Surveillance of surgical site infections (SSIs) is effective in reducing the rates of these complications, but it is extremely time-consuming and, consequently, underused. We determined the sensitivity and specificity of a computer-assisted surveillance system, compared with a conventional method involving review of medical records, and the time saved with the computer-assisted system.

A prospective study was conducted from January 1 to December 31, 2001. With the computer-assisted method, screening for SSIs relied on identification in the laboratory database of positive results of microbiological tests of surgical-site specimens; confirmation was obtained via computer-generated questionnaires completed by the surgeon in charge of the patient. In the conventional method, SSIs were identified by exhaustive chart review. The time spent on surveillance was recorded for both methods.

A 25-bed gastrointestinal surgery unit in a tertiary care hospital.

A total of 766 consecutive patients who underwent gastrointestinal surgery.

The sensitivity of the computer-assisted method was 84.3% (95% confidence interval, 0.66-0.94); the specificity was 99.9%. For the 807 surgical procedures in the study, 197 had an SSI identified by culture of a surgical-site specimen. After elimination of 63 duplicate cultures with positive results, 134 questionnaires were sent to the surgeons, who confirmed 27 SSIs. The conventional method identified 32 SSIs. The computer-assisted method required 60% less time than the conventional method (90 hours vs 223 hours).

Surveillance for SSIs using computer-assisted, laboratory-based screening and case confirmation by surgeons is as efficient as and far less time-consuming than the conventional method of chart review. This method permits routine surveillance for SSIs with reliable accuracy.

To evaluate the admission chronic disease score (ACDS) and a variant of the ACDS as predictors of surgical site infection (SSI) for study participants who underwent coronary artery bypass graft (CABG) surgery.

Retrospective case-control study.

A 750-bed academic medical center.

All participants with an SSI that was identified through hospital-based surveillance (defined as case patients) and a random sample of participants without SSI following CABG surgery (defined as control subjects) between July 1, 1999, and June 30, 2001.

An ACDS based on medications ordered on the day of hospital admission was determined for 264 study participants admitted prior to the day of the surgical procedure. A preadmission chronic disease score (PACDS) based on outpatient medications was calculated for 281 participants, using the record of preadmission medications in the patient's discharge summary. The ACDS and PACDS were significantly higher for case patients, compared with control subjects (P = .03 and P = .05, respectively). American Society of Anesthesiologists (ASA) score and the standard National Nosocomial Infection Surveillance system (NNIS) risk index were not significant predictors of SSI. In logistic regression models, only the ACDS (odds ratio, 1.02 per 100 ACDS points), the PACDS (odds ratio, 1.02 per 100 PACDS points), the highest PACDS quintile (odds ratio, 2.89 [compared with lowest quintile]), and a modified NNIS-PACDS score of 2 (odds ratio, 3.5 [compared with a score of 0]) were significant predictors of SSI.

Because preoperative medications are likely to reflect comorbidities that influence the risk of SSI, medication-based scoring systems such as the ACDS and PACDS may allow for better risk stratification than the standard NNIS risk index, particularly for patient populations with relatively homogenous wound classification and ASA score distributions.

To compare the number of surgical site infections (SSIs) registered after hospital discharge with respect to various surgical procedures and to identify the procedures for which postdischarge surveillance (PDS) is most important.

Prospective SSI surveillance with voluntary PDS. Recommended methods for PDS in the Dutch national nosocomial surveillance network are addition of a special registration card to the outpatient medical record, on which the surgeon notes clinical symptoms and whether a patient developed an SSI according to the definitions; an alternative method is examination of the outpatient medical record.

Hospitals participating in the Dutch national nosocomial surveillance network between 1996 and 2004.

We collected data on 131,798 surgical procedures performed in 64 of the 98 Dutch hospitals. PDS was performed according to one of the recommended methods for 31,134 operations (24%) and according to another active method for 32,589 operations (25%), and passive PDS was performed for 68,075 operations (52%). Relatively more SSIs were recorded after discharge for cases in which PDS was performed according to a recommended method (43%), compared with cases in which another active PDS method was used (30%) and cases in which passive PDS was used (25%). The highest rate of SSI after discharge was found for appendectomy (79% of operations), followed by knee prosthesis surgery (64%), mastectomy (61%), femoropopliteal or femorotibial bypass (53%), and abdominal hysterectomy (53%).

For certain surgical procedures, most SSIs develop after discharge. SSI rates will be underestimated if no PDS is performed. We believe we have found a feasible and sensitive method for PDS that, if patients routinely return to the hospital for a postdischarge follow-up visit, might be suitable for use internationally.

To evaluate whether the standardized incidence ratio (SIR) is a more reliable tool for comparing rates and temporal trends of surgical site infection (SSI) in surgery wards than the incidence rate among patients with an National Nosocomial Infections Surveillance system (NNIS) risk index category of 0.

Observational, prospective cohort study in a sequential SSI surveillance system.

Volunteer surgery wards in a surveillance network in northern France that annually conducted SSI surveillance for 3 months from 1998 to 2000.

The incidence rate was the number of SSIs divided by the number of patients included, stratified by the NNIS risk index category. SIR was the observed number of SSIs divided by the expected number computed using a multiple regression model.

Overall, 26,904 patients in 67 surgery wards were enrolled. Between 1998 and 2000, the SSI incidence rate among patients with NNIS risk index category 0 decreased from 2.1% to 1.4%, which was a 33% reduction (P = .002). The SIR decreased from 1.2 (95% confidence interval [CI], 1.1-1.3) to 0.8 (95% CI, 0.7-0.9), which was a 20% decrease per year and an overall 33% reduction. The number of SSIs was significantly higher than expected in 17 of 201 surveillance periods over the 3 years. The classification of the wards according to the 2 indicators over the 3 years showed that wards with a high SIR did not consistently have the highest SSI incidence rate among patients with NNIS risk index category 0, partly because the type of surgical procedure and the duration of follow-up are not taken into account in the NNIS risk index.

SIR should be considered a reliable indicator to estimate the reduction in SSI incidence that results from implementation of infection control policies and for comparison of SSI rates between wards.

To assess which adverse postsurgical outcomes are best predicted by the Study on the Efficacy of Nosocomial Infection Control (SENIC) index and the National Nosocomial Infection Surveillance system (NNIS) index.

Prospective cohort study.

The service of general surgery at a tertiary care hospital.

A consecutive series of patients hospitalized for more than 1 day (n = 2,989).

The outcome best predicted by the SENIC and NNIS indices was assessed by estimating the area under the receiver operating characteristic (ROC) curve. The areas under the ROC curves for nosocomial infection and in-hospital death were higher for the NNIS index than they were for the SENIC index (P<.05). The NNIS index predicted in-hospital death better than it predicted surgical site infection (area under the ROC curve ± SE, 0.836 ± 0.022 vs 0.689 ± 0.017; P = .001).

The NNIS index is superior to the SENIC index for all adverse postsurgical outcomes. Its ability to predict in-hospital mortality is clearly better than its ability to predict surgical site infection.

To describe the results of an intervention program to reduce the rate of surgical site infection (SSI) in the breast tumor department of a referral teaching hospital for patients with cancer.

Preventive measures introduced in the Breast Tumor Department of the study hospital included the following: starting in July 2000, use of sterile technique for wound care; starting in 2001, use of closed antireflux silicone evacuation systems, use of perioperative antimicrobial prophylaxis, provision of feedback to surgeons, and remodeling of the ambulatory wound care clinic. We conducted surveillance of all patients who underwent mastectomy between February 1 and December 31, 2001, and the SSI rate was calculated. A case-control analysis was performed for risk factors known to be associated with SSI. Results were compared with the data from 2000.

The study included data on 385 surgeries. SSIs were registered in 52 (13.7%) of these 385, which was a rate 58.6% less than the 2000 infection rate (33.1%). Risk factors associated with SSI included concomitant chemotherapy and radiation therapy (OR, 3.6 [95% confidence interval {CI}, 1.9-7.1]), surgery performed during an evening shift (OR, 1.9 [95% CI, 1.1-3.6]), and insertion of a second drainage tube during the late postoperative period (OR, 2.8 [95% CI, 1.4-5.7]). The mean number (± SD) of postoperative visits to the outpatient wound care clinic was reduced from 11.6 ± 7.1 in 2000 to 9.2 ± 4.4 in 2001 (P< .001, Student's t test). The mean number of days that the evacuation systems were used was reduced from 19.0 to 16.0 days (P =.001, Student's t test).

Continuous wound surveillance, along with feedback to surgeons, use of closed antireflux evacuation systems, and standardized practices in wound and drainage-tube care, decreased by 58.6% the rate of SSI in a breast surgical department with high rates of infection.

To evaluate the application of surgical site infection control procedures in general surgery departments in hospitals in the Piemonte region of Italy.

The descriptive study entailed 1 week of observation in the general surgery departments and 1 week of observation in the operating rooms of 49 hospitals in Piemonte; the survey was conducted in 2003.

Data collection forms were designed to record information about presurgical patient preparation (form 1) and infection control practices routinely used by surgical teams (form 2).

A total of 856 patients were observed; 88% of operations were surgical wound class I or II; 70.6% of patients had hair removed, 28.8% showered the day before the operation; antimicrobial prophylaxis was administered in 63.3% of cases (68.4% on induction of anesthesia and 26% on the day of the operation) and was continued into the postoperative period in 43% of cases. A total of 799 operations were observed; the mean number of healthcare personnel in the operating room was 6; doors were opened an average of 12 times during an operation; 88% of the surgical team members wore a cap/hood and mask correctly; 25% of surgeons and 41% of instrument nurses wore an eye shield; preoperative hand and forearm scrubbing technique was correct in 78% of cases (surgeons, 74.6%; instrument nurses, 86.6%; and anesthesiologists, 73%).

A comparison between the survey data and the international recommendations for SSI prevention highlighted practices that could be improved with corrective interventions. The study provided an opportunity for sharing feedback on appropriate data with healthcare personnel and was an effective instrument to audit infection control practices.

Most reusable biopsy forceps and all of the currently available single-use biopsy forceps do not have a port that allows fluid flow down the inner tubular shaft of the device. Reusable biopsy forceps are widely used and reprocessed in healthcare facilities, and single-use biopsy forceps are reprocessed either in-house (eg, in Canada and Japan) or by third-party reprocessors (eg, in the United States). The objective of this study was to determine the cleaning efficacy of automated narrow-lumen sonic irrigation cleaning, sonication-only cleaning, and manual cleaning for biopsy forceps.

A simulated-use study was performed by inoculating the inner channel of single-use biopsy forceps with artificial test soil containing both Enterococcus faecalis and Geobacillus stearothermophilus at concentrations of 106 colony-forming units per milliliter. The cleaning methods evaluated were manual cleaning, sonication-only cleaning, and “retroflush” cleaning by an automated narrow-lumen irrigator. Bioburden and organic soil reduction after washing was evaluated. Forceps used in biopsies of patients were also tested to determine the worst-case soiling levels.

Only retroflush irrigation cleaning could effectively remove material from within the shaft portion of the biopsy forceps: it achieved an average reduction of more than 95% in levels of protein, hemoglobin, carbohydrate, and endotoxin. However, even this method of cleaning was not totally effective, as only a 2 log10 reduction in bioburden could be achieved, and there were low residual levels of hemoglobin and carbohydrate.

The data from this evaluation indicate that manual and sonication-only cleaning methods for biopsy forceps were totally ineffective in removing material from within the biopsy forceps. Even the use of retroflush cleaning was not totally effective. These findings suggest that in-hospital reprocessing of biopsy forceps with currently available equipment and cleaning methods is suboptimal.

Urinary tract infections are the leading nosocomial urologic infections and may be a cause of added morbidity and costs, and sometimes sepsis. The aim of this study was to design a predictive score for these complications after prostate surgery.

Multicenter prospective survey.

Eleven French urology centers.

All patients undergoing transurethral resection of prostate (TURP) during a 3-month period.

The overall incidence of postoperative bacteriuria was 25.0% (95% confidence interval, 17.7%-29.5%). Almost all patients (95.7%) received antibiotic prophylaxis. A predictive postoperative bacteriuria score (POBS), with a 6-point scale of 0 to 5, was constructed on the basis of independent risk factors identified in multivariate analysis of a test sample of patients (n = 135) and tested in a validation sample (n = 73). Significantly more infections occurred in patients with a POBS of 2 or higher (87 [8%] vs 48 [50%]; P<.0001). With the test sample, this yielded a sensitivity of 77%, a specificity of 77%, a positive predictive value of 50%, a negative predictive value of 92%, and a global accuracy of 77%.

POBS could be used to distinguish patients at risk of developing infection after TURP. This information might be useful for implementing selective prevention measures or for adjustment for differences in nosocomial infection rates when comparing data between urology centers.

To determine the pathogens associated with surgical site infections (SSIs) and describe patterns of antimicrobial use and resistance in orthopedic and neurosurgical patients in a large university hospital in Vietnam.

Prospective cohort study.

Cho Ray Hospital, Ho Chi Minh City, Vietnam.

All patients who had operations during a 5-week study period.

Of 702 surgical patients, 80 (11.4%) developed an SSI. The incidence of SSI among orthopedic patients was 15.2% (48 of 315), and among neurosurgical patients it was 8.3% (32 of 387). Postoperative bacterial cultures of samples from the surgical sites were performed for 55 (68.8%) of the 80 patients with SSI; 68 wound swab specimens and 10 cerebrospinal fluid samples were cultured. Of these 78 cultures, 60 (76.9%) were positive for a pathogen, and 15 (25%) of those 60 cultures yielded multiple pathogens. The 3 most frequently isolated pathogens were Pseudomonas aeruginosa (29.5% of isolates), Staphylococcus aureus (11.5% of isolates), and Escherichia coli (10.3% of isolates). Ninety percent of S. aureus isolates were methicillin resistant, 91% of P. aeruginosa isolates were ceftazidime resistant, and 38% of E. coli isolates were cefotaxime resistant. All but 1 of the 702 patients received antimicrobial therapy after surgery, and the median duration of antimicrobial therapy was 11 days. Commonly used antimicrobials included aminopenicillins and second- and third-generation cephalosporins. Two or, more agents were given to 634 (90%) of the patients, and most combination drug regimens (86%) included an aminoglycoside.

Our data indicate that the incidence of SSI is high in our study population, that the main pathogens causing SSI are gram-negative bacteria and are often resistant to commonly used antimicrobials, that the use of broad-spectrum antimicrobials after surgery is widespread, and that implementation of interventions aimed at promoting appropriate and evidence-based use of antimicrobials are needed in Vietnam.

Nasal carriage of Staphylococcus aureus is an important risk factor for S. aureus infection and a reservoir for methicillin-resistant S. aureus. We investigated whether nose picking was among the determinants of S. aureus nasal carriage.

The study cohort comprised 238 patients who visited the ear, nose, and throat (ENT) disease outpatient clinic of a tertiary care hospital and did not have a nose-specific complaint (defined as ENT patients) and 86 healthy hospital employees (including medical students and laboratory personnel).

All participants completed a questionnaire on behavior regarding the nose and were screened for S. aureus nasal carriage; only ENT patients underwent nasal examination by an ear, nose, and throat physician for clinical signs of nose picking.

Among ENT patients, nose pickers were significantly more likely than non–nose pickers to carry S. aureus (37 [53.6%] of 69 vs 60 [35.5%] of 169 patients; relative risk, 1.51 [95% confidence interval, 1.03-2.19]). Among healthy volunteers, there was a statistically significant positive correlation between the self-perceived frequency of nose picking and both the frequency of positive culture results (R = 0.31; P = .004) and the load of S. aureus present in the nose (R = 0.32; P = .003).

Nose picking is associated with S. aureus nasal carriage. The role of nose picking in nasal carriage may well be causal in certain cases. Overcoming the habit of nose picking may aid S. aureus decolonization strategies.

To assess the knowledge, attitudes, and practices of Iranian physicians regarding contact isolation precautions.

Data were collected between May and November 2002 using a cross-sectional survey design.

Teaching hospitals in Shiraz, Iran.

A total of 155 physicians: 78 attending clinicians and 77 resident physician surgeons or internists.

The mean scores for knowledge and attitude were acceptable, with 71% of physicians scoring the maximum for knowledge and 65% achieving the maximum scores for attitude, whereas the mean score for practice was low, with only 26% achieving the maximum score. A good level of knowledge be associated with a good attitude (odds ratio [OR], 68.4 [95% confidence interval {CI}, 20.0-285.6]; P< .001), good practices were associated with good knowledge (OR, 22.5 [95% CI, 7.1-91.3]; P< .001), and a good attitude was associated with good practice (OR, 20.0 [95% CI, 5.7-105.2]; P<.001).

Although strong associations were found among knowledge, attitude, and practice, the level of compliance with precautions was not nearly as high as it should be.