Class of 2012 Abstract / Specific Aims: The primary purpose of this study was to evaluate the time of vancomycin pre-operative surgical site infection prophylaxis administration relative to other scheduled antibiotic therapy at a tertiary care, academic medical center. The secondary purpose was to characterize the incidence of adverse events post-surgery that were associated with vancomycin therapy in patients who received both pre- operative scheduled vancomycin therapy and vancomycin for surgical site infection prophylaxis Methods: This descriptive study was a retrospective medical chart review of all patients over the age of 28 days who received vancomycin for surgical site infection prophylaxis between February 2011 and May 2011 at a tertiary care, academic medical center. This study was approved be the Institutional Review Board. The subject population included patients admitted to the hospital for at least 72 hours who received at least 48 hours of scheduled vancomycin (IV), daptomycin or linezolid therapy before index surgery and subsequently received surgical site infection prophylaxis with vancomycin. Main Results: Of the 20 subjects who meet the study inclusion criteria, 18 (90%) subjects received scheduled vancomycin doses within 48 hours prior to surgery, 5 (25%) subjects within 4 hours, and 4 (20%) subjects within 2 hours. No surgical site infections were reported. Conclusions: This was a pilot study to evaluate the timing of vancomycin surgical site infection prophylaxis doses with scheduled vancomycin, linezolid, and daptomycin. No adverse effects associated with surgical site infection prophylaxis were reported but the sample size is small and likely inadequate to detect this potential issue.

ABSTRACT BACKGROUND. There have been few studies conducted in hospitalized patients in Viet nam on the epidemiology of surgical site infections (SSIs) and the impact of hand hygiene practices. This study aimed to assess the impact of a bedside hand sanitizer program on SSIs in orthopaedic and neurosurgical patients. DESIGN. A prospective quasi-experimental study was conducted with an untreated control group design in neurosurgical patients and before-after design in orthopaedic patients. A cost analysis based on data derived from the results of this study was also performed. SETTING. Cho Ray Hospital, a tertiary university hospital in Ho Chi Minh City, Viet nam. PATIENTS. All patients admitted for operation between 11 July and 15 August 2000 (Before), and 14 July and 18 August 2001 (After) were included, except those who had undergone another operation within one month prior to admission or were admitted because of SSIs. INTERVENTION. Bedside hand sanitizers were introduced into the Orthopaedic ward and one Neurosurgical ward (Ward A) from September 2000. Training on proper use was also provided to ward staff. Another Neurosurgical ward (Ward B) was used as a control group with no intervention conducted. RESULTS. A total of 1368 patients were recruited into the study. After intervention, in Ward A of the neurosurgical department, the SSI rate between the two periods was reduced by 54% (8.3% to 3.8%; p=0.09). Superficial SSIs were eliminated after the intervention (p=0.007). Comparison between Ward A (intervention) and Ward B (control) showed that, before the intervention, there was no difference in incidence of SSI between the two wards (Ward A: 8.3%, Ward B: 7.2%, p=0.7); however, after intervention, the incidence of SSI in Ward A was significantly lower than Ward B (3.8% and 9.2%, p=0.04). For orthopaedic patients, the SSI rate between the two periods was reduced by 34% (14.8% to 9.8%; p=0.07). SSI patients had a median post-operative length of stay of 19 days longer than patients without SSI (p&lt0.001). Costs were 2.5 times higher in patients with in-hospital SSI compared to uninfected patients (p&lt0.001). Mean SSI-attributable costs were conservatively estimated at US$368 in neurosurgical patients and US$207 in the orthopaedic patients in the before period. SSIs were responsible for at least 14 percent of the annual budget before intervention. The savings per SSI prevented were estimated at US$332 in neurosurgical patients and US$157 in orthopaedic patients. Annual cost savings arising from the intervention were estimated at US$11,112 in orthopaedic patients and US$19,320 in neurosurgical patients. CONCLUSIONS. The incidence of SSI in the hospital was high. The use of hand sanitizers reduced SSI rates, particularly impacting on the incidence of superficial SSIs. The hand sanitization program was found to be a dominant intervention being both more effective and cost saving as compared with no intervention in both study departments. The use of bedside hand sanitizers should be encouraged in the hospitals in Viet nam, where there often is a lack of other hand-washing facilities. / PhD Doctorate

Surgical site infections (SSIs) are an emerging cause of increased morbidity, mortality, and treatment cost, in veterinary medicine. Medical records were searched to evaluate for associations that could increase the risk of developing SSIs. Logistic regression was used to analyze the risk factors statistically, to determine their influence on SSI risk. An SSI incidence rate of 3.0% was found in this study for all small animal surgical procedures performed from September 2010 to July 2011, with implants, hypotension and surgical classification associated with increased likelihood of SSI. Active surveillance is crucial for the development of methods to prevent SSI’s. Biofilms contribute to the antimicrobial resistance properties commonly found in bacteria such as methicillin-resistant Staphylococcus pseudintermedius, which is found in canines. An enzyme known as DispersinB was studied to assess its effect on biofilm formation and degradation. DispersinB prevented the formation and eradicated biofilm in vitro. In vivo testing is required to further assess the effects of DispersinB. / Ontario Veterinary College Pet Trust, Canadian Institutes of Health Research, Kane Biotchech

Surgical site infections (SSIs) are a leading cause of morbidity and mortality in the United States. Researchers have demonstrated the impact that SSIs have on the healthcare system and the need to improve patient outcomes. The purpose of this project was to develop an educational program for the 8-member nursing staff of an outpatient vascular surgical office to help reduce the occurrence of SSI rates for patients seen pre and postoperatively after a noted increase in SSI rates at this clinical setting. Guided by the Fitzpatrick model, a group of 6 health care providers comprising 3 surgeons and 3 nurse practitioners served as content experts to conduct formative evaluation during development of the educational program. Members of the surgical office nursing staff completed a questionnaire; results were analyzed using descriptive analysis. Findings indicated that 100% of nursing staff had no on-site work training on basic signs and symptoms of infection and infection control; 100% of staff were not confident in assessment of the surgical site and addressing patient issues; and at least 50% reported that they lacked knowledge of proper wound care including bathing, dressing changes, and expected symptoms for healing and/or complications postoperatively. Educational materials were designed to address these gaps. This project might benefit the surgical center nursing staff by providing education to help reduce surgical site infection in vascular patients, and bring about positive social change by improving quality of life and patient outcomes for the vascular surgery patient through a reduction in the occurrence of SSIs.

Purpose: Administration of a mechanical bowel preparation (MBP) has long been standard before colorectal surgery with the aim of preventing complications such as surgical site infection (SSI). Newer evidence suggests that MBP does not reduce the risk of infection and that oral antibiotic (OA) use may be important in reducing post-operative infectious complications, however, there is little evidence comparing MBP, OA, and combination preparations. Our goal was to determine the relationship between type of bowel preparation and SSI in patients undergoing elective colorectal resections Methods: All patients within the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database undergoing elective colorectal resections from 2012 to 2013 were identified. The primary outcomes of interest were: any post-operative SSI, wound SSI, and organ/space SSI. Secondary outcomes were anastomotic leak, post-operative ileus, cardiac complications, renal complications, death, unplanned readmission, and length of stay (LOS). Univariate models were used to compare frequencies of patient and surgical characteristics across types of bowel preparation, and propensity adjustment was used to study the relationship between type of bowel preparation and all outcomes of interest. Results: Among the study sample, 25.5% received no bowel preparation, 40.8% received MBP, 3.3% received OA, and 30.4% received OA+MBP. A total of 1,844 patients (9.5%) developed any type of post-operative SSI. 1,231 (6.4%) developed a wound SSI and 672 (3.5%) developed an organ/space SSI. MBP was not associated with a reduced risk of any type of SSI compared to no bowel preparation. Both OA and OA+MBP were significantly associated with a decreased risk of any SSI and wound SSI compared to both no preparation and compared to MBP. No differences were observed for any SSI or wound SSI between OA and OA+MBP. Compared to no preparation, OA+MBP was associated with a decreased risk of anastomotic leak and post-operative ileus. No differences were observed between MBP and OA, or between these preparation methods and no preparation, for these secondary outcomes. There were no significant associations between type of bowel preparation and cardiac or renal complications, mortality, or readmissions. Both OA and OA+MBP were associated with a reduction in LOS. Conclusion: These results suggest that a combination oral and mechanical bowel preparation may be most effective at preventing SSI after elective colorectal resection and that OA alone may also be effective. Future prospective studies comparing combination and OA preparations may be warranted to explore this relationship further. / Clinical Research and Translational Medicine

In response to improving quality patient care, combined with the growing rates of surgical site infections (SSIs) in vascular patients, the need to explore current practice trends with current evidence has been identified. SSIs affect quality patient care and compromise patient safety. Empirical evidence has recommended the use of a chlorhexidine wash preoperatively to reduce SSIs. Despite this recommended practice, vascular patients were not receiving it in their routine plan of care within a hospital organization in southern Ontario. Guided by Lewin's theory of planned change, this project explored how the planning of a chlorhexidine preoperative surgical skin preparation protocol impacted progress toward improved care of vascular patients. The project was designed as a quality improvement project examining approximately 110 vascular surgical procedures over a 1-month period and staff surveys that were provided to staff in the preoperative (n = 88), same day surgery (n = 68), and inpatient (n = 47) units. These data were analyzed and demonstrated a reduction in vascular SSIs from 4.9% pre-implementation to 2.8% 1-month post-implementation. Major themes generated from the staff surveys demonstrated the nursing staff had a good understanding of the content that was presented in the in-service provided. These findings have implications for social change by highlighting the benefits of incorporating evidence in to practice and further informing the preoperative practice in other surgical specialties.

Few investigators have used robust analytic methods to assess risk factors and outcomes for surgical site infections (SSIs) after craniotomy and craniectomy (CRANI) procedures. We performed a retrospective study among patients undergoing CRANI procedures between 2006 and 2010 at the University of Iowa Hospitals and Clinics (UIHC) to assess the effect of an intervention (e.g., limiting Gliadel wafer use among patients with malignant brain tumors) on the trend of SSI rates, to identify independent risk factors for SSIs, and to evaluate one-year postoperative patient outcomes associated with these SSIs. We abstracted demographic data and clinical data from medical records or from the UIHC's Health information Management System. We identified 104 patients with SSIs and selected 312 controls. Of SSIs, 88% were deep incisional or organ space infections, 70% were identified after patients were discharged from their initial hospitalizations, 32% were caused by Staphylococcus aureus alone or in combination with other organisms, and 27% were caused by Gram-negative organisms alone or in combination with other organisms. Significant independent risk factors for SSIs were: previous chemotherapy (odds ratio [OR], 10.0; 95% confidence interval [CI] 1.1, 92.1), preoperative length of stay ≥ 1 day (OR, 2.1; 95% CI 1.3, 3.5), preoperative serum glucose ≥ 100 mg/dL (OR, 1.7; 95% CI, 1.0, 3.0), Gliadel® wafer use (OR, 8.6; 95% CI 3.2, 23.1), and postoperative cerebrospinal fluid leak (OR, 4.0; 95% CI, 1.6, 10.3). Gliadel® wafer use was the strongest risk factor; however, limiting Gliadel® wafer use did not decrease SSI rate significantly among patients with brain tumors. Perioperative ventricular drains or lumbar drains were not independently associated with an increased risk of SSIs, but drains may have clinical significance. An SSI risk index that included the significant preoperative patient-related risk factors had a better predictive power than the National Healthcare Safety Network (NHSN) risk index. After adjusting for preoperative length of stay, age, comorbidity score, severity of illness score, the reason for the procedure, and procedure month, patients with SSIs were hospitalized longer postoperatively than were controls during their readmissions (2.3 days; P < 0.0001). After controlling for the same covariates and treating SSI as a time-varying factor, patients with SSIs were more likely than controls to: die (hazard ratio [HR], 3.3; 95% CI, 1.8, 5.8), be readmitted (HR, 4.1; 95% CI, 2.9, 5.8), and have reoperations (HR, 56.6; 95% CI, 38.1, 84.0). In conclusion, surgeons could predict patients' risk of SSIs based on their preoperative risk factors and surgeons could modify some processes of care to lower the SSI risk. Preventing SSIs after CRANI procedures could improve patient outcomes and decrease healthcare utilization.

Introdução: A profilaxia antimicrobiana cirúrgica tem se demonstrado como uma das mais importantes medidas para redução das infecções de sítio cirúrgico. O momento da administração dessa profilaxia é essencial para atingir concentrações terapêuticas nos tecidos durante o procedimento cirúrgico, condição freqüentemente não observada. O objetivo deste estudo foi caracterizar o lapso de tempo transcorrido entre a profilaxia antimicrobiana e o início da incisão cirúrgica. Métodos: Amostra de procedimentos cirúrgicos eletivos realizados em um hospital geral acompanhada mediante observação direta do momento de administração da antibioticoprofilaxia e da incisão. Resultados: Foram analisados 130 procedimentos. A maioria dos pacientes da amostra era do sexo feminino (64,6%). Em 60% dos procedimentos avaliados, os pacientes internaram no mesmo dia da cirurgia e o antimicrobiano mais utilizado foi cefazolina (91,5%). O antimicrobiano profilático foi administrado com uma mediana de 8 minutos antes da incisão, sendo que em 18 (13,8%) procedimentos foi aplicado num tempo maior que 30 min e em 37 (28,5%), foi administrado após a incisão. Em apenas 13,8% a profilaxia foi administrada conforme o protocolo da instituição. As especialidades cujos procedimentos cirúrgicos apresentaram menor freqüência de adequação do horário de administração foram cirurgias plástica (4,5%), urologia (6,7) e vascular (9,1%). Conclusão: Apesar de consagrada, a administração da profilaxia em tempo adequado ainda permanece longe do ideal no nosso meio. As instituições devem adotar medidas eficazes para minimizar a inadequação desta medida. / Introduction: Antimicrobial surgical prophylaxis has been demonstrated as one of the most important steps to reduce surgical site infections. The timing of administration of prophylaxis is essential to achieve therapeutic concentrations in tissues during the surgical procedure, which is frequently not observed. The aim of this study was to characterize the lapse of time between antimicrobial prophylaxis and beginning of surgical incision. Methods: A sample of elective surgeries performed in a general hospital accompanied by direct observation of the timing of administration of antibiotic prophylaxis and the incision. Results: We analyzed 130 procedures. Most of the patients were female (64.6%). In 60% of the procedures evaluated, patients hospitalized on the same day of surgery and antimicrobial more used was cefazolin (91.5%). The antibiotic prophylaxis was administered with a median of 8 minutes before incision, and in 18 (13.8%) procedures were applied to a time longer than 30 min and 37 (28.5%) was administered after the incision. In only 13.8% prophylaxis was administered according to institutional protocol. Whose specialty surgical procedures had lower rates of appropriateness of administration time were plastic surgery (4.5%), urology (6.7) and vascular (9.1%). Conclusion: Although established, the administration of prophylaxis in a timely manner remains far from ideal in our midst. Institutions should adopt effective measures to minimize the inadequacy of this measure.

Introdução: A profilaxia antimicrobiana cirúrgica tem se demonstrado como uma das mais importantes medidas para redução das infecções de sítio cirúrgico. O momento da administração dessa profilaxia é essencial para atingir concentrações terapêuticas nos tecidos durante o procedimento cirúrgico, condição freqüentemente não observada. O objetivo deste estudo foi caracterizar o lapso de tempo transcorrido entre a profilaxia antimicrobiana e o início da incisão cirúrgica. Métodos: Amostra de procedimentos cirúrgicos eletivos realizados em um hospital geral acompanhada mediante observação direta do momento de administração da antibioticoprofilaxia e da incisão. Resultados: Foram analisados 130 procedimentos. A maioria dos pacientes da amostra era do sexo feminino (64,6%). Em 60% dos procedimentos avaliados, os pacientes internaram no mesmo dia da cirurgia e o antimicrobiano mais utilizado foi cefazolina (91,5%). O antimicrobiano profilático foi administrado com uma mediana de 8 minutos antes da incisão, sendo que em 18 (13,8%) procedimentos foi aplicado num tempo maior que 30 min e em 37 (28,5%), foi administrado após a incisão. Em apenas 13,8% a profilaxia foi administrada conforme o protocolo da instituição. As especialidades cujos procedimentos cirúrgicos apresentaram menor freqüência de adequação do horário de administração foram cirurgias plástica (4,5%), urologia (6,7) e vascular (9,1%). Conclusão: Apesar de consagrada, a administração da profilaxia em tempo adequado ainda permanece longe do ideal no nosso meio. As instituições devem adotar medidas eficazes para minimizar a inadequação desta medida. / Introduction: Antimicrobial surgical prophylaxis has been demonstrated as one of the most important steps to reduce surgical site infections. The timing of administration of prophylaxis is essential to achieve therapeutic concentrations in tissues during the surgical procedure, which is frequently not observed. The aim of this study was to characterize the lapse of time between antimicrobial prophylaxis and beginning of surgical incision. Methods: A sample of elective surgeries performed in a general hospital accompanied by direct observation of the timing of administration of antibiotic prophylaxis and the incision. Results: We analyzed 130 procedures. Most of the patients were female (64.6%). In 60% of the procedures evaluated, patients hospitalized on the same day of surgery and antimicrobial more used was cefazolin (91.5%). The antibiotic prophylaxis was administered with a median of 8 minutes before incision, and in 18 (13.8%) procedures were applied to a time longer than 30 min and 37 (28.5%) was administered after the incision. In only 13.8% prophylaxis was administered according to institutional protocol. Whose specialty surgical procedures had lower rates of appropriateness of administration time were plastic surgery (4.5%), urology (6.7) and vascular (9.1%). Conclusion: Although established, the administration of prophylaxis in a timely manner remains far from ideal in our midst. Institutions should adopt effective measures to minimize the inadequacy of this measure.

Introdução: A profilaxia antimicrobiana cirúrgica tem se demonstrado como uma das mais importantes medidas para redução das infecções de sítio cirúrgico. O momento da administração dessa profilaxia é essencial para atingir concentrações terapêuticas nos tecidos durante o procedimento cirúrgico, condição freqüentemente não observada. O objetivo deste estudo foi caracterizar o lapso de tempo transcorrido entre a profilaxia antimicrobiana e o início da incisão cirúrgica. Métodos: Amostra de procedimentos cirúrgicos eletivos realizados em um hospital geral acompanhada mediante observação direta do momento de administração da antibioticoprofilaxia e da incisão. Resultados: Foram analisados 130 procedimentos. A maioria dos pacientes da amostra era do sexo feminino (64,6%). Em 60% dos procedimentos avaliados, os pacientes internaram no mesmo dia da cirurgia e o antimicrobiano mais utilizado foi cefazolina (91,5%). O antimicrobiano profilático foi administrado com uma mediana de 8 minutos antes da incisão, sendo que em 18 (13,8%) procedimentos foi aplicado num tempo maior que 30 min e em 37 (28,5%), foi administrado após a incisão. Em apenas 13,8% a profilaxia foi administrada conforme o protocolo da instituição. As especialidades cujos procedimentos cirúrgicos apresentaram menor freqüência de adequação do horário de administração foram cirurgias plástica (4,5%), urologia (6,7) e vascular (9,1%). Conclusão: Apesar de consagrada, a administração da profilaxia em tempo adequado ainda permanece longe do ideal no nosso meio. As instituições devem adotar medidas eficazes para minimizar a inadequação desta medida. / Introduction: Antimicrobial surgical prophylaxis has been demonstrated as one of the most important steps to reduce surgical site infections. The timing of administration of prophylaxis is essential to achieve therapeutic concentrations in tissues during the surgical procedure, which is frequently not observed. The aim of this study was to characterize the lapse of time between antimicrobial prophylaxis and beginning of surgical incision. Methods: A sample of elective surgeries performed in a general hospital accompanied by direct observation of the timing of administration of antibiotic prophylaxis and the incision. Results: We analyzed 130 procedures. Most of the patients were female (64.6%). In 60% of the procedures evaluated, patients hospitalized on the same day of surgery and antimicrobial more used was cefazolin (91.5%). The antibiotic prophylaxis was administered with a median of 8 minutes before incision, and in 18 (13.8%) procedures were applied to a time longer than 30 min and 37 (28.5%) was administered after the incision. In only 13.8% prophylaxis was administered according to institutional protocol. Whose specialty surgical procedures had lower rates of appropriateness of administration time were plastic surgery (4.5%), urology (6.7) and vascular (9.1%). Conclusion: Although established, the administration of prophylaxis in a timely manner remains far from ideal in our midst. Institutions should adopt effective measures to minimize the inadequacy of this measure.