bypass grafting at a tertiary heart center in Singapore from 2009 to 2011 were obtained. The first glucose level on arrival in the cardiothoracic intensive care unit was set at 4 to 8 mmol/L in 2009 and 2010 and 4 to 10 mmol/L in 2011. Glucose control was achieved with intravenous insulin infusion with a strict glucose monitoring protocol. Clinical covariates were analyzed, with surgical site infection as the primary outcome. RESULTS: The majority of patients presenting for coronary artery bypass grafting were male, Chinese, and diabetic. Diabetic patients had significantly higher glucose levels on arrival in the cardiothoracic intensive care unit. The change in target glucose control was independently associated with an increase in surgical site infection (odds ratio, 2.280; 95% confidence interval, 1.250-4.162; P = .007). Subgroup analysis revealed that unlike in nondiabetic patients, a less stringent target was independently associated with a significant increase in surgical site infection incidence from 2.2% to 6.9% for the diabetic patients (odds ratio, 3.131; 95% confidence interval, 1.431-6.851; P = .004). CONCLUSIONS: A target blood glucose of less than 8 mmol/L was associated with a lower incidence of surgical site infection in diabetic patients presenting for elective coronary artery bypass grafting in the local Southeast Asian population.

Endometrial cancer in morbidly obese women: do racial disparities affect surgical or survival outcomes?

OBJECTIVE: Endometrial cancer mortality disproportionately affects black women and whether greater prevalence of obesity plays a role in this disparity is unknown. We examine the effect of race on post-surgical complications, length of stay, and mortality specifically in a morbidly obese population. METHODS: Black and white women with endometrial cancer diagnosed from 1996 to 2012 were identified from the University Pathology Group database in Detroit, Michigan, and records were retrospectively reviewed to obtain clinicopathological, demographic, and surgical information. Analysis was limited to those with a body mass index of 40kg/m(2) or greater. Differences in the distribution of variables by race were assessed by chi-squared tests and t-tests. Kaplan-Meier and Cox regression analyses were performed to examine factors associated with mortality. RESULTS: 97 white and 89 black morbidly obese women were included in this analysis. Black women were more likely to have type II tumors (33.7% versus 15.5% of white women, p-value=0.003). Hypertension was more prevalent in black women (76.4% versus 58.8%, p-value=0.009), and they had longer hospital stays after surgery despite similar rates of open vs minimally invasive procedures and lymph node dissection (mean days=5.4) compared to whites (mean days=3.5, p-value=0.036). Wound infection was the most common complication (16.5% in whites and 14.4% in blacks, p-value=0.888). Blacks were more likely to suffer other complications, but overall the proportions did not differ by race. In univariate analyses, black women had higher risk of endometrial cancer-related death (p-value=0.090). No racial differences were noted in adjusted survival analyses. CONCLUSION: A more complete investigation, incorporating socio-demographic factors, is warranted to understand the effects of morbid obesity and race on endometrial cancer.

Incidence, secular trends, and outcomes of cardiac surgery in Aboriginal peoples.

BACKGROUND: Canada's Aboriginal people experience a disproportionate burden of comorbid illnesses predisposing them to higher rates of atherosclerotic disease. We set out to investigate secular rates of cardiovascular surgery (CVSx) and postsurgical outcomes in Aboriginals compared with non-Aboriginals. METHODS: All patients undergoing CVSx in Manitoba, Canada from 1995-2007 (N =12,170 [Aboriginal, 574, 4.7%; non-Aboriginal, 11,596, 95.3%]) were included in our study cohort. Race was self-identified. Age- and sex-adjusted incidence were determined using 2001 and 2006 census data. Multivariable logistic regression models were constructed to determine the association between race and the outcomes of death, infections, and a composite of adverse events. RESULTS: CVSx rates were significantly lower in Aboriginals compared with non-Aboriginals (all CVSx, 63.6 vs 97.7 per 10,000 population; coronary artery bypass grafting only, 46.2 vs 71.9 per 10,000 population, respectively). The lower CVSx rates were most pronounced among Aboriginals residing in urban areas (21.0 vs 78.0 per 10,000). Postoperatively, Aboriginals experienced significantly higher odds of infections (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.13-2.34; P = 0.008), in particular pneumonia (OR, 2.24; 95% CI, 1.58-3.19; P < 0.0001). There was no increase in risk of death after surgery (OR, 1.15; 95% CI, 0.63-2.08; P = 0.6) or the composite outcome (OR, 1.0; 95% CI, 0.66-1.52; P = 1.0) compared with non-Aboriginals. CONCLUSIONS: Aboriginal peoples, particularly in the urban setting, are considerably less likely to undergo CVSx. When they do, they have postoperative mortality similar to that of non-Aboriginals. Our findings suggest an urban racial disparity in access to CVSx.

Risk factors and outcomes of surgical site infection in children.

BACKGROUND: Indices for prediction of surgical site infection (SSI) are well documented in the adult population; however, these factors have not been validated in children. STUDY DESIGN: A retrospective case-control study was performed by examining the medical records of children (0 to 18 years) who developed an SSI within 30 days of selected class I and class II procedures at our institution from 1996 to 2008. Two controls were selected from among patients undergoing identical procedures within 12 months of each case. Statistical analysis was performed using Wilcoxon test for continuous and chi-square test for categorical variable. Factors thought a priori to be associated with risk of SSI and statistically significant variables from a univariate analysis were used to create a logistic regression model. RESULTS: Of 16,031 patients, 159 children (0.99%) developed an SSI. Univariate analysis showed race, postoperative location, skin preparation, urinary catheter, procedure duration, and implantable device as risk factors for development of an SSI. Independent predictors of SSI in multiple conditional logistic regression were age (adjusted odds ratio [aOR] 4.97 neonate vs adolescent; 95% CI 1.38 to 17.90), race (aOR 2.36 for African American vs white; 95% CI 1.32 to 4.18), postoperative location (aOR 6.55 ICU vs home; 95% CI 1.58 to 27.21), urinary catheter placement (aOR 3.56; 95% CI 1.50 to 8.48), and implantable device (aOR 3.05; 95% CI 1.14 to 8.21). Wound classification and antibiotic administration were not independent predictors of SSI. CONCLUSIONS: Postoperative location, urinary catheter insertion, and use of an implantable device are potentially modifiable risk factors for an SSI in children. The higher risk of SSI in younger patients and non-white race suggest a possible developmental, socioeconomic, or genetic marker for impaired host defense.

Infectious complications after elective vascular surgical procedures.

OBJECTIVE: This study was conducted to evaluate and compare the rates of postoperative infectious complications and death after elective vascular surgery, define vascular procedures with the greatest risk of developing nosocomial infections, and assess the effect of infection on health care resource utilization. METHODS: The Nationwide Inpatient Sample (2002-2006) was used to identify major vascular procedures by International Classification of Diseases, 9th Clinical Modification (ICD-9-CM) codes. Infectious complications identified included pneumonia, urinary tract infections (UTI), postoperative sepsis, and surgical site infections (SSI). Case-mix-adjusted rates were calculated using a multivariate logistic regression model for infectious complication or death as an outcome and indirect standardization. RESULTS: A total of 870,778 elective vascular surgical procedures were estimated and evaluated with an overall postoperative infection rate of 3.70%. Open abdominal aortic surgery had the greatest rate of postoperative infections, followed by open thoracic procedures and aorta-iliac-femoral bypass. Thoracic endovascular aneurysm repair (TEVAR) infectious complication rates were two times greater than after EVAR (P < .0001). Pneumonia was the most common infectious complication after open aortic surgery (6.63%). UTI was the most common after TEVAR (2.86%) and EVAR (1.31%). Infectious complications were greater in octogenarians (P < .0002), women (P < .0001), and blacks (P < .0001 vs whites and Hispanics). Nosocomial infections after elective vascular surgery significantly increased hospital length of stay (13.8 +/- 15.4 vs 3.5 +/- 4.2 days; P < .001) and reported total hospital cost ($37,834 +/- $42,905 vs $11,851 +/- $11,816; P < .001). CONCLUSIONS: Elective vascular surgical procedures vary widely in the estimated risk of postoperative infection. Open aortic surgery and endarterectomy of the head and neck vessels have, respectively, the greatest and the lowest reported incidence for postoperative infectious complications. Women, octogenarians, and blacks have the highest risk of infectious complications after elective vascular surgery. Disparities in the development of infectious complications on a systems level were also found in larger hospitals and teaching hospitals. Hospital infectious complications were found to significantly increase health care resource utilization. Strategies that reduce nosocomial complications and target high-risk procedures may offer significant future cost savings.

Infection rates after tympanostomy tube insertion, comparing Aboriginal and non-Aboriginal children in the Northern Territory, Australia: a retrospective, comparative study.

OBJECTIVE: To determine if there is a difference in infection rates between Aboriginal and non-Aboriginal children, following tympanostomy and ventilation tube placement, in the Northern Territory, Australia. MATERIALS AND METHODS: A cohort of 213 patients aged zero to 10 years who had undergone tympanostomy and ventilation tube placement at the Royal Darwin Hospital between 1996 and 2004 were identified. Patients were divided into Aboriginal or non-Aboriginal groups, from their medical record. Factors such as age, sex, dwelling (remote or urban) and season were compared for each group, in order to ascertain if they contributed to infection rates. A retrospective analysis of cases was conducted for the two-year post-operative period. RESULTS: There was no statistically significant difference in infection rates between the two groups (37 vs 35 per cent). There was no statistically significant difference when comparing the two groups for age, sex, season, or remote vs urban dwelling. CONCLUSION: Aboriginal children were not prone to more infections following tympanostomy tube placement when compared with non-Aboriginal children.

Factors predicting complication rates following total knee replacement.

BACKGROUND: The purpose of this investigation was to expand on previous studies by more fully examining the role of a variety of patient and hospital characteristics in determining adverse outcomes following total knee replacement. METHODS: With use of data from all hospital admissions in California from 1991 through 2001, multiple logistic regression was performed on the information regarding patients treated with total knee replacement. Rates of mortality and readmission due to infection and pulmonary embolism during the first ninety days after discharge were regressed against a variety of independent variables, including demographic factors (age, gender, race, ethnicity, and insurance type), burden of comorbid disease (Charlson comorbidity index), and provider variables (hospital size, teaching status, and surgical volume). A separate baseline probability analysis was then performed to compare the relative importance of all predictor variables. RESULTS: The sample size for this analysis was 222,684. A total of 1176 deaths (rate, 0.53%), 1586 infections (0.71%), and 914 pulmonary emboli (0.41%) occurred within the first ninety days after discharge. The average age of the patients at the time of surgery was sixty-nine years. Sixty-two percent of the patients were women, and 32% had a Charlson comorbidity index of >0. The significant predictors for complications (p < 0.05) included age, gender, race/ethnicity, Charlson comorbidity index, insurance type, and hospital volume. A baseline probability analysis was performed with the base case considered to be a white woman who was over the age of sixty-five years, had a Charlson comorbidity index of 0, had Medicare insurance, and was treated at a high-volume, non-teaching hospital. For a patient with the baseline case characteristics, the probability of death was 31/10,000, the probability of infection was 59/10,000, and the probability of pulmonary embolism was 41/10,000 in the first ninety days after discharge. Altering the base case by assuming that care was received at a low-volume hospital increased the expected mortality rate by a factor of 26%. Increasing the Charlson comorbidity index to 1 increased the mortality rate by 170%, whereas decreasing the age to younger than sixty-five years lowered the mortality rate by 73%. Hospital volume, comorbidity, and age had similar effects on the expected rates of readmission due to infection and pulmonary embolism. CONCLUSIONS: The effects of age and the Charlson comorbidity index on the baseline probability of adverse outcomes following total knee replacement were shown to be similar to or greater than the effect of hospital volume. This study elucidates and compares the relative importance of the effects of several different factors on outcome. This information is important when considering the conclusions and implications of this type of policy-relevant outcomes research.

Relationship between race and mortality and morbidity after valve replacement surgery.

BACKGROUND: Previous studies have shown that black race is an independent predictor of increased operative mortality after coronary artery bypass surgery. Given the higher incidence of hypertension and hypertension-associated left ventricular hypertrophy in blacks, we hypothesized that black race might be associated with increased risk of mortality and morbidity after aortic valve replacement (AVR) or mitral valve replacement (MVR). We could not identify a previous study that used a multivariable model to evaluate the association between race and operative mortality after AVR or MVR. METHODS AND RESULTS: The Society of Thoracic Surgeons National Cardiac Database was used for a retrospective review of 3137 black and 46,249 white patients who underwent MVR alone or AVR alone from 1999 through 2002. Multivariate logistic regression was used to assess the association between race and mortality and 6 other adverse outcomes (stroke, renal failure, prolonged ventilation, prolonged postoperative stay, sternal infection, and bleeding) after adjustment for covariates. Unadjusted operative mortality for MVR only was 5.60% for blacks versus 6.18% for whites (OR 0.90 [95% CI 0.71 to 1.14]) and 4.60% for blacks versus 3.62% for whites for AVR only (OR 1.28 [95% CI 1.02 to 1.62]). After adjustment for other risk factors, black race was not a significant predictor of operative mortality after AVR or MVR; however, black race was associated with an increased risk of several complications: prolonged ventilation after AVR or MVR, postoperative stay >14 days after AVR or MVR, reoperation for bleeding after AVR, and postoperative renal failure after MVR. There was no significant association between race and the risk of stroke or deep sternal wound infection for either AVR or MVR. CONCLUSIONS: In contrast to previously published results that defined race as an independent risk factor for operative mortality after coronary artery bypass surgery, race does not appear to be a significant predictor of operative mortality after isolated AVR or MVR; however, there is evidence of an association between race and certain complications.

The human dimension of nosocomial wound infection: a study in liminality.

Nosocomial wound infection is a disease that has to date been primarily understood through the language of science and biomedicine. This paper reports on findings from a sociological, interpretive study that focused on the experiential dimension of this phenomenon. The illness experience of a nosocomial wound infection is examined within a cultural milieu that values the smooth, untroubled body and alternatively ascribes cultural meaning to a body that has a definable illness. Within this context the person with a chronic wound from nosocomial infection defies normative categorisation and is thus situated outside the patterning of society. The human dimension of nosocomial wound infection includes the private, existential and embodied aspects of living with a chronic, infected wound. This report indicates that the experiential dimension is characterised by an embodied state of liminality. People with this illness live an indeterminate existence that is in-between health and illness, cure and disease. As such they have no recognised place in the medical or social world.