Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). 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 “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

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Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update

Disclosures outside the scope of this work: Dr. Minei receiv grant support from Irrespet Corp. AtoxBio. Dr. Laronga rec sation for lectures from Genomic Health Inc. and royalties Date. Dr. Jensen is a consultant and paid speaker for Ethico ceives honoraria from CareFusion for their Speaker’s Progr from Irrimax Corp. for consulting and Research Funding honoraria from Surgical Inc. for consultation. Dr. Itani for a multi-institutional study for Sanofi-Pastuer and the Committee Chair. Dr. Dellinger is on the Advisory B Melinta, and Therevance and a grant recipient from Moti trial of iclaprim vs. vancomycin for treatment of skin and so tions. The remaining authors declare no conflicts. Presented at the Surgical Infection Society, Palm Beach, FL

https://www.journalacs.org/article/S1072-7515(16)31563-0/pdf

American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update

The World Health Organization (WHO) has released new guidelines [1] for reducing health care associated infections related to surgery. The new guidelines include 29 concrete recommendations distilled by 20 of the world’s leading experts from 26 reviews of the latest evidence. The recommendations are designed to address the increasing burden of health care associated infections on both patients and health care systems globally. The guidelines include 13 recommendations for the period before surgery, and 16 for preventing infections during and after surgery. They range from simple precautions such as ensuring that patients bathe or shower before surgery and the best way for surgical teams to clean their hands, to guidance on when to use antibiotics to prevent infections, what disinfectants to use before incision, and which sutures to use.

Global Guidelines for the Prevention of Surgical Site Infection

OBJECTIVE To determine the independent association between diabetes and surgical site infection (SSI) across multiple surgical procedures. DESIGN Systematic review and meta-analysis. METHODS Studies indexed in PubMed published between December 1985 and through July 2015 were identified through the search terms "risk factors" or "glucose" and "surgical site infection." A total of 3,631 abstracts were identified through the initial search terms. Full texts were reviewed for 522 articles. Of these, 94 articles met the criteria for inclusion. Standardized data collection forms were used to extract study-specific estimates for diabetes, blood glucose levels, and body mass index (BMI). A random-effects meta-analysis was used to generate pooled estimates, and meta-regression was used to evaluate specific hypothesized sources of heterogeneity. RESULTS The primary outcome was SSI, as defined by the Centers for Disease Control and Prevention surveillance criteria. The overall effect size for the association between diabetes and SSI was odds ratio (OR)=1.53 (95% predictive interval [PI], 1.11-2.12; I2, 57.2%). SSI class, study design, or patient BMI did not significantly impact study results in a meta-regression model. The association was higher for cardiac surgery 2.03 (95% PI, 1.13-4.05) compared with surgeries of other types (P=.001). CONCLUSIONS These results support the consideration of diabetes as an independent risk factor for SSIs for multiple surgical procedure types. Continued efforts are needed to improve surgical outcomes for diabetic patients. Infect. Control Hosp. Epidemiol. 2015;37(1):88-99.

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Diabetes and Risk of Surgical Site Infection: A Systematic Review and Meta-analysis.

Summary Background Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world Methods This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI) Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI) Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models This trial is registered with ClinicalTrialsgov, number NCT02662231 Findings Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis 12 539 patients from 343 hospitals in 66 countries were included 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries) In total, 1538 (12·3%) patients had SSI within 30 days of surgery The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p Interpretation Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication Funding DFID-MRC-Wellcome Trust Joint Global Health Trial Development Grant, National Institute of Health Research Global Health Research Unit Grant

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Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Objective To determine if an evidence-based practice bundle would result in a significantly lower rate of surgical site infections (SSIs) when compared with standard practice. Design Single-institution, randomized controlled trial with blinded assessment of main outcome. The trial opened in April 2007 and was closed in January 2010. Setting Veterans Administration teaching hospital. Patients Patients who required elective transabdominal colorectal surgery were eligible. A total of 241 subjects were approached, 211 subjects were randomly allocated to 1 of 2 interventions, and 197 were included in an intention-to-treat analysis. Interventions Subjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector. Main outcome measure Overall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions. Results The overall rate of SSI was 45% in the extended arm of the study and 24% in the standard arm (P = .003). Most of the increased number of infections in the extended arm were superficial incisional SSIs (36% extended arm vs 19% standard arm; P = .004). Multivariate analysis suggested that allocation to the extended arm of the trial conferred a 2.49-fold risk (95% confidence interval, 1.36-4.56; P = .003) independent of other factors traditionally associated with SSI. Conclusions An evidence-based intervention bundle did not reduce SSIs. The bundling of interventions, even when the constituent interventions have been individually tested, does not have a predictable effect on outcome. Formal testing of bundled approaches should occur prior to implementation.

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Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial.

Introduction The purpose of this study was to evaluate the long-term complications of surgical site infection (SSI) in the colorectal population, specifically its association with incisional hernia and small bowel obstruction. Methods Using standardized definitions of SSI, a retrospective review of patients undergoing transabdominal colorectal surgery from January 2002 to December 2005 was performed. Primary outcomes included incisional hernia and small bowel obstruction in patients with SSIs. Results A total of 443 patients were analyzed. The median surgical follow-up was 12 months (2–3,091 days). Infections were identified in 101 (23%) cases. There were 99 cases (22%) of incisional hernia and 32 cases (7%) of small bowel obstruction. Logistic regression revealed SSI to be independently associated with incisional hernia after adjusting for clinical covariates (adjusted odds ratio = 2.23, P = .003; 95% confidence interval, 1.3–3.8). Patients with incisional hernia were 1.9 times more likely to have had an SSI (36.3% vs 18.8%, P ≤ .01). They required a longer operative time (224 minutes vs 198 minutes, P = .03), had an increased body mass index (29.0 vs 26.8, P ≤ .01), and had increased estimated blood loss (363 vs 289, mL, P = .03). Small bowel obstruction was significantly associated with operations involving the rectum (11.5% in operations involving the rectum vs 5.9% in nonrectal operations, P = .05), increased estimated blood loss (409 ml vs 297 ml, P = .04), and red blood cell transfusion (15.5% with transfusion vs 5.7% without, P = .01). SSI was not an independent predictor of small bowel obstruction (adjusted odds ratio = 1.05, P = .91; 95% confidence interval, .45–2.5). Conclusions Patients with an SSI were 1.9 times more likely to have an incisional hernia than those without an SSI. An SSI after colorectal s urgery was a risk factor for the development of incisional hernia but was not a risk factor for small bowel obstruction in our population.

The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery

P S c a d o a c e o v a h s c t t t c t urgical site infections (SSI) are among the most common ource of nosocomial morbidity for patients undergoing surical procedures. SSIs are associated with increased hospital ength of stay, increased risk of mortality, and decreased ealth-related quality of life. SSIsalso increasehospital costsby 1,300to$5,000percase. SoSSIscausea substantialburdento he patient, the hospital, and the third party payers, and represent n important target for surgical quality improvement. In the United States, an individual subjected to a major peration is expected to carry a 2% risk of SSI. This rate is ubstantially higher if the individual undergoes colorectal surery, with a current rate of 5% to 30% for SSIs in colorectal perations. The wide variation in reported rates is largely a unction of the varying definitions that have been applied to efine SSI. The most widely used definition for SSIs was provided by he Centers for Disease Control in 1992 and updated in 2003. t broadly categorized SSIs into incisional and organ/space nfections. Incisional SSIs were further split into 2 categoies: superficial (involving the skin and subcutaneous tissue) nd deep (involving fascia and muscle layers). This categoriation is important because the etiology, risk factors, and clincal consequences vary depending on the location. An infection in the surgical site is the result of inoculation ith a bacterial load that is greater than the ability of the mmune system to control it. Therefore, increased contamiation (contaminated or dirty-infected wound classes) and ecreased host immunity lead to increased incidence of SSI. ince Lister’s time, we have applied the scientific method to urgical practice to identify options for decreasing bacterial ontamination and augmenting host immunity, and although he incidence of SSI has been reduced by applying the results f our investigations, the current rates of SSI, particularly in olorectal surgery, suggest that there is still room for mprovement. Contributing to the development and/or prevention of

Surgical site infection in colorectal surgery: a review of the nonpharmacologic tools of prevention.

Interventions: Subjects received either a combination of 5 evidenced-based practices (extended arm) or were treated according to our current practice (standard arm). The interventions in the extended arm included (1) omission of mechanical bowel preparation; (2) preoperative and intraoperative warming; (3) supplemental oxygen during and immediately after surgery; (4) intraoperative intravenous fluid restriction; and (5) use of a surgical wound protector. Main Outcome Measure: Overall SSI rate at 30 days assessed by blinded infection control coordinators using standardized definitions.

Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection

The management of rectal cancer has drastically evolved over the past two decades as a result of implementation of circular stapling devices and the introduction of neoadjuvant chemoradiation. In spite of current aggressive multimodality treatments, the recurrence rate remains unacceptably high and the expected 5-year survival in patients who develop recurrent disease is dismal. The management of rectal cancer must involve a multidisciplinary approach. An understanding of the biology of rectal tumours may allow for selection of patients who may have an aggressive phenotype allowing for alterations in the operative and neoadjuvant planning. Efforts to improve local control and survival in rectal cancer are the focus of multiple current clinical and preclinical research efforts. Preoperative chemoradiation for and surgical management of rectal cancer, including the laparoscopic approach are areas of dynamic progression. In the present report, we review the current evidence in the new strategies pertaining to the multimodality approach in the management of rectal cancer.

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Bryce W. Murray

Papers

Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial.

The impact of surgical site infection on the development of incisional hernia and small bowel obstruction in colorectal surgery

Surgical site infection in colorectal surgery: a review of the nonpharmacologic tools of prevention.

Evaluating an Evidence-Based Bundle for Preventing Surgical Site Infection

Current evidence-based opinions in the management of adenocarcionoma of the rectum