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Surgical Site Infection Basics

A surgical site infection (SSI) is an infection in the part of the body where a surgery took place.
SSIs can generally be treated with antibiotics but may require additional medical care.
There are ways to reduce your risk of contracting an SSI.

A surgical site infection (SSI) is a type of healthcare-associated infection (HAI). It is an infection that occurs in the part of the body where a surgery took place.

SSIs can occur in:

Implanted material, like a hip replacement

Signs and symptoms

Redness and pain around the area where you had surgery.
Cloudy fluid draining from your surgical wound.
Other signs and symptoms may also occur.

Reducing risk

Before surgery:.

Tell your healthcare provider about other medical problems you may have. Health problems such as allergies, diabetes and obesity could affect your surgery and your treatment.
Quit smoking. Patients who smoke get more infections. Talk to your healthcare provider about how you can quit before your surgery.
Do not shave near where you will have surgery. Shaving with a razor can irritate your skin and make it easier to develop an infection.

At the time of surgery:

Speak up if someone tries to shave you with a razor in the area where you will have surgery. Ask why you need to be shaved in the area and talk with your surgeon if you have any concerns.

After surgery:

If you do not see your healthcare provider clean their hands, please ask them to do so.
Family and friends should not touch the surgical wound or dressings.
Family and friends should clean their hands with soap and water or an alcohol-based hand rub before and after visiting you. If you do not see them clean their hands, ask them to clean their hands.
Always clean your hands before and after caring for your wound.

Before you leave the hospital:

Make sure you understand how to care for your wound.
Make sure you know who to contact if you have questions or problems.

Once you are home:

If you have any symptoms of an infection, such as redness and pain at the surgery site, drainage, or fever, call your healthcare provider immediately.

Healthcare providers should always follow Core Infection Control Practices and SSI Prevention Guidelines to reduce the risk of spreading germs to patients.

Treatment and recovery

Treatment generally includes antibiotics, but the type of treatment depends on the germ causing the infection. Sometimes, patients need another surgery to treat SSIs.

What CDC is doing

Working closely with health departments , other federal agencies, healthcare providers and patients to SSIs.
Data is also available on the AR & Patient Safety Portal .

This website provides information on surgical site infections (SSIs). Learn the signs and symptoms and how to reduce your risk of SSIs.

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Surgical Site Infection Prevention : A Review

1 Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
2 Department of Surgery, Duke University School of Medicine, Durham, North Carolina
Original Investigation Effect of Incisional Negative Pressure Wound Therapy vs Standard Wound Dressing on Deep SSI Matthew L. Costa, PhD; Juul Achten, PhD; Ruth Knight, PhD; Julie Bruce, PhD; Susan J. Dutton, MSc; Jason Madan, PhD; Melina Dritsaki, PhD; Nick Parsons, PhD; Miguel Fernandez, PhD; Richard Grant; Jagdeep Nanchahal, PhD; WHIST Trial Collaborators; Peter Hull; Simon Scott; David Melling; Javed Salim; Hemant Sharma; William Eardley; Peter V Giannoudis; Jitendra Mangwani; Andrew Riddick; Paul Harnett; Edward Mills; Mike (R) Reed; Ben J Ollivere; Xavier L Griffin; Mark D Brinsden; Ravichandran Karthikeyan; Benedict A Rogers; Peter Bates; Haroon Majeed; Damian McClelland; Sharad Bhatnagar; Caroline B Hing; Rajarshi Bhattacharya; Usman Butt; George Cox; Khitish Mohanty; Mateen Arastu; Paul Harwood; Alex L Sims; Brett Rocos; Ian Baxter; Tanvir Khan; Paul M Guyver; Siddhant Kapoor; Michalis Kaminaris; Edward Massa; Richard Unsworth; Robert Jordan; Tarek Boutefnouchet; Laura Beddard; Graham Lawton JAMA
JAMA Insights Preventing Surgical Site Infections—Looking Beyond the Current Guidelines Adam C. Fields, MD; Jason C. Pradarelli, MD, MS; Kamal M. F. Itani, MD JAMA

Importance Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer.

Observations Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient’s endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient’s immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis.

Conclusions and Relevance Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol–based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.

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Surgical Site Infections

Resources include The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections (SSIs).

Preventing Infections in ASCs

It's All About Teamwork

Surgical site infections are dangerous, costly, and preventable, and everyone in ambulatory surgery centers has a role in preventing them. The new infographic, “It Takes a Team,” has tips for ASC leaders, caregivers, patients and families on ways they can keep patients safe from harm. The infographic was developed as part of the AHRQ Safety Program for Ambulatory Surgery, a national safety effort funded by the Agency for Healthcare Research and Quality. Share it with your entire team as well as patients and families.

Resources from The Joint Commission E nterprise

The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections
Hand Hygiene

External Resources

SHEA: Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update
CDC: Surgical Site Infections 2017 Guidelines
CDC: Frequently Asked Questions about Surgical Site Infections
AHRQ: It Takes a Team: Preventing Infections in Ambulatory Surgery Centers
Central Line-Associated Bloodstream Infections Toolkit and Monograph
CLABSI Toolkit - Introduction
CLABSI Toolkit - Chapter 1
CLABSI Toolkit - Chapter 2
CLABSI Toolkit - Chapter 3
CLABSI Toolkit - Chapter 4
CLABSI Toolkit - Chapter 5
CLABSI Toolkit - Chapter 6
CLABSI Toolkit Directory, Glossary, Acknowledgements, and Disclaimer
Ambulatory Health Care Infection Prevention and Control
Antibiotic Stewardship
Behavioral Health Care Infection Prevention and Control
Catheter-Associated Urinary Tract Infections
Central Line-Associated Bloodstream Infections
Compendium of Strategies to Prevent Healthcare-Associated Infections
Critical Access Hospital Infection Prevention and Control
Disinfection and Sterilization
General Infection Prevention and Control
High Reliability and Infection Prevention
Applying High Reliability Principles to Infection Prevention and Control in Long Term Care
Home Care Infection Prevention and Control
Hospital Infection Prevention and Control
Infection Prevention and Control Hierarchy
Infection Prevention and Control Safety Alerts
Infectious Disease Outbreaks and Response
Influenza and Other Related Diseases
Laboratory Infection Prevention and Control
Legionnaires' Disease
Multidrug-Resistant Organisms
Nursing Care Center Infection Prevention and Control
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Hospital Respiratory Protection: Resources and Projects
Vaccination

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Eden Nohra 1 ,
http://orcid.org/0000-0002-6401-4060 Rachel D Appelbaum 2 ,
http://orcid.org/0000-0001-7665-2775 Michael Steven Farrell 3 ,
Thomas Carver 4 ,
Hee Soo Jung 5 ,
http://orcid.org/0000-0001-8314-1180 Jordan Michael Kirsch 6 ,
http://orcid.org/0000-0001-6433-9159 Lisa M Kodadek 7 ,
Samuel Mandell 8 ,
Aussama Khalaf Nassar 9 ,
Abhijit Pathak 10 ,
Jasmeet Paul 11 ,
Bryce Robinson 12 ,
http://orcid.org/0000-0003-1456-6841 Joseph Cuschieri 13 ,
http://orcid.org/0000-0003-3683-3963 Deborah M Stein 14
1 Department of Surgery , University of Colorado Anschutz Medical Campus , Aurora , Colorado , USA
2 Department of Surgery , Vanderbilt University Medical Center , Nashville , Tennessee , USA
3 Department of Surgery , Lehigh Valley Health Network , Allentown , Pennsylvania , USA
4 Department of Surgery , Medical College of Wisconsin , Milwaukee , Wisconsin , USA
5 Department of Surgery , University of Wisconsin Madison School of Medicine and Public Health , Madison , Wisconsin , USA
6 Department of Surgery , Westchester Medical Center/ New York Medical College , Valhalla , NY , USA
7 Department of Surgery , Yale University School of Medicine , New Haven , Connecticut , USA
8 Department of Surgery , The University of Texas Southwestern Medical Center , Dallas , Texas , USA
9 Department of Surgery, Section of Acute Care Surgery , Stanford University , Stanford , California , USA
10 Department of Surgery , Temple University School of Medicine , Philadelphia , Pennsylvania , USA
11 Department of Surgery , University of New Mexico Health Sciences Center , Albuquerque , New Mexico , USA
12 Department of Surgery , Harborview Medical Center , Seattle , Washington , USA
13 Department of Surgery , Zuckerberg San Francisco General Hospital and Trauma Center , San Francisco , California , USA
14 Department of Surgery , University of Maryland Baltimore , Baltimore , Maryland , USA
Correspondence to Dr Deborah M Stein; dstein{at}som.umaryland.edu

The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical consensus document, created by the American Association for the Surgery of Trauma Critical Care Committee, is to synthesize the available evidence, and to provide practical recommendations. We discuss the evaluation of fever, the indications to obtain cultures including urine, blood, and respiratory specimens for diagnosis of infections, the use of procalcitonin, and the decision to initiate empiric antibiotics. We then describe the treatment of common infections, specifically ventilator-associated pneumonia, catheter-associated urinary infection, catheter-related bloodstream infection, bacteremia, surgical site infection, intra-abdominal infection, ventriculitis, and necrotizing soft tissue infection.

critical care

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/tsaco-2023-001303

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Introduction

As clinicians and intensivists, we strive to diagnose and treat infection. Fever occurs commonly in the surgical intensive care unit (ICU), but the etiology is infectious only half the time. In the management of infections, the right treatment and duration is an essential component of critical care management. In this clinical consensus document, the AAST Critical Care Committee aims to provide practical guidance to the surgical intensivist on the best practices in the evaluation of fever and the treatment of infections in the adult, age ≥16 years of age, critically ill and injured patient.

The AAST Critical Care Committee chose antibiotic management in the ICU as a clinically relevant topic for review. This document is one of a three-part series on this topic (Appelbaum, TSACO (in submission), Farrell, TSACO (in submission)). The subtopics reviewed are not comprehensive for the topic of antibiotic management in the ICU but were specifically selected to be practical and useful for the surgical intensivist. A working group was formed from the committee at large to complete this work. The members of the working group were each assigned a subtopic to review using research to date. The members were asked to base their recommendations on research within the last 10 years. If research is unique, important, and has not been replicated, then it may be used even if it is older than 10 years. The research on which the recommendations are based was compiled at the discretion of the working group. Iterative selection of studies was not performed as in a systematic review, and the methodology of the literature search was at the discretion of the authors. The recommendations were then reviewed by the AAST Critical Care Committee at large. Consensus was either achieved by conference or reported as ‘no consensus’. The recommendations apply to adult trauma patients, aged ≥16 years of age. Clinicians must take into account other considerations such as weight and pregnancy for adjustments in dosing and specific antibiotic selection.

Disclaimer from the AAST Critical Care Committee

The work represents expert opinion and the recommendations of the entire committee. These recommendations do not intend to substitute for the provider’s clinical experience. The intent of the AAST Critical Care Committee clinical consensus documents is to provide healthcare professionals with evidence-based recommendations regarding care of the critically ill patient. The clinical consensus documents do not include all potential options for prevention, diagnosis, and treatment, and they are not intended as a substitute for the provider’s clinical judgment and experience. The responsible provider must make all treatment decisions based on their independent judgment and the patient’s individual clinical presentation. The AAST and any entities endorsing the clinical consensus document shall not be liable for any direct, indirect, special, incidental, or consequential damages related to the use of the information contained here. The AAST may modify the clinical consensus documents at any time without notice.

How is fever in the ICU assessed and defined?

Recommendation

A temperature >38.3°C in critically ill patients is defined as a fever, 1 and >39.5°C as a high fever, except in neutropenia. It is important to consider that, in the elderly, the fever response may be blunted and thus, an infected elderly person may not manifest a fever. Additionally, certain ICU conditions and treatments can easily mask fever, as discussed below.

Therapies such as continuous renal replacement therapy (CRRT), peritoneal lavage, or extracorporeal membrane oxygenation (ECMO) may alter core temperature. Environmental considerations such as room temperature, mattress type, lights, and external warming devices may also impact core body temperature. Clinicians should consider patient-specific factors when evaluating temperature data in a critically ill patient. Furthermore, not all patients with infection will generate a fever: the elderly, those with open abdominal wounds or large total body surface area burns, patients treated with antipyretics, or those on ECMO or CRRT may be euthermic or hypothermic. 2 Fever in patients with neutropenia (absolute neutrophil count <500 cells/mm) is defined as temperature ≥38.0°C sustained over 1 hour or recurrent over 12 hours. 3

In the elderly, a lower cut-off for fever is considered specifically for older adult residents of long-term care facilities. 4 The definition has not been extended to critically ill older adults as evidenced by the joint guidelines of the Society of Critical Care Medicine (SCCM) and Infectious Disease Society of America (IDSA) on the workup of fever written in 2023. 1 However, and importantly so, other signs of infection besides fever should be closely evaluated as it is common that an infected elderly person does not manifest a fever due to blunted physiological responses. 5 6 In older adult patients, change in behavior, a rise in baseline temperature by 1 degree, lack of cooperativeness with care, laboratory values that indicate organ dysfunction, altered mentation, and change from baseline including fatigue, loss of appetite, delirium, and falls should all be considered possible signs of an infection. 6 7

Devices used should be assessed, maintained, and calibrated regularly according to manufacturer’s guidelines. Temperature is most accurate when measured with esophageal probes and bladder catheter thermistors (as opposed to axillary or tympanic), however central measurement is not always necessary. 8

What is the recommended approach to a patient with fever in the ICU?

A comprehensive differential diagnosis for fever must be considered, weighing all causes of fever including infectious and non-infectious etiologies. A targeted workup guided by clinical and physical evaluation should be ordered, and close re-evaluation should be performed for escalation, de-escalation, or discontinuation of the treatment regimen. Please see approach to fever in the ICU in figure 1 .

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Flow chart for intensive care unit (ICU) fever and antibiotic management. *Defined as sepsis 3—life-threatening organ dysfunction caused by a dysregulated host response to infection where organ dysfunction is represented by an increase in Sequential Organ Failure Assessment (SOFA) score by 2 points or the patient has septic shock. 17

While infections are a common occurrence in the ICU patient, any process that causes a release of inflammatory cytokines can lead to fever. 9 This is important in the surgical ICU because tissue injury is a well-known cause of fever and up to 39% of postoperative patients will have at least one febrile episode. 10 11 The pattern of fever may be helpful in distinguishing certain pathologies. For instance, non-infectious causes are associated with temperatures <38.9°C while extreme temperatures (>41°C) are almost never infectious. 9 Extreme temperatures raise concern for neuroleptic malignant syndrome, drug fever, or malignant hyperthermia. 12 Alternatively, temperatures >39.3°C, especially if they persist for several days, are more likely infectious. 13

Non-infectious causes of fever are often overlooked due to the overwhelming concern for a bacterial source. 13 14 Some of these non-infectious causes are listed in table 1 . Therapies used may cause fever, such as drug fevers especially in the presence of a rash. Some drugs commonly implicated in fever in the ICU are listed in table 2 . In addition, temperature variation occurs frequently in critical illness due to altered circadian rhythms and autonomic dysfunction. 10 While fever itself is a poor predictor of positive cultures, 11 it is highly associated with obtaining cultures (OR 3.8 in one study) which underscores the fact that fever does not equate with infection. 15

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Non-infectious causes of fever in the intensive care unit

Common medications associated with drug fever

In surgical and neurological ICUs, respiratory infections account for the majority of infectious fevers. 14 16 Postoperative patients are at an obvious risk for certain infections, including skin and soft tissue infections, 9 Clostridium difficile colitis, central line-associated bloodstream infections; and rarely, catheter-associated urinary tract infections (CAUTIs). 10 17 Certain patient populations have additional infection risk exposures such as ventriculitis in neurosurgical patients or those with open brain injury.

The widespread application of ‘pan-culture’ for fever has come into question as it is associated with increased antibiotic use without added clinical benefit and with significant harms, 18 including increased antibiotic use, costs, patient discomfort, and iatrogenic infections. 13 19 On the other hand, since the diagnostic accuracy of clinical exam alone is lacking (60% sensitive and 64% specific), we recommended that the clinical evaluation be supplemented with additional tests selectively guided by the clinical suspicion, patient symptomatology, and/or risk for certain infections. 10 18 We are reassured that delaying antibiotics for a period of hours until relevant workup has returned or the workup and evaluation for fever has further developed does not worsen outcome. 20 We therefore encourage a comprehensive evaluation of the patient, including risk factors, for all potential sources of fever (including non-infectious sources) and weighing this carefully with the developing clinical condition prior to any decision for antibiotic initiation and prior to subjecting the patient with fever to a broad panel of cultures. 11 17 The caveat is that the clinician should have a heightened awareness for the true definition of sepsis (new organ dysfunction resulting from an infection), which would necessitate immediate antibiotic treatment, source evaluation, and control. 21

Cultures in the evaluation of a fever

In the workup of fever, when should urinalysis and culture be obtained?

The absence of urinary symptoms in the correct clinical setting should obviate the need for urinalysis and culture, regardless of the presence or absence of a catheter. Fever alone should never trigger urine studies. In a patient with sepsis (per sepsis-3 guideline definition) 22 or septic shock, a decision can be made to obtain urinalysis and culture provided the source of sepsis is determined to be unclear after careful evaluation by the ICU.

Decades of surgical dogma has led to the pervasive belief that the urine should be evaluated in a patient with fever, particularly if a catheter is present. This practice is misguided given that pyuria and bacteriuria are frequently present in patients with urinary catheters in the absence of clinical infection. 23 No cut-offs for the degree of leukocytosis or fever have even been found to correlate with UTI. 24 Urinary workup in the absence of appropriate concern for UTI is both costly and leads to unnecessary antibiotics. 25 26 Most of the time, an alternative cause of the fever is identified. 27 When urinalysis and cultures are done, one will find bacterial growth about half the time which may be indistinguishable from colonization. We do not encourage routine urinalysis and culture for screening because these may incur unintended harms including unnecessary treatment. 28 Colonization of the urine rarely develops into urosepsis, but it is possible after a urological procedure or other urological abnormality so testing and diagnosis of UTI may be differently nuanced in this setting. 12 13 Furthermore, we make no comment on straight catheterization versus indwelling catheterization because there is no convincing evidence of decreased risk of infection with intermittent straight catheterization even in patients with spinal injury. 29

Clinical risk factors that should raise concern for UTI include previous episodes, urological procedure, abnormal urological anatomy, neutropenia, kidney transplant, and urinary obstruction. The use of multidisciplinary input and algorithms to determine likelihood of UTI are useful alongside the evaluation of fever prior to initiating urinalysis and cultures. 30 Especially in patients who cannot display symptoms, urinalysis and culture can be part of an evaluation for sepsis when the sepsis is determined, after evaluation by the ICU, to be without a clear source. If the patient can be alert enough, urinary symptoms must be assessed including flank pain and pelvic discomfort. Discoloration, odor, and consistency of urine or any kind of change in its appearance are not considered symptoms of UTI. 28 Finally, in the ICU, the chance that colonization and other abnormal urinalysis results will be misclassified and diagnosed as CAUTI is unacceptably high, which reinforces the need to abandon the old surgical dogma of obtaining a urinalysis for every fever. 31 32

In the workup of fever, when should blood cultures be obtained?

Initial blood cultures are needed for conditions associated with bacteremia including necrotizing skin and soft tissue infections, meningitis, systemic infection associated with asplenia and severe intra-abdominal infections (IAIs). Fever alone should not trigger blood cultures. A localized infection should not trigger blood cultures. Sepsis (per sepsis-3 guideline definition) and/or septic shock can trigger blood cultures. Repeat blood cultures are not routine but may be clinically warranted in certain situations. Blood cultures can be considered if the risk to the patient is high if a bacteremia is missed. If a patient has a central line and blood cultures are warranted based on the clinical evaluation, then the diagnosis of catheter-related bloodstream infection (CRBSI) should be made where appropriate.

Neither normothermia nor the presence of fever correlate with bacteremia. 11 Similarly, the combination of leukocytosis and fever has no correlation to bacteremia. 33 Finally, contrary to popular belief, arterial lines appear to have the same risk as central lines for bloodstream infections. 11 34 Testing stewardship is important, in part because the rate of false positive cultures from contamination can be as high as 50%. 35 36 The likelihood of bacteremia based on the clinical judgment of pretest probability should guide the decision to draw blood cultures. 37 Ordering blood cultures should be predicated on the nature and severity of the suspected infection.

The importance of obtaining blood cultures during a febrile episode is overemphasized, even when a central line is present. 5 If a patient has sepsis (per sepsis-3 guidelines) or septic shock or if the source of their suspected infection is associated with a high rate of bacteremia, then they may need blood cultures. If new blood cultures are being considered, a new physical examination and evaluation of the patient’s likely diagnosis and condition need to be made prior to this decision. It is important to recall that if blood cultures return negative in a patient with sepsis, this should not give the clinician reassurance about their condition. 38

There is no role for routine surveillance blood cultures. Routine repeat blood cultures to assess clearance of bacteremia are usually not needed except if the patient does not clinically improve or if they are at risk for metastatic infections (eg, Staphylococcus aureus ). 39–41 Blood cultures can be considered if the risk to the patient is high if a bacteremia is missed (eg, in a patient with a pacemaker and cellulitis). 39

Regarding culturing methods, separate fungal cultures are not needed because most Candida species grow better in normal culture media. 42 Two sets of blood cultures yield the most reasonable data with sensitivity and specificity for true bacteremia. When faced with a positive blood culture, it is important to use multidisciplinary support to differentiate contaminant from true bacteremia. If a central line is present for >48 hours and the infection is not attributable to a different source, then the diagnosis of CRBSI must be entertained in a multidisciplinary fashion. 43

Respiratory

In the workup of fever, when should respiratory cultures be obtained?

The lack of evidence of a new clinical syndrome of pneumonia should obviate the need for a respiratory specimen. Fever alone should not trigger respiratory cultures.

Pulmonary infections are one of the most common causes of fever in critically ill patients, affecting an estimated 25%–33% of ICU patients, this is more common in trauma and the risk is increased in certain injury patterns and with increased injury severity. 9 44 Neither fever nor leukocytosis, nor the combination are associated with positive respiratory cultures, but they are frequently obtained even in the absence of X-ray findings or clinical evidence of pneumonia. 45 46 Respiratory cultures may help support the diagnosis, but the presence of bacteria on culture is not diagnostic of a pneumonia because a majority of intubated patients will have colonization of the endotracheal tube—this is especially true if tracheal aspirates are used, although the use of bronchioalveolar lavage (BAL) does not eliminate false positives or false negatives. 18 47 Unfortunately, a positive culture is often routinely managed with antibiotics regardless of the diagnostic impression. 25 48

The clinical determination or strong suspicion of the syndrome of pneumonia should guide whether or not cultures are initiated. Information for this determination includes imaging findings (chest X-ray, ultrasound or CT), new or acutely worsened oxygenation deficit, the onset of purulent secretions, with concomitant new fever or white count that is not otherwise explained. We find that the clustering of factors in the correct clinical setting is more useful than a single score or numerical cut-off.

There is no strong data to support BAL, mini-BAL, or protected specimen brushing over non-invasive methods of tracheal aspiration or for semi-quantitative over qualitative cultures. 49 An argument can be made for or against either. The joint guideline from the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) weakly recommends non-invasive sampling based on low-quality evidence, while in trauma patients the utility of mini-BAL has been demonstrated specifically in its ability to parse the diagnosis of pneumonia from acute respiratory distress syndrome (ARDS). 44 We recommend institutional multidisciplinary review of accepted practices and verification of correct interpretation based on techniques used.

When is it appropriate to hold antibiotics in cases of fever in the ICU?

Due to significant harm associated with inappropriate antibiotic therapy, it is important to evaluate the likelihood of infection when deciding for or against empiric antibiotic initiation. Once started, de-escalation or stoppage should occur in a timely manner with decision-support by multidisciplinary evaluation and local protocols. Procalcitonin can be used in the context of a multidisciplinary institutional protocol, however, the utility is limited in critically injured patients and certain surgical populations.

The benefits and detriments of antibiotic use, especially in patients without an infection, are not clearly understood; however, antibiotic exposure has been associated with an increased risk of subsequent infections, increased length of stay, and increased mortality. 25 50 It is therefore imperative to closely examine the likelihood of infection in a patient prior to antibiotic initiation taking into context the entire clinical presentation and clinical trajectory.

Prompt re-evaluation and discontinuation of ineffective therapies is important. 25 Intentionally withholding antibiotics may have a benefit when appropriate care is otherwise provided. 20 De-escalation, or stopping antibiotics altogether, should be done once cultures are finalized because this practice both decreases bacterial resistance and lowers 90-day mortality. 10

Procalcitonin has been shown to significantly reduce antibiotic use for lower respiratory infections without adversely impacting outcome. 51 52 It has a high negative predictive value of 91% 40 and follow-up levels have been shown useful for antibiotic discontinuation, 18 however, caution is advised in circumstances that raise procalcitonin at baseline such as trauma including surgical trauma, and inflammatory conditions, like pancreatitis. There is no standard recommended use of procalcitonin in the critically ill trauma population. 53

ICU infections

Ventilator-associated pneumonia.

What is the appropriate treatment approach for ventilator-associated pneumonia (VAP)?

Initiation of broad-spectrum antibiotics for VAP requires consideration of patient-specific culture data, recent antibiotic exposure, the local antibiogram, and timing of when infection developed. Common regimens for hospital-acquired infections are vancomycin plus either cefepime or piperacillin-tazobactam or in cases of severe penicillin allergy, aztreonam, although no specific regimen is generally superior. Empiric anaerobic coverage is not routinely recommended. We recommend de-escalation of antibiotic treatment when culture data are available. Seven days of treatment is sufficient for most patients. Methicillin-resistant S. aureus (MRSA) nasal swab testing should be used to determine the need for empiric coverage.

Evidence suggests mortality is lower when the initial antibiotic therapy is effective, even when switched to adequate therapy after culture data become available. 49 Therefore, it is important to initiate appropriate antibiotics when there is strong clinical suspicion of VAP. There is no evidence of superiority of one specific empiric regimen over another and appropriateness is targeted in context of the hospital antibiogram and specific patient risk factors.

Trauma is a risk factor for staphylococcal infections, specifically traumatic head injury and road traffic injuries. 54 55 MRSA nasal swab testing is useful because of its high negative predictive value for MRSA carrier status and if negative can obviate the need for MRSA coverage, as evidenced by recent data in the trauma population. 56 57 Anaerobic coverage is not routinely recommended due to lack of evidence of benefit and some evidence of harm. 58 59 Empiric coverage is specifically tailored to S. aureus , Pseudomonas , and Gram-negative bacilli.

High-level evidence shows no benefit with treating longer than 7 days in most patients with exceptions limited to severe lung disease, severe immunosuppression, concomitant ARDS, and multidrug resistance. 60 61 To de-escalate an antibiotic regimen, it is important that culture data be obtained at the time of diagnosis. Duration of therapy of 7 days and antibiotic de-escalation recommendations are consistent with the ATS/IDSA guidelines of 2016. 49

Catheter-associated urinary tract infection

What is the appropriate treatment of CAUTI in the critically ill patient?

Treatment for CAUTI should be targeted to the likely causative organisms, local antibiograms, and patient risk factors. In complicated UTI, 7 days of piperacillin-tazobactam, or meropenem if the risk of extended-spectrum beta-lactamase (ESBL) producers is high. Seldom are longer courses needed unless there is no symptomatic improvement within the first few days (then 10–14 days are required). The catheter should be removed or exchanged wherever possible.

Note that the diagnosis of CAUTI should not be made on urinalysis alone and a positive urinalysis without symptoms or sepsis (per sepsis-3 guidelines) should not trigger treatment. Upper urinary tract symptoms include flank pain, costophrenic angle tenderness, shaking fever or chills, severe systemic symptoms. Choice of antibiotic will depend on clinical severity, previous antibiotic use, risk of resistant organisms, and clinical risk of deterioration, and local antibiograms. De-escalation of antibiotic treatment should also occur based on culture data. The catheter should be removed or exchanged wherever possible at the time infection is first suspected. 62 Note that protocolized urine sampling, such as requiring a culture via new urine catheter or straight catheterization, has reduced the rate of CAUTI infection diagnosis by reducing the risk of contamination by colonization, 63 however, it is unlikely that this practice completely eliminates colonization from the urinary specimen. There has been no update to the IDSA guidelines or significant new data since 2009. 64

Catheter-related bloodstream infection

What is the most effective approach and antibiotic therapy for the management of CRBSI?

Effective management of CRBSI involves timely diagnosis, prompt removal of vascular access if at all possible (source control), and appropriate antibiotic therapy for 7–14 days depending on the causative microorganism, as shown in table 3 . Vancomycin plus a beta-lactam (such as piperacillin-tazobactam or a ceftazidime) is usually a good empiric regimen if the risk of ESBL is not high. Reference to the local antibiogram and hospital recommendations is recommended for the selection of empiric therapy.

Summary of antibiotic durations for common ICU infections

The diagnosis of CRBSI should be distinguished from secondary bacteremia due to other sources. 65 Surveillance cultures for patients with central lines are not recommended when CRBSI is not suspected such as in an asymptomatic patient and should not be done when other cultures are more appropriate to evaluate for the clinically suspected infection (eg, respiratory cultures for a suspected pneumonia). 66

The choice of antibiotic therapy should be based on local susceptibility patterns and the severity of illness and should be de-escalated when culture data become available. The recommended duration of antibiotic therapy is 7 days for coagulase-negative staphylococci, 7 days for Gram-negative bacilli, 67–69 14 days for S. aureus (unless a complicated infection is present) 41 ; and 14 days for Candida (in the absence of retinitis or risk factors for it, as described in the ‘Bacteremia’ section). Examples of when a S. aureus infection is considered complicated include endocarditis, osteomyelitis, foreign body or implant, metastatic infection, low minimum inhibitory concentration (MIC), immunocompromise, and recurrent infection. An infectious disease consultation should be sought in S. aureus CRBSI.

The management described here applies to non-tunneled lines. When a CRBSI is suspected, the central line should be removed. 70 Catheter salvage options when the line cannot reasonably be removed are beyond the scope of this text.

What is the management of bacteremia in the critically ill patient?

Management of bacteremia includes prompt initiation of antibiotics at an appropriate dose based on a priori knowledge of guidelines, prompt microbial identification, and source control wherever possible. Empiric coverage may include piperacillin-tazobactam or cefepime plus metronidazole or a carbapenem (if concern for ESBL) with vancomycin or daptomycin. The recommended duration is 7 days for Gram-negatives and coagulase-negative staphylococci, and 14 days for MRSA and Candida species, and longer for complicated and resistant infections, immunocompromised patients, as well as endocarditis and osteomyelitis, as shown in table 3 . For S. aureus bacteremia, an ID consultation should be considered. Stepdown to oral antibiotics is appropriate based on organism identified, severity of illness, and suspected source.

Early and adequate treatment of bacteremia is essential. In general, higher doses of antibiotic are required early in the treatment course. Distinguishing community-acquired versus healthcare-acquired bacteremia is important to dictate antibiotic management. Previous antibiotic therapy, local antibiograms, and pharmacokinetic knowledge are important. The utilization of pharmacist expertise is critical for the provision of the best care in this circumstance. The specific antimicrobial treatment should be inspired by the primary source of infection in cases of secondary bacteremia. 71 Early identification of the microbe, its sensitivities, and targeting of the antibiotic is important. There should be a high pretest probability for bacteremia prior to drawing blood cultures because the risk of contamination of blood culture specimens (false positive) remains significant. ‘Double coverage’ for Gram-negative bacteremia is no longer routinely recommended. 72 73 An antifungal agent may be initiated depending on the clinical presentation and previous knowledge of Candida colonization. Where source control is obtained, the patient is clinically improved, and an appropriate oral antibiotic with favorable efficacy for the microbe is used, there is sufficient evidence to recommend stepdown to oral antibiotics to complete the total antibiotic course. 74 75

There is now sufficient evidence to recommend 7 days of antibiotic therapy in cases of coagulase-negative staphylococci and Gram-negative bacteremia, 14 days for MRSA (unless a complicated infection is present as described in the section on CRBSI), and 14 days for Candida . Patients with candidemia require screening for retinitis if they are symptomatic for vision disturbance, are non-verbal, or have risk factors for ocular involvement (risk factors include long intravascular lines, parenteral nutrition, prolonged hospital stays, and recent abdominal surgery). 76 These criteria based on recent data, reviews, and statements by the Royal College of Ophthalmologists and the American Academy of Ophthalmology have not yet been evaluated by the IDSA. 77 78 Patients with ocular involvement should have an infectious disease consultation.

Follow-up blood cultures are not routinely needed for bacteremia and are discouraged except for S . aureus infections or in patients lacking clinical response. 79 In difficult-to-treat infections, infectious disease consultation is advisable. Intravenous beta-lactam antibiotics are the best antibiotics for initial management of methicillin-susceptible S. aureus . Removal an infected device or a device suspected to be infected must be considered. Appropriate durations of therapy must be prescribed. Of note, an infectious disease consultation is of benefit for S . aureus bacteremia as it reduces morbidity and mortality, even in relatively minor infections. 80 81

Surgical site infections

What are the treatment and antibiotic use recommendation for surgical site infection (SSI)?

The treatment of an SSI involves evacuation of infected material and one to 1–2 days of antibiotics if cellulitis is >5 cm or if significant systemic symptoms are present.

The most important therapy for a patient with an SSI is prompt source control by removing the infected material. In superficial SSIs, removing sutures/staples may accomplish this. If the surrounding erythema is minor and the patient has no significant systemic symptoms, antibiotics are unnecessary. Otherwise, a short course of antibiotics (24–48 hours) may be appropriate, such as cefazolin for clean procedures and ceftriaxone plus metronidazole for intra-abdominal procedures. 82 Persistence or recurrence of superficial signs/symptoms may indicate a deep or organ space SSI.

Intra-abdominal infection

In patients with IAI, what is the treatment and duration?

Initial antibiotic selection for IAI should be based on the source of infection, local antibiogram, and clinical severity. One reasonable empiric regimen is piperacillin-tazobactam for high-risk patients (plus vancomycin or linezolid in healthcare-associated IAI and ceftriaxone plus metronidazole for low-risk patients. Uncomplicated IAI (uIAI) can be managed with a single dose of preoperative antibiotic or a maximum of 24 hours postoperatively. Complicated IAI (cIAI) can be managed with 4 days of antibiotics once source control is achieved. When source control is not possible, we recommend 5–7 days of antibiotics. There is no demonstrated benefit in empiric antifungal therapy.

uIAI include uncomplicated appendicitis or acute cholecystitis, traumatic bowel perforations managed within 12 hours, gastroduodenal perforations operated on within 24 hours, and resected ischemic bowel. cIAI are any IAI that extend beyond the site of origin or include the peritoneum. Treatment should involve prompt source control including emergent or urgent surgical exploration commensurate with the level of illness. Percutaneous options can be used if they achieve good source control. Any delay >24 hours is a predictor of failure and should be avoided. In systemically ill patients or patients with sepsis, initial blood cultures are indicated. Fluid or tissue from the source control procedure should be obtained to target antimicrobial selection. 83

Antimicrobial therapy should be initiated as soon as an IAI is diagnosed or considered likely. The selection of antibiotics should be based on the local antibiogram and guided by a combination of culture results and the patient’s clinical status. Empiric antibiotics for severe community-acquired IAIs should include broad-spectrum Gram-negative coverage. 83 Anaerobic coverage is also needed for which metronidazole is a recommended regimen, while for patients receiving piperacillin-tazobactam metronidazole is not necessary. Dual anerobic coverage is not recommended (except in specific infections including complicated C. difficile infections with vancomycin plus metronidazole and toxic shock syndrome for which treatment includes both vancomycin and clindamycin). In healthcare-associated infections, patients should be covered for MRSA such as with vancomycin or linezolid. 84 High-risk patients should be given enterococcal coverage such as with vancomycin if they are not being treated with piperacillin-tazobactam. 84

Patients with uIAI can be managed with either a single dose of perioperative antibiotic or a maximum of 24 hours of therapy. 83 For cIAI, the most recent guidelines from the IDSA in 2010 and the Surgical Infection Society (SIS) in 2017 recommend shorter courses of antibiotics in patients who have adequate source control, 4–7 days and 4 days, respectively. The Study to Optimize Peritoneal Infection Therapy (STOP-IT trial) concluded that 4 days is sufficient. 85 The SIS recommends a short 5–7 days course in patients without adequate source control with a reassessment of potential source control if the patient remains ill. 84 We concur that there has not been evidence that describes a situation of IAI where courses >7 days are recommended, even in the presence of intraperitoneal sources with secondary bacteremia, and we agree that the emphasis is on thorough diagnostic evaluation and consideration for additional procedures when there is suspected failure of source control.

Empiric/Prophylactic preoperative antifungal therapy is not needed 86 and routine post operative antifungal therapy in average risk patients is not recommended either. 87 Only in high-risk patients, patients with prolonged perforation or preceding risk factors such as high-risk upper gastrointestinal perforations, recurrent bowel perforations, surgically treated pancreatitis, or prolonged antibiotic therapy can benefit from antifungal therapy. 84 Additionally, the Candida score remains a useful tool, however, we recommend it be applied in the context of the data from the SIS. For instance, promptly treated bowel perforation in the absence of other risk factors should not be counted as a reason toward empiric fungal therapy based on recent evidence. 88 89

Ventriculitis

In patients with ventriculitis, what is the most appropriate treatment?

Recommendations

A common antibiotic regimen for ventriculitis consists of vancomycin plus cefepime to cover hospital-acquired organisms. Removal of foreign body (ventricular shunt or external ventricular drain (EVD) may aid bacterial clearance. The duration of treatment is generally 10−14 days and can be longer for recurrent culture positivity or for S. aureus .

Ventriculitis in hospitalized patients most commonly occurs in association with neurosurgical procedures, trauma resulting in dural tears and cerebrospinal fluid (CSF) leaks, or the insertion of a central nervous system (CNS) device such as a shunt or EVD. Diagnosis involves the biochemical profile and cultures of CSF and sometimes imaging such as CT or MRI to detect complications of ventriculitis including abscess. The organism may not always grow on culture media or may grow in a delayed fashion so the clinical context must be closely considered. Attention to CSF penetration must be given in antibiotic selection. In cases refractory to systemic antimicrobials, limited data support consideration of intraventricular administration. 90 Specific recommendations about device-related infections, relative need for neuroimaging, and timeline of removal and re-implantation are beyond the scope of this article.

Necrotizing soft tissue infection

In patients with necrotizing soft tissue infection (NSTI), what is the preferred antibiotic therapy and duration?

Empiric antibiotic therapy for NSTIs should be broad-spectrum and reflect local resistance patterns. First-line treatments include linezolid or (vancomycin plus clindamycin in combination with piperacillin-tazobactam.

We recommend 2–4 days of antibiotics after final debridement if the following conditions are met: (1) favorable wound appearance, (2) subjective clinical improvement, (3) no fever for 48 hours after last debridement, (4) relative improvement of laboratory values (white blood cell, lactate, etc) and (5) the initial blood cultures are negative. We recommend 5–7 days of therapy in patients who meet sepsis (sepsis-3) or have septic shock that does not improve after initial resuscitation or who did not have blood cultures drawn at presentation. Patients with marine or fresh water exposure require special antibiotic considerations, as described in the discussion.

Initial therapy should include coverage for Gram-positive and Gram-negative (aerobic and anaerobic) organisms including MRSA, as well as group A and group B streptococci. Antibiotics chosen should have good tissue penetrance, especially since many patients with NSTI have severe diabetes.

Piperacillin-tazobactam has broad Gram-negative aerobic coverage which is a gap in coverage with linezolid and microbes causing NSTI continue to have good sensitivity. 91

Linezolid has recently been shown to be associated with better clinical and microbiological cure rates than vancomycin. 92 Because linezolid has antitoxin activity, it obviates the need for clindamycin. 93 Furthermore, linezolid is more likely to cover group B streptococci which are common in NSTI. 94 Clindamycin has a long history of clinical data and there is not enough data to discern whether the rising resistance in group A Streptococcus is clinically significant. Clinical superiority for linezolid is suggested in NSTI caused by MRSA, 93 although the most recent evidence does not show overall clinical superiority. 95 Linezolid is associated with less acute kidney injury than the alternative treatment with vancomycin and a shorter hospital length of stay but a higher risk of thrombocytopenia. 96 Vancomycin plus clindamycin remain a different but equal choice as linezolid as the debate continues. 97

Rare but important exposures that can lead to fatal infections are the following: (1) marine exposure—the antibiotic regimen must then cover vibrio species, namely (a quinolone or a tetracycline) plus a third-generation cephalosporin. 98 Exposure to fresh water, soil, wood—the antibiotic regimen must then cover Aeromonas , namely a tetracycline with either ciprofloxacin or ceftriaxone, based on known effectiveness of these agents. 82 99 We do not advise carbapenems because there are rising reports of resistance. 100–102

Regarding the duration of antibiotics, we base our current antibiotic recommendation on recent literature and recommend a 2-day to 4-day course provided the conditions above are met. The presence of initial negative blood cultures would obviate the need to treat a bacteremia; furthermore, given that patients with positive blood culture were excluded from the index study, one cannot conclude that patients without initial blood culture data are safe to be included in the short-course treatment strategy. 103 104

Evaluating fever and determining the likelihood of an underlying infection can be challenging. It is important for the surgical intensivist to remain vigilant to identify sepsis and septic shock and also to exercise clinical judgment and forethought when ordering antibiotics. In the absence of sepsis (as defined by sepsis-3 guidelines) and septic shock, the data support selective utilization of cultures and antibiotic use. In most infections, the evidence is accumulating in favor of the safety and efficacy of shorter courses of treatment. Table 3 provides a summary of the recommendations for antibiotic durations for common ICU infections. We present here a consensus summary from the AAST Critical Care Committee for our approach to fever in the ICU and for the treatment of common surgical intensive care infections, namely VAP, UTI, CRBSI, bacteremia, intra-abdominal abscess, SSI, ventriculitis, and necrotizing skin and soft tissue infections.

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Collaborators American Association for the Surgery of Trauma Critical Care Committee.

Contributors All authors were involved in the design, research, and writing of this guideline, as well as critical revision of the manuscript. EN, RDA, MSF, JC and DMS performed the final revisions of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests TC reports: Innovital—funding paid to my institution related to research performed; Cytovale—direct payments to me for research-related medical monitoring. SM reports: UpToDate—Author Royalty; AHRQ grant funding, but not related to this topic. LK reports: Eastern Association for the Surgery of Trauma Vice Chair Guidelines Committee; American Association for the Surgery of Trauma Palliative Care Committee, American Association for the Surgery of Trauma Critical Care Committee, American College of Surgeons Geriatric Surgery Verification Standards and Verification Committee, Journal of Surgical Research Editorial Board Member. DMS reports: grant funding from PCORI, DoD, NIH, NHTSA and consultant fees—CSL Behring.

Provenance and peer review Not commissioned; externally peer reviewed.

Linked Articles

Commentary Conundrums in the surgical intensive care unit: fevers and antibiotic prophylaxis Diane N Haddad Patricia Martinez Quinones Sriharsha Gummadi Niels D Martin Trauma Surgery & Acute Care Open 2024; 9 - Published Online First: 03 Jun 2024. doi: 10.1136/tsaco-2023-001352

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Published: 06 June 2024

Editorial: Management of PJI/SSI after joint arthroplasty

Javad Parvizi 2 ,
Xiaogang Zhang 1 ,
Xianzhe Liu 3 ,
Wierd P. Zijlstra 4 &
Saad Tarabichi 5

Arthroplasty volume 6 , Article number: 31 ( 2024 ) Cite this article

Metrics details

The management of periprosthetic joint infection (PJI) and surgical site infection (SSI) after joint arthroplasty poses a major challenge in orthopedic surgery. This Editorial provides an overview of the studies published in the special issue “Management of PJI/SSI after Joint Arthroplasty”, summarizing the key findings from these studies, which cover a wide range of topics, including stringent preventive strategies, comprehensive diagnostic methods, and personalized treatment modalities. The authors concluded the editorial with their perspectives regarding the status quo of research in this field and future directions for research, such as the development of novel antibiotics, biofilm research, patient-specific risk factors, and the integration of technological advancements (such as machine learning and artificial intelligence) into clinical practice. The authors emphasized the need for continued research, interdisciplinary collaboration, and the application of innovative technologies to enhance patient outcomes and mitigate the burden of these infections on healthcare systems.

Introduction

Periprosthetic joint infection (PJI) and surgical site infection (SSI) following joint arthroplasty still present significant challenges in the field of orthopedic surgery. These infections can lead to severe consequences, including protracted hospital stays, increased healthcare costs, patient discomfort, and even implant failure [ 1 , 2 ]. The management of PJI/SSI requires a comprehensive and multidisciplinary approach to effectively prevent, diagnose, and treat these infections.

Prevention of PJI/SSI begins with strict adherence to infection control guidelines during the perioperative period. Strategies such as preoperative screening for infection risk factors, appropriate surgical site preparation, administration of prophylactic antibiotics, and rigorous sterile technique are critical in reducing the incidence of these infections [ 3 ]. However, PJI/SSI can still occur despite stringent preventative measures, so prompt and accurate diagnosis is essential. The diagnosis of PJI/SSI is often complicated and tends to involve clinical assessment, laboratory tests, imaging examinations, and sometimes invasive procedures such as joint aspiration or tissue sampling [ 4 ]. Differentiation between aseptic failure and infection is critical to the selection of the appropriate management approach [ 5 ]. Various diagnostic criteria and scoring systems have been developed to aid in this process, but challenges remain.

Once diagnosed, the management of PJI/SSI requires an approach tailored to the specific features of the infection, including the causative microorganisms, the extent of tissue involvement, and the stability of the implant [ 6 ]. Treatment options range from antimicrobial therapy alone for early and low-grade infections [ 7 ] to a combination of various surgical interventions for more severe cases [ 8 ]. The choice of treatment modality must carefully consider factors such as patient comorbidities, implant stability, and the potential for functional restoration. Recent years have witnessed significant advances in the understanding and management of PJI/SSI, with research focusing on improving diagnostic accuracy [ 9 ], developing novel antimicrobial strategies [ 10 ], exploring the role of biofilms in infection persistence [ 11 ], and investigating the impact of implant design and surface modifications on infection rates [ 12 ].

This special issue “Management of PJI/SSI after Joint Arthroplasty” (Available via: https://www.biomedcentral.com/collections/pji , Accessed on 1 March 2024), is important to the field of PJI/SSI management. It brings together a collection of research papers that addressed the challenges and explored potential solutions associated with these infections. The papers included in this special issue covered various aspects of PJI/SSI, such as advances in diagnostic techniques, innovative treatment modalities, and infection prevention strategies. We aimed to stimulate discussion, generate new ideas, and encourage collaboration between experts in the field, thereby contributing to the ongoing efforts to combat post- arthroplasty PJI/SSI.

Preventive strategies in joint arthroplasty

SSI prevention is a key aspect of joint replacement management. Parvizi et al. [ 13 ] proposed a comprehensive ten-step approach to SSI prevention, involving all stages of the surgical procedure from preoperative planning, including patient education and skin preparation, through intraoperative strategies such as antibiotic prophylaxis and aseptic techniques, to postoperative wound care. They believed that, by consistently following these steps, the risk of SSI could be significantly reduced, thereby enhancing patient safety, and improving surgical outcomes.

The emphasis on prevention is further underscored by some studies that aimed at identifying and managing risk factors associated with SSIs in joint replacement surgery. For example, Lin et al. [ 14 ] conducted a study on the incidence and risk factors of SSI following primary hip hemiarthroplasty in elderly patients, identifying chronic steroid use, increased BMI, and prolonged intraoperative time as independent risk factors. They highlighted the importance of tailored interventions to manage these risk factors in this population. Similarly, Chan et al. [ 15 ] reviewed the risk factors associated with SSI after joint replacement surgery, with the following patient-related factors taken into account, such as age, BMI, and comorbidities, and surgery-related factors such as surgical technique, duration of surgery, and perioperative management. They emphasized the significance of understanding these risk factors in developing effective prevention strategies. In a similar vein, van de Kuit et al. [ 16 ] conducted a systematic review and meta-analysis comparing the risk of SSI in patients undergoing elective knee and hip arthroplasty with either staples or sutures for wound closure. Results indicated that suturing may be a safer choice than stapling (especially in hips), a conclusion that has important implications for surgical practice and patient outcomes in orthopedic surgery. Taken together, these studies highlighted the importance of personalized and evidence-based approaches to reducing the risk of SSI and underscored the critical role of prevention in improving patient safety and surgical outcomes.

Antibiotic-loaded bone cement (ALBC) has been recognized as an important tool in the prevention and treatment of PJI. Soriano et al. [ 17 ] examined the use of ALBC and discussed its pharmacokinetics, efficacy in infection prevention, prophylactic and therapeutic effects, and potential risks of antimicrobial resistance. They highlighted the need for careful patient selection and appropriate antibiotic choice to maximize benefits and minimize risks. Berberich et al. [ 18 ] reviewed the potential of dual antibiotic-loaded bone cement (ALBC) in the prevention of PJI in high-risk patients. Studies indicated that the local delivery of antibiotics via bone cement could provide enhanced and sustained antimicrobial effects, thereby lowering the incidence of PJI. This paper provided a compelling argument for the potential of ALBC in PJI prevention, especially in high-risk patient groups. However, Bos et al. [ 19 ] were unable to prove that dual ALBC was superior to single ALBC in aseptic revision hip and knee surgery.

In addition to these strategies, Zhou et al. [ 20 ] stressed the critical role of soft tissue management in the treatment of PJI. They provided an in-depth review of guidelines for soft tissue management at various stages of the surgical process, including preoperative evaluation, surgical exposure, intraoperative removal of infected tissues, defect coverage, postoperative assessment, wound management, and rehabilitation. One of the fundamental aspects was the importance of thorough debridement and reconstruction of soft tissues with a good blood supply for successful PJI treatment. They emphasized that, by carefully following these principles, surgeons could significantly enhance infection control rates and postoperative joint function, leading to improved patient outcomes.

Diagnostic methods for joint infection

The diagnosis of chronic PJI remains a formidable challenge due to the lack of a “gold standard”. Jennings et al. [ 21 ] addressed this complicated issue head-on, emphasizing the need for a comprehensive clinical evaluation, which includes patient history, physical examination, laboratory tests, and imaging studies, for the accurate diagnosis of chronic PJI. They also delved into the possibility of utilizing joint aspiration and the interpretation of multiple diagnostic tests to improve diagnostic accuracy. In addition, they emphasized the need for meticulous assessment of multiple factors and the application of validated scoring systems or consensus-based criteria for PJI diagnosis, thereby providing valuable guidance that helps clinicians make informed decisions. This comprehensive approach confronts the challenges of diagnosing chronic PJI and highlights the importance of integrating different diagnostic modalities and patient-specific factors into the diagnostic workup.

Advances in diagnostic techniques and biomarkers have significant potential to improve the accuracy of PJI diagnosis. This was the focus of a study by Tripathi et al. [ 22 ], who explored the potential of these advancements. They studied the use of novel biomarkers in conjunction with traditional biomarkers and reviewed the efficacy of various diagnostic methods, such as synovial fluid analysis, serum markers, and molecular techniques, their results particularly suggesting the superiority of synovial fluid biomarkers over serum ones. They further highlighted the promise of diagnostic algorithms that integrate these biomarkers with other clinical and radiological parameters for a more accurate diagnosis. Despite the promising findings, further research is needed to fully validate the clinical utility of these biomarkers. The review highlights the updates of diagnostic biomarkers and provides valuable insights into their potential role in enhancing PJI diagnosis.

Determining the optimal interval for two-stage exchange in PJI remains a complex and controversial issue, as explored in the review by Sousa et al. [ 23 ]. They examined the existing evidence and proposed that an interval of 8 weeks may achieve optimal success rates. However, this interval should not be applied universally but should be tailored according to individual patient factors, including the type of infecting organism, comorbidities, and the local soft tissue condition. The authors also discussed the imaging and intraoperative findings as guides for this crucial decision-making process. Their comprehensive exploration provided valuable data for surgeons and highlights the importance of a patient-specific approach in determining the most effective interval for two-stage exchange in PJI.

Treatment protocols and patient outcomes

There are several treatment strategies for PJI management, each having unique advantages and challenges. Gramlich et al. [ 24 ] conducted an in-depth review on salvage procedures. These procedures included implant retention with irrigation and debridement, a technique that aims to preserve the prosthesis while eliminating the infection, thus minimizing disruption to joint function. The review covered the more invasive procedures of implant exchange and two-stage exchange, which involved the removal and replacement of the infected prosthesis. Meanwhile, patient selection is very important, with the patient’s overall health, the severity of the infection, and the type of infecting organism have been taken into consideration, so a multidisciplinary approach to preoperative planning is required. Complementing Gramlich’s work, Chen et al. [ 25 ] reviewed the use of articulating spacers, devices designed to maintain joint mobility and space during the interim period between the removal of the infected prosthesis and its replacement. They discussed various designs of spacers, their indications, and the technical aspects of their implantation and removal. They argued that the correct use of these spacers could significantly enhance patient comfort and mobility during the challenging period between staged revisions for PJI. Meanwhile, Cao et al. [ 26 ] comprehensively analyzed a single-stage revision as a solution for chronic PJI following knee and hip arthroplasties. This procedure involved the removal of the infected prosthesis and immediate replacement within the same surgery, thereby reducing the need for multiple surgeries. They also provided valuable suggestions on patient selection, which takes into consideration the factors such as the type of infecting organisms, the patient's general health, and the extent of the infection.

Several studies have investigated the efficacy of different surgical strategies for the treatment of acute PJI after total knee arthroplasty. Natali et al. [ 27 ]. compared debridement, antibiotics, and implant retention (DAIR) with debridement, antibiotics, and bead insertion. Their results showed no significant difference in success rates between these two methods, indicating both are viable strategies for the treatment of PJI. In another study [ 28 ], the use of gentamycin beads or sponges however showed inferior outcomes, and their use has been discouraged in some DAIR treatment protocols. This notion of flexibility in surgical strategies is reinforced by Fokkema et al. [ 29 ], who reported an unusual case of PJI caused by Streptobacillus moniliformis , a pathogen typically associated with rat-bite fever. This infection was successfully managed using the DAIR, underlining the importance of considering both common and rare pathogens in the differential diagnosis of PJI. Further emphasizing the effectiveness of the DAIR method, Spangehl et al. [ 30 ]. argued for its use as a first-line treatment for acute PJI, subject to appropriate technical considerations and patient selection. They also highlighted the crucial role of early intervention and suitable antibiotic therapy in attaining the success of DAIR. Complementing these findings, Mian et al. [ 31 ] reviewed current practices in PJI debridement and revision arthroplasty, including the use of antibiotics, implant retention, and two-stage revision. They believed that early detection and proper management of PJI can enhance patient outcomes and minimize the need for revision surgery. Overall, these studies underscored the potential efficacy of different surgical strategies for the treatment of PJI and the importance of individualized treatment, early intervention, and consideration of the possibility of the various causative pathogens.

Wouthuyzen-Bakker et al. [ 32 ] discussed the critical role of antibiotics in the management of PJI. They outlined the basic principles of antimicrobial treatment, focusing on rifampicin for Gram-positive bacteria and fluoroquinolones for Gram-negative bacteria, which are the most common causes of PJI. They also discussed the importance of tailoring antibiotic regimens based on culture results and patient characteristics. In addition, this group [ 33 ] presented the Northern Infection Network for Joint Arthroplasty (NINJA) protocol for PJI treatment, which incorporates the latest evidence-based practices and a multidisciplinary approach, including diagnostic, surgical and antibiotic treatment steps. This protocol serves as a model for regions seeking to enhance PJI management, highlighting the need for a comprehensive, patient-centered, and evidence-based approach.

Lastly, a special case report by Ferry et al. [ 34 ] discussed Coxiella burnetti prosthetic joint infection in an immunocompromised woman. A patient underwent a protracted treatment with ofloxacin-rifampin, multiple surgeries, and a complex reconstruction. This case highlighted the challenge of managing PJI in immunocompromised patients the need for a multidisciplinary approach.

Future directions & perspective

The management of PJI and SSI has been dynamically evolving. The challenges presented by these complications require a multidisciplinary approach and a commitment to continued research and innovation. One promising pathway is the development of novel antibiotics and their delivery systems. By conceiving, rigorously testing, and using effective antibiotics, especially those with enhanced efficacy against biofilm-producing bacteria, complete with delivery systems that improve antibiotic penetration into biofilm matrices, we could revolutionize the therapeutic practice for PJI and SSI. Additionally, intra-articular antibiotic infusion represents a promising route of administration. It can circumvent systemic circulation, reduce the risk of hepatic and renal function impairment, and provide a sufficiently high antibiotic concentration at the prosthetic infection site. However, further research with a higher level of evidence are still needed to confirm the efficacy of this administration method and its impact on pathogen resistance. At the same time, the role of biofilm research is undeniably critical. Since biofilms are significant hurdles in the way, future research endeavors should be directed at looking into the biology of biofilm formation and working out strategies to disrupt or inhibit their formation. This includes investigating the genetic and environmental factors that speed up or underlie biofilm formation and developing materials that are resistant to biofilm adherence. Furthermore, there is a need for the development of physical technologies capable of directly disrupting biofilms, such as ultrasound and radiofrequency modalities. Equally important is a comprehensive understanding of patient-specific contributors to the risk of PJI and SSI. Intensive research into the role of comorbidities, genetic predispositions, and lifestyle factors in infection could help develop targeted interventions to mitigate these risks and enable shared decision-making with the patient based on his or her comorbidities and lifestyle choices. The potential of technological advancements, such as machine learning (ML) and artificial intelligence (AI), is significant. Integration of ML and AI into the management of PJI and SSI could enhance diagnostic accuracy and improve treatment outcomes. For instance, the predictive algorithms based on patient data can better assess infection risk, and the real-time patient monitoring systems can identify/capture early signs of infection. Lastly, robust, high-quality randomized controlled trials and continuous surveillance in orthopedic registries are of paramount importance to the validation of findings from observational studies and case reports and the formulation of evidence-based guidelines for PJI and SSI management.

The management of PJI and SSI continues to be a formidable task within the realm of orthopedic surgery. These infections, with their inherent complexity, present a considerable challenge, but significant progress has been made in understanding their pathophysiology, pinpointing risk factors, and developing effective countermeasures. The future of PJI and SSI management depends on sustained research, interdisciplinary efforts, and the integration of novel technologies. By constantly expanding our knowledge and honing our skills, we can improve patient outcomes and ease the burden these infections place on our healthcare systems.

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Acknowledgements

As guest editors, we would like to express our heartfelt gratitude to the authors who have contributed their valuable research to this Special Issue. We would also like to extend our appreciation to the diligent reviewers for their meticulous efforts in ensuring the quality and relevance of the papers published, as well as the Arthroplasty editorial team for their efforts to assist in operating this successful special issue. We are highly expecting this article collection about PJI and SSI management could better assist the joint orthopaedic surgeons’ community, and also provide something new and advanced to the joint patient’s treatment.

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Department of Orthopedics, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830011, China

Li Cao & Xiaogang Zhang

International Joint Center, Acibadem University Hospital, Istanbul, 34746, Turkey

Javad Parvizi

Department of Orthopedic Surgery, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China

Xianzhe Liu

Department of Orthopedic Surgery, Medical Center Leeuwarden, 8934 AD, Leeuwarden, the Netherlands

Wierd P. Zijlstra

Rothman Orthopedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA

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Cao, L., Parvizi, J., Zhang, X. et al. Editorial: Management of PJI/SSI after joint arthroplasty. Arthroplasty 6 , 31 (2024). https://doi.org/10.1186/s42836-024-00256-0

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DOI : https://doi.org/10.1186/s42836-024-00256-0

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Periprosthetic joint infection
Surgical site infection
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Diagnostic method
Joint arthroplasty

Arthroplasty

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presentation of surgical site infections

Effects of povidone-iodine wound irrigation on surgical site infection in gastroenterological surgery: A randomized controlled trial

Affiliations.

1 Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan.
2 Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan; Division of Surgical Care, Morimachi, Hamamatsu University School of Medicine, Hamamatsu, Japan.
3 Data Ops Center, Hamamatsu University School of Medicine, Hamamatsu, Japan.
4 Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Perioperative Functioning Care and Support, Hamamatsu University School of Medicine, Hamamatsu, Japan.
5 Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan. Electronic address: [email protected].
PMID: 38825398
DOI: 10.1016/j.surg.2024.04.034

Background: The irrigation efficacy of a povidone-iodine solution to prevent surgical site infection is still controversial. We assessed the irrigation effect with a povidone-iodine solution on the incidence of surgical site infection after gastroenterological surgery.

Methods: This study is a single-center, prospective, randomized, blinded-end point superiority trial for surgical wound irrigation. Patients undergoing gastroenterological surgery were randomly assigned in a 1:1 replacement ratio using computer-generated randomization. Patients were grouped according to their surgical wound treatment into the control group using the normal sterile saline and the povidone-iodine group using 10% povidone-iodine solution after the NS solution. The main finding was 30-day surgical site infections assessed in the full analysis set.

Results: From November 2020 to December 2022, 697 of 894 patients were eligible for the study, among which 347 were in the povidone-iodine group and 350 in the control group. Thirty-day surgical site infections occurred in 100 (14%) patients-54 (16%) in the povidone-iodine group and 46 (13%) in the control group (odds ratio, 1.229; 95% CI, 0.800-1.889; P = .406). Superficial incisional surgical site infections occurred in 30 (9%) and 15 (4%) patients, respectively (odds ratio, 2.154; 95% CI, 1.134-4.090; P = .026). Only 3 patients (1%) in the control group developed adverse skin reactions.

Conclusion: This study examined the irrigation efficacy of povidone-iodine for surgical site infection prevention compared to control in gastroenterological surgery. Povidone-iodine wound irrigation has shown no additional beneficial effect on the occurrence of surgical site infections.

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Three steps to reduction surgical site infection: presentation of a comprehensive model

Saeid amini rarani.

1 Department of Operating Room, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Axel Kramer

2 Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald, Germany

To prevent surgical site infections (SSIs), a three-step model is proposed, which integrates perioperative measures, multidisciplinary collaboration, and continuous quality improvement (CQI) initiatives.

Zur Prävention von postoperativen Wundinfektionen wird ein 3-Stufen Modell vorgeschlagen, in dem perioperative Maßnahmen, multidisziplinäre Zusammenarbeit und kontinuierliche Qualitätsverbesserung aufeinander abgestimmt umgesetzt werden.

Introduction

Surgical site infections (SSIs) are defined as infections occurring up to 30 days after surgery (or up to one year after surgery in patients receiving implants) and affecting either the incision or deep tissue at the surgical site [ 1 ]. SSIs are a significant concern, as they not only lead to increased morbidity and mortality rates but also impose a considerable economic burden on healthcare systems worldwide. SSIs pose a substantial challenge to patient safety and healthcare systems worldwide. Despite advancements in surgical techniques and infection control measures, SSIs continue to occur at an alarming rate. SSIs are responsible for approximately $3.5 billion to $10 billion in US healthcare costs annually. Compared to patients without SSIs, those with SSIs remain in the hospital approximately 7 to 11 days longer; one study involving 177,706 postsurgical patients reported that SSI was the cause of 78% of all readmissions [ 2 ]. Therefore, measures to reduce surgical site infection are necessary [ 3 ] and must be adaptedunder pandemic situations [ 4 ].

The proposed 3-step model integrates perioperative measures, multidisciplinary collaboration, and continuous quality improvement (CQI) initiatives to enhance patient safety and outcomes.

Perioperative measures

This subsection emphasizes the importance of adhering to evidence-based guidelines for infection prevention during surgical procedures. It explores preoperative strategies (e.g., patient optimization, antimicrobial prophylaxis), intraoperative measures (e.g., sterile technique adherence), and postoperative care (e.g., wound management) [ 1 ].

Preoperative strategies

Patient optimization.

Preoperatively identifying and addressing modifiable risk factors such as obesity, smoking cessation programs, glycemic control in diabetic patients, and decolonization of nasal carriers of Staphylococcus aureus can significantly reduce the risk of SSIs.

Antimicrobial prophylaxis

Administering appropriate antimicrobial prophylaxis based on established guidelines is crucial in preventing SSIs.

Skin preparation

Proper skin preparation using residually-acting alcohol-based formulations that contain e.g. povidone-iodine or chlorhexidine gluconate, significantly reduces bacterial colonization at the surgical site.

Intraoperative strategies

Aseptic technique.

Adherence to strict aseptic techniques during surgery minimizes contamination risks.

Surgical attire

Wearing appropriate surgical attire including sterile gowns and gloves reduces the introduction of pathogens into the surgical field [ 5 ].

Surgical drapes

The use of sterile surgical drapes creates a barrier between the surgical site and potential sources of contamination.

Surgical site irrigation

Antiseptic irrigation solutions, such as polyhexanide or povidone-iodine, can be used intraoperatively to reduce bacterial load at the surgical site.

Postoperative strategies

Proper wound care techniques, including regular dressing changes and monitoring for signs of infection, are essential in preventing SSIs.

Early mobilization

Encouraging early mobilization postoperatively aids in improving blood circulation and reducing the risk of infection.

Antibiotic stewardship

Rational use of antibiotics, including appropriate duration and selection based on culture results, helps prevent the development of antibiotic-resistant organisms.

Multidisciplinary collaboration

The role of surgeons.

Surgeons play a pivotal role in preventing SSIs, for instance, through appropriate antimicrobial prophylaxis, meticulous surgical technique, and timely wound closure. Collaborative efforts with other healthcare professionals can enhance compliance with these practices and promote standardized protocols.

The role of nurses

Nurses are integral members of the multidisciplinary team involved in perioperative care. Their contributions include preoperative patient education, strict adherence to aseptic techniques during surgery, effective wound management postoperatively, and surveillance for early detection of SSIs.

The role of anesthesiologists

Anesthesia providers contribute significantly to SSI reduction by optimizing patients’ physiological status before surgery, ensuring normothermia during procedures, and implementing strategies such as antibiotic stewardship programs that minimize the risk of infection.

Infection prevention specialists

Infection prevention specialists play a critical role in developing comprehensive infection control programs tailored to each surgical setting’s unique needs. Their involvement includes surveillance, monitoring compliance with infection control practices, and providing education and training to healthcare professionals.

Importance of environmental services

Environmental services personnel play a crucial role in maintaining a clean and hygienic surgical environment. Their collaboration with the multidisciplinary team ensures proper cleaning and disinfection surfaces and validated reprocessing of surgical equipment.

The role of information technology

Information technology systems can facilitate communication, enhance data collection, and support decision-making processes related to SSI prevention. Collaborative efforts between healthcare professionals and IT specialists can lead to the development of innovative tools for real-time monitoring, risk assessment, intervention implementation and auditing [ 3 ].

Patient engagement

Engaging patients in their care is vital for SSI reduction. Educating patients about preoperative hygiene measures, promoting adherence to prescribed medications, and involving them in shared decision-making processes can empower patients to actively participate in infection prevention.

CQI initiatives

To sustain long-term improvements in SSI rates, this subsection emphasizes the importance of CQI initiatives. It explores the use of surveillance systems, data analysis, feedback mechanisms, and regular audits to identify areas for improvement and implement targeted interventions.

Methodologies employed in CQI initiatives

Various methodologies are utilized in CQI initiatives to reduce SSIs. This section explores the application of Lean Six Sigma principles, Plan-Do-Study-Act cycles, root cause analysis, process mapping, and other quality improvement tools in different healthcare settings.

Outcomes of CQI initiatives

This section presents a comprehensive analysis of the outcomes associated with CQI initiatives aimed at reducing SSIs. It examines reductions in SSI rates, improvements in compliance with infection prevention protocols, enhanced patient satisfaction scores, decreased length of hospital stays, and cost savings achieved through these initiatives.

Conclusions

In conclusion, SSIs remain a significant concern in operating rooms worldwide. However, by implementing a comprehensive model that integrates perioperative measures, multidisciplinary collaboration, and CQI initiatives, healthcare institutions can effectively decrease the incidence of SSIs and improve patient outcomes.

Competing interests

The authors declare that they have no competing interests.

Authors’ ORCIDs:

Saeid Amini Rarani: 0000-0003-4700-0211
Axel Kramer: 0000-0003-4193-2149

News Releases

Surgical site infection rates and other secondary outcomes decrease dramatically at multi-state hospital system through standardized, preoperative, surgical, antibiotic practices

Improved outcomes for orthopedic, colorectal, and abdominal hysterectomy surgery patients

Association for Professionals in Infection Control

San Antonio, Texas, June 4, 2024 – Mortality, length of stay, readmissions, and surgical site infections (SSI) all declined after a six-state hospital system implemented a comprehensive surgical site infection (SSI) prevention bundle, according to a report presented today at the 2024 APIC Annual Conference .

Banner Health, which operates facilities in Arizona, California, Colorado, Nebraska, Nevada, and Wyoming, reported on the impact of a surgical antimicrobial prophylaxis (SAP) bundle on more than 57,000 surgical cases from January 2019 to December 2023. Four publicly reportable procedures were included in the analysis: hip and knee arthroplasty, colorectal surgery, and abdominal hysterectomy.

The infection prevention (IP) team at Banner Health began delving into an all-encompassing clinical practice for SSI prevention in 2019 with the goal of reducing their Standardized Infection Ratios (SIRs). It was determined that focusing on one bundle component, specifically SAP across all 30 of their facilities, could have the greatest impact on SSI reduction. As part of the intervention, they monitored adherence to the appropriate selection of preoperative antibiotics, dose, administration times, and redose. Starting from a baseline of 67.1% in 2019, adherence to this process measure increased to 82.2% by 2023.

During the same period, compliance with the SAP bundle produced the beneficial effect of shortening length of stay (LOS) by 4 days, decreasing overall mortality rates by 4.4%, and lowering the average 30-day readmission rates by 3.9%. Similarly, compliance with the SAP bundle in hip arthroplasty procedures evidenced a statistically significant (p<0.0001) reduction in average 30-day readmission rates from 11% to 7%.

“This work shows that a bundle of evidence-based interventions designed to reduce infections can also impact other important outcomes like mortality, length of stay, and readmissions,” said Aarikha D'Souza, BS, MPH, CIC, FAPIC, clinical practice lead and infection prevention regional director at Banner Health. “If we’re sending patients home earlier there’s a ripple effect as we also decrease the chances of them developing deep vein thrombosis, pneumonia, pressure injuries, or having a fall.”

Increased adherence to the SAP bundle illustrated the most benefit among orthopedic patients. Hip arthroplasty procedures resulted in a statistically significant 32.8% decrease in SSI rates and 48.3% drop in SIR, while knee arthroplasty procedures resulted in a 15.2% reduction in SSI rates and 33.1% decrease in SIR. Additionally, adherence to the SAP bundle in colorectal surgeries and abdominal hysterectomy procedures decreased SSI rates by 17.4% and SIR by 8.11%, respectively.

“This project shows the value of intense focus on a specific set of process measures to influence not just infection rates, but also other important quality metrics,” said Tania Bubb, PhD, RN, CIC, FAPIC , 2024 APIC president. “We are grateful to Banner Health for their exceptional patient safety work and for sharing their success at the APIC Conference.”

The oral abstract, “ Effect of a Standardized Preoperative Prophylactic Antimicrobial Guideline on Improved Postoperative Surgical Site Infection (SSI) Outcomes ,” (ISR 11) is being presented at 2:30 pm CT, June 4, at the APIC Annual Conference in San Antonio, Texas.

Founded in 1972, the Association for Professionals in Infection Control and Epidemiology (APIC) is the leading association for infection preventionists and epidemiologists. With more than 15,000 members, APIC advances the science and practice of infection prevention and control. APIC carries out its mission through research, advocacy, and patient safety; education, credentialing, and certification; and fostering development of the infection prevention and control workforce of the future. Together with our members and partners, we are working toward a safer world through the prevention of infection. Join us and learn more at apic.org .

APIC’s Annual Conference , June 3-5, is one of the most comprehensive infection prevention conferences in the world, with programs led by experts from across the globe and attended by physicians, researchers, epidemiologists, educators, administrators, and medical technologists, with strategies that can be implemented immediately to improve prevention programs and make healthcare safer. Join the conversation on social media with the hashtag #APIC24.

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

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COMMENTS

Surgical Site Infection (SSI) Prevention Guideline
Guideline for Prevention of Surgical Site Infection (2017) Skip directly to site content Skip directly to search. An official website of the United States government. Here's how you know Official websites use .gov. A .gov website belongs to an official government organization in the United States.
Overview of the evaluation and management of surgical site infection
INTRODUCTION. Surgical site infection (SSI) is the most common health care-associated infection following surgery and is associated with significant morbidity and mortality, transfer to an intensive care unit setting, prolonged hospitalizations, and hospital readmission [].Among those who undergo surgical procedures annually in the United States, 2 to 4 percent will develop an SSI ...
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58570. Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less. Note: Scope is reported based on the primary incision site. If an open and scope code is assigned to procedures in the same NHSN procedure category, then the procedure should be reported to NHSN as Scope = NO.
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But surgical site infections are not just a problem for poor countries. In the United States, they contribute to patients spending more than 400 000 extra days in hospital at an additional cost of US$ 900 million per year. ... PPT Trainer guide Student handbook . Surgical site infections prevention key facts. Key facts on patient bathing and ...
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A surgical site infection may range from a spontaneously limited wound discharge within 7 to 10 days of an operation to a life-threatening postoperative complication, such as a sternal infection after open heart surgery. Most surgical site infections are caused by contamination of an incision with microorganisms from the patient's own body ...
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1. Introduction. Surgical site infections (SSIs) are responsible for about 20% of all healthcare-associated infections (HAIs) and at least 5% of patients undergoing a surgical procedure develop a surgical site infection [1,2,3].The incidence of SSIs is 2-5% in patients undergoing inpatient surgery; however, the number of SSIs is likely to be underestimated given that approximately 50% of ...
CDC Guideline for the Prevention of Surgical Site Infection, 2017
Surgical site infections (SSIs) are infections of the incision or organ or space that occur after surgery. 1 Surgical patients initially seen with more complex comorbidities 2 and the emergence of antimicrobial-resistant pathogens increase the cost and challenge of treating SSIs. 3-5 The prevention of SSI is increasingly important as the number ...
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Key points. A surgical site infection (SSI) is an infection in the part of the body where a surgery took place. SSIs can generally be treated with antibiotics but may require additional medical care. There are ways to reduce your risk of contracting an SSI.
PDF Global Guidelines for The Prevention of Surgical Site Infection
The designations employed and the presentation of the material in this publication do not ... 3.1 Surgical site infection risk factors: epidemiology and burden worldwide..... 27 3.2 Surgical site infection surveillance: definitions and methods and impact..... 38 3.3 Importance of a clean environment in the operating room and decontamination of ...
Global guidelines for the prevention of surgical site infection
Overview. The first ever Global guidelines for the prevention of surgical site infection (SSI) were published on 3 November 2016, then updated in some parts and published in a new edition in December 2018. They include a list of 29 concrete recommendations on 23 topics for the prevention of SSI in the pre-, intra and postoperative periods ...
Postoperative Wound Infections
Surgical site infections represent the primary source of nosocomial infections in surgical patients.[1] Before the advent of the germ theory of infection and the recognition of the preventive efficacy of antisepsis, the incidence of postoperative surgical infections was alarmingly high, often resulting in limb amputation or mortality. However, the adoption of antiseptic techniques ...
Global Guidelines for the Prevention of Surgical Site Infection
SSIs are potential complications associated with any type of surgical procedure. Although SSIs are among the most preventable HAIs (1, 2), they still represent a significant burden in terms of patient morbidity and mortality and additional costs to health systems and service payers worldwide (3-11). SSI is both the most frequently studied and the leading HAI reported hospital-wide in LMICs ...
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Systematic Review on the Management of Surgical Site Infections. ... To assist with this effort we offer a range of tools to help share information, including PowerPoint presentations, Care Pathways, patient handouts, clinician checklists, plain language summaries, and Impactful Statements - all of which are fully vetted by content experts. ...
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patients from surgical infections. In some clinics, staff silence during surgery was also required to limit bacterial contamination thought to be spread by talking. Some physicians began to keep records of infections and use active surveillance systems to track surgical infection trends.6 Today's more sophisticated strategies for preventing wound
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Surgical Site Infection Prevention: A Review. ImportanceApproximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 ...
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Surgical Site Infection. Nov 4, 2015 • Download as PPT, PDF •. 183 likes • 105,380 views. Uthamalingam Murali. This PPT is mainly for the Final - Yr MBBS - Students. It is purely based on Bailey & Love - Short Practice of Surgery. Health & Medicine. Slideshow view. Download now.
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855-695-4872 Outside of Maryland. +1-410-502-7683 International. Find a Doctor. Your skin is a natural barrier against infection, so any surgery that causes a break in the skin can lead to an infection. Doctors call these infections surgical site infections because they occur on the part of the body where the surgery took place.
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SURGICAL SITE INFECTIONSu000b PREVENTION AND CARE. Aug 10, 2013 • Download as PPTX, PDF •. 159 likes • 51,141 views. Society for Microbiology and Infection care.
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Presentation Definition and Classification. Surgical-site infection (SSI) is a difficult term to define accurately because it has a wide spectrum of possible clinical features. The Centers for Disease Control and Prevention (CDC) has defined SSI to standardize data collection for the National Nosocomial Infections Surveillance (NNIS) program. ...
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place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are more serious and can involve tissues under the skin, organs, or implanted material." Symptoms present within a 30 day post surgical time frame and include: • Redness and pain around the area where you had surgery
Fever and infections in surgical intensive care: an American
The evaluation and workup of fever and the use of antibiotics to treat infections is part of daily practice in the surgical intensive care unit (ICU). Fever can be infectious or non-infectious; it is important to distinguish between the two entities wherever possible. The evidence is growing for shortening the duration of antibiotic treatment of common infections. The purpose of this clinical ...
Editorial: Management of PJI/SSI after joint arthroplasty
The management of periprosthetic joint infection (PJI) and surgical site infection (SSI) after joint arthroplasty poses a major challenge in orthopedic surgery. This Editorial provides an overview of the studies published in the special issue "Management of PJI/SSI after Joint Arthroplasty", summarizing the key findings from these studies, which cover a wide range of topics, including ...
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Serum albumin plays an important role in physiological and inflammatory haemostasis, and low serum levels are linked with an increased incidence of surgical site infections (SSI). Although this has been demonstrated in the spine and elective arthroplasty settings, there is a paucity of evidence with …
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This study examined the irrigation efficacy of povidone-iodine for surgical site infection prevention compared to control in gastroenterological surgery. Povidone-iodine wound irrigation has shown no additional beneficial effect on the occurrence of surgical site infections.
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Introduction. Surgical site infections (SSIs) are defined as infections occurring up to 30 days after surgery (or up to one year after surgery in patients receiving implants) and affecting either the incision or deep tissue at the surgical site [].SSIs are a significant concern, as they not only lead to increased morbidity and mortality rates but also impose a considerable economic burden on ...
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"surgical site infection", "SSI", "wound infection", "postoperative complication", "post-operative complication". It is made available under a CC-BY-NC-ND 4.0 International license. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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Editorial: Management of PJI/SSI after joint arthroplasty

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Arthroplasty

Effects of povidone-iodine wound irrigation on surgical site infection in gastroenterological surgery: A randomized controlled trial

Three steps to reduction surgical site infection: presentation of a comprehensive model

Axel Kramer

Introduction

Perioperative measures

Preoperative strategies

Antimicrobial prophylaxis

Skin preparation

Intraoperative strategies

Surgical attire

Surgical drapes

Surgical site irrigation

Postoperative strategies

Early mobilization

Antibiotic stewardship

Multidisciplinary collaboration

The role of nurses

The role of anesthesiologists

Infection prevention specialists

Importance of environmental services

The role of information technology

Patient engagement

CQI initiatives

Methodologies employed in CQI initiatives

Outcomes of CQI initiatives