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(a) Demonstrates an abdominal abscess on the right side of the abdomen following a right hemicolectomy. (b) Demonstrates a large pelvic abscess from a leaking anastomosis following a rectosigmoid colectomy.
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Infections at the surgical site continue to occur in as many as 20% of elective colon resection cases. Methods to reduce these infections are inconsistently applied. Surgical site infection (SSI) is the result of multiple interactive variables including the inoculum of bacteria that contaminate the site, the virulence of the contaminating microbes,...
Similar publications
To investigate the risk factors for surgical site infection together with the identification of the etiological pathogens and their antimicrobial susceptibility at King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia.
Citations
... Suturing is a critical step in many surgical procedures [1][2][3]. Although suturing techniques are well established, tissue injury due to excessive suturing, localized inflammation, bacterial infections, and leakage around the suture have often been reported [1][2][3]. ...
... Suturing is a critical step in many surgical procedures [1][2][3]. Although suturing techniques are well established, tissue injury due to excessive suturing, localized inflammation, bacterial infections, and leakage around the suture have often been reported [1][2][3]. More importantly, leakage from the sutured regions occasionally causes serious complications [4][5][6][7][8][9][10][11]. ...
The occurrence of leakage from anastomotic sites is a significant issue given its potential undesirable complications. The management of anastomotic leakage after gastrointestinal surgery is particularly crucial because it is directly associated with mortality and morbidity in patients. If adhesive materials could be used to support suturing in surgical procedures, many complications caused by leakage from the anastomosis sites could be prevented. In this study, we have developed self-healing, shear-thinning, tissue-adhesive, carbon-black-containing, gallic acid-conjugated chitosan (CB/Chi-gallol) hydrogels as sealing materials to be used with suturing. The addition of CB into Chi-gallol solution resulted in the formation of a crosslinked hydrogel with instantaneous solidification. In addition, these CB/Chi-gallol hydrogels showed enhancement of the elastic modulus (G′) values with increased CB concentration. Furthermore, these hydrogels exhibited excellent self-healing, shear-thinning, and tissue-adhesive properties. Notably, the hydrogels successfully sealed the incision site with suturing, resulting in a significant increase in the bursting pressure. The proposed self-healing and adhesive hydrogels are potentially useful in versatile biomedical applications, particularly as suture support materials for surgical procedures.
... Specifically, the antibiotics should be characterized with susceptible MIC values for the anticipated pathogens and achieve a concentration equal to or greater than the MIC at the potentially contaminated surgical wound site (Bratzler et al., 2013;Zelenitsky et al., 2016). Previous attempts to reduce the SSI rates via prolonged postoperative systemic exposure were ineffective (Branch-Elliman et al., 2019;Scher, 1997) likely due to a combination of vasoconstriction, thrombosis, and the inflammatory response that occurs at the wound site, which all together lead to a form of wound tissue isolation from the vascular system and render additional systemic antibiotics ineffective (Fry, 2013;Ongom PA, 2013). One of the potential resolutions for this challenge is to utilize a targeted approach and locally administer the antibiotics at the surgical site. ...
Despite significant advances in infection control guidelines and practices, surgical site infections remain a substantial cause of morbidity, prolonged hospitalization, and mortality. The most effective component of SSI reduction strategies is the preoperative administration of intravenous antibiotics; however, systemic antibiotics drug exposure diminishes rapidly and may result in insufficient prophylactic activity against susceptible and resistant SSI pathogens at the wound. D-PLEX100 (D-PLEX) is an antibiotic-releasing drug (doxycycline) that is supplied as a sterile powder for paste reconstitution with sterile saline. D-PLEX paste is administered locally into the incision site along the entire length of soft tissue and sternal bone wound surfaces prior to skin closure. A single D-PLEX administration is intended for 30 days of constant antimicrobial prophylaxis in the prevention of incisional SSIs. We evaluated D-PLEX minimal bactericidal concentration (MBC) against a panel of bacteria that is prevalent in the abdominal wall and sternal surgical procedures including doxycycline susceptible and resistant strains. D-PLEX in vivo efficacy was assessed in incisional infection rabbit models (abdominal wall and sternal) challenged with a similar bacterial panel. The D-PLEX drug exposure profile was determined by in vitro release assay, and in vivo by quantitative pharmacokinetic parameters of local and systemic doxycycline concentrations released from D-PLEX after local administration in incisional rabbit models. Analyses of pathogens and variations in antibiotic resistance from wound isolates were determined from patients who participated in a previously reported prospective randomized trial that assessed the SSI rate in D-PLEX plus standard of care (SOC) versus SOC alone in colorectal resection surgery. The D-PLEX MBC values demonstrated >3- Log10 reduction in all the organisms tested relative to untreated controls, including doxycycline-resistant bacteria (i.e., Methicillin-resistant Staphylococcus aureus (MRSA), K. pneumoniae, and P. aeruginosa). In vivo, D-PLEX significantly reduced the bacterial loads in all the bacteria tested in both animal models (p=0.0001) with a marked impact observed in E. Coli (>6.5 Log10 reduction). D-PLEX exhibited a zero-order release kinetics profile in vitro for 30 days (R2 = 0.971) and the matched in vivo release profile indicated a constant local release of protein-unbound doxycycline for 30 days at 3-5 mcg/mL with significantly lower (>3 orders of magnitudes) systemic levels. In colorectal surgery patients, where significant SSI reduction was observed, analysis of the positive cultures in the overall population indicated similar pathogen diversity and antibiotic resistance rates in both treatment arms. However, almost all the patients with positive culture in the SOC arm were adjudicated as SSI (94%) compared to only 28% in the D-PLEX arm. The SSI-adjudicated D-PLEX patients also exhibited lower resistance rates to the SOC antibiotics and to MDRs compared to patients in the SOC arm. Thus, D-PLEX provides safe and effective prophylaxis activity against the most prevalent SSI pathogens including doxycycline-susceptible and resistant bacteria. Our findings suggest that D-PLEX is a promising addition to SSI prophylactic bundles and may address the gaps in current SSI prophylaxis. D-PLEX is now evaluated in phase 3 clinical trial.
... 3,4 Fecal content analysis demonstrated significant changes in the intestinal environment after surgery, including an increase in pathogenic bacteria. 7 Escherichia coli is the main enteric Gram-negative rod in the colon 8 and the most abundant after the completion of an anastomosis, 8,9 representing 94% of the microorganisms found. 9 Although the colon lumen is the biggest source of contamination, colorectal surgery is also widely influenced by infections of the surgical site promoted by bacteria on the skin and from the environment, such as Staphylococcus aureus, 8 and therefore, their potential to cause postoperative disturbances should not be discarded. ...
... 3,4 Fecal content analysis demonstrated significant changes in the intestinal environment after surgery, including an increase in pathogenic bacteria. 7 Escherichia coli is the main enteric Gram-negative rod in the colon 8 and the most abundant after the completion of an anastomosis, 8,9 representing 94% of the microorganisms found. 9 Although the colon lumen is the biggest source of contamination, colorectal surgery is also widely influenced by infections of the surgical site promoted by bacteria on the skin and from the environment, such as Staphylococcus aureus, 8 and therefore, their potential to cause postoperative disturbances should not be discarded. ...
... 7 Escherichia coli is the main enteric Gram-negative rod in the colon 8 and the most abundant after the completion of an anastomosis, 8,9 representing 94% of the microorganisms found. 9 Although the colon lumen is the biggest source of contamination, colorectal surgery is also widely influenced by infections of the surgical site promoted by bacteria on the skin and from the environment, such as Staphylococcus aureus, 8 and therefore, their potential to cause postoperative disturbances should not be discarded. ...
Metronidazole (MTZ) is a drug potentially used for the treatment of intestinal infections, namely, the ones caused by colorectal surgery. The traditional routes of administration decrease its local effectiveness and present off-site effects. To circumvent such limitations, herein a drug delivery system (DDS) based on MTZ-loaded nanoparticles (NPs) immobilized at the surface of electrospun fibrous meshes is proposed. MTZ at different concentrations (1, 2, 5, and 10 mg mL-1) was loaded into chitosan-sodium tripolyphosphate NPs. The MTZ loaded into NPs at the highest concentration showed a quick release in the first 12 h, followed by a gradual release. This DDS was not toxic to human colonic cells. When tested against different bacterial strains, a significant reduction of Escherichia coli and Staphylococcus aureus was observed, but no effect was found against Enterococcus faecalis. Therefore, this DDS offers high potential to locally prevent the occurrence of infections after colorectal anastomosis.
... 31 These measures could be considered to reduce contamination and infection. 32 As regards CAIs, MRSA was observed in 14% of inpatients; this highlights the risk of introducing potentially troublesome and antibiotic-resistant bacteria to the hospital from the community. This potential risk of transmission would be akin to 'antibiotic resistance in communities is antibiotic resistance in hospitals, and will be antibiotic resistance everywhere'. ...
Setting:
Dhulikhel Hospital, Kathmandu University Hospital, Kathmandu, Nepal.
Objectives:
1) To report the incidence of health-care-associated infections (HAIs), 2) to compare demographic, clinical characteristics and hospital outcomes in those with and without HAIs; and 3) to verify bacterial types in HAI and community-acquired infections (CAIs) among inpatients with invasive devices and/or surgical procedures.
Design:
This was a cohort study using secondary data (December 2017 to April 2018).
Results:
Of 1,310 inpatients, 908 (69.3%) had surgical procedures, 125 (9.5%) had invasive devices and 277 (21.1%) both. Sixty-six developed HAIs (incidence = 5/100 patient admissions, 95% CI 3.9-6.3). Individuals with HAIs had a 5.5-fold higher risk of longer hospital stays (⩾7 days) and a 6.9-fold risk of being in intensive care compared to the surgical ward. Unfavourable hospital exit outcomes were higher in those with HAIs (4.5%) than in those without (0.9%, P = 0.02). The most common HAI bacteria (n = 70) were Escherichia coli (44.3%), Enterococcus spp. (22.9%) and Klebsiella spp. (11.4%). Of 98 CAIs with 41 isolates, E. coli (36.6%), Staphylococcus aureus (22.0%) and methicillin-resistant S. aureus (14.6%) were common.
Conclusion:
We found relatively low incidence of HAIs, which reflects good infection prevention and control standards. This study serves as a baseline for future monitoring and action.
... Despite significant advances in surgical protocols aimed at reducing SSI incidence, SSIs remain significant contributors to morbidity and mortality in surgical populations [2]. Patients undergoing colorectal surgery suffer one of the highest postoperative SSI rates, with reported incidence ranging from 3 to 28% [3,4]. ...
Background
Surgical site infection (SSI) is common in colorectal surgery patients and associated with morbidity and mortality. Guidelines recommend preoperative intravenous antimicrobial prophylaxis with aerobic and anaerobic coverage to reduce SSI risk. Cephalosporin based prophylaxis (CBP) regimens are recommended as first-line prophylaxis, and non-cephalosporin based are recommended as alternative prophylaxis (AP). We evaluate the efficacy of CBP versus AP in preventing surgical site infections in colorectal surgery patients.
Methods
A systematic review and meta-analysis was conducted of studies published between 2005 and 2020 in MEDLINE and Web of Science. Studies were excluded if intravenous antimicrobial prophylaxis was not administered, or if oral and intravenous prophylaxis were routinely co-administered. Heterogeneity was reported using the Q-statistic and I2-statistic. Publication bias was evaluated using a funnel plot and Egger test for small study effects. Statistical significance was defined as a two-sided p < 0.05.
Results
11 studies met inclusion criteria. AP was not associated with increased SSI risk at 30 days compared to CBP (OR 1.01, 95% CI 0.91, 1.13; OR < 1 favors AP). There was no effect size variability in subgroup analysis comparing higher-to lower-quality studies (I2 = 99%, P = 0.17). Subgroup analysis by publication year approached a significant difference in effect size between studies published prior to 2014 and later than 2014 (I2 = 99%, P = 0.06).
Conclusions
Meta-analysis of 11 studies of SSI risk in adult colorectal surgery patients suggest that SSI risk is similar for patients receiving CBP or AP, subgroup analysis of studies published since 2014 suggest increased SSI risk with AP compared to CBP.
... E. coli and Bacteroides fragilis (B. fragilis) are the most common organisms in colon surgery [19]. Without surprise, the nature of wounds is strongly associated with the incidence of SSIs. ...
Surgical site infections are significant health care issues, and efforts to mitigate their occurrence have been ongoing worldwide, mainly focusing to reduce the spillage of microbes to the otherwise sterile tissues. Optimization of host immunity has been also recognized including temperature regulation (normothermia), adequate oxygenation, and glucose management. A number of papers have described the role of anesthetics in host immunity. The role of anesthetics in postoperative outcomes including surgical site infections has been also studied. We will review the current literature and propose the importance of anesthetic selection to potentially mitigate surgical site infections.
... Mechanical bowel preparation was first used in the late 1800s by William Halsted, and it became popular in the 1930s. 1 By the 1970s, antibiotics were introduced as an adjunct to the mechanical bowel preparation. 2 Bowel preparation became more popular as a number of studies demonstrated the benefit of antibiotics in improving surgical outcomes such as an anastomotic leak, hospital length of stay, readmission, and surgical site infection (SSI). [3][4][5][6] Later, popularity decreased due to conflicting outcomes from randomized trials. ...
Background:
Mechanical bowel preparation with antibiotics is associated with decreased surgical site infections (SSI) after colorectal surgery. However, antibiotics have side effects, such as vomiting. It is unknown how patient willingness to take antibiotics is affected by side effect severity.
Materials and methods:
This was a single-center study of 86 patients (37 undergoing colorectal surgery) using a modified standard gamble technique. We presented patients with four hypothetical scenarios, holding SSI reduction constant and varying antibiotic side effect severity. Patients reported willingness to take antibiotics using a scale from 0 to 100. Patients also reported the maximum level of side effects they would accept. We examined the association between side effect severity and willingness to take antibiotics with a multivariable mixed-effects regression model and investigated differences in surgical and nonsurgical patients.
Results:
After adjusting for age, sex, and patient type, willingness scores decreased with increasing side effect severity. No side effects: 92 (CI 86,99), mild: 83 (CI 76,90), moderate: 76 (CI 69,83), and severe: 46 (CI 38,52), P < 0.001. Surgical patients were more willing to take antibiotics at all severity levels compared with nonsurgical patients, P < 0.001. Surgical (57%) and nonsurgical (58%) patients reported that they would accept moderate side effects. Patients with prior SSI (n = 5) would take antibiotics regardless of side effect severity.
Conclusions:
Increasing antibiotic side effect severity is associated with decreased willingness to take antibiotics during bowel preparation, despite a reduction in SSI. Adherence may be improved with strategies that increase patient education and decrease side effects during bowel preparation.
... The preventive effect of the routine use of preoperative surgical antibiotic prophylaxis on the occurrence of surgical site infections prior to non-clean surgery such as different types of implant surgery or different types of grafting in surgery has been long time recognized, but the benefit of continued surgical antibiotic prophylaxis after completion of the procedure is still unclear. A large amount of worldwide evidence shows that a single preoperative dose of surgical antibiotic prophylaxis may be not inferior to additional post-operative multiple doses for the prevention of surgical site infections including intraoperative doses according to the duration of the surgical intervention [8][9][10]. ...
We report in this paper the synthesis and characterization of a new collagen-based material. This material was obtained in a spongy form and was functionalized with an antibiotic, ciprofloxacin. The targeted applications of these kind of materials concern the post-operative prophylaxis. The in vitro tests (antimicrobial, cytotoxic, drug release) showed that sponges with a concentration of 0.75 g of ciprofloxacin per gram of collagen could be beneficial for the desired applications.
... Non-modifiable factors comprise male gender, ad-vanced age, hypoalbuminemia, immunosuppression, recent radiotherapy, and a history of SSI. Operation-related factors refer to laparotomy, emergency operations, major complex surgical procedures, longer operative time, intra-operative blood transfusion [6,[7][8][9][10][11][12][17][18][19]. ...
... This was not the case in our study (n = 17, 38.6%), however. In terms of pathogens, E. coli is the most common culprit microorganism in SSI after colon operation, followed by Bacteroides fragilis [9,19,20]. Indeed, E. coli was the most frequently isolated bacterium from wounds in our study (n = 17, 38.6%); however, interestingly enough, B. fragilis was not isolated from any of the SSI. The explanation of the latter succumbs to the delayed transportation of isolates to the laboratory, during which the aerobe micro-organisms died. ...
Background:
Colon operations have the highest rate of surgical site infections (SSI) among all general surgical procedures. The aim of this study was to identify the risk factors associated with the development of SSI after colon resection.
Patients and methods:
A prospective study was conducted including patients over 18 years of age who underwent colon resection at a tertiary center. Data concerning peri-operative parameters were collected. Uni-variable and multi-variable statistics were employed. For identifying the potential risk factors, we used odds ratio (OR) with 95% confidence interval (CI).
Results:
A total of 44 SSI were recorded from a total patient cohort of 300, yielding a rate of 14.7%. The SSIs were categorized into incisional (n = 37, 77.1%), deep (n = 4, 8.3%), and organ/space SSI (n = 11, 22.9%). Escherichia coli was the most common culprit micro-organism. Seventeen (35.4%) infections were poly-microbial. The following factors were found to be associated with the development of SSI after colon resection: male gender (OR: 2.01, 95% CI: 1.03-3.90, p = 0.03), age ≥60 years (OR: 3.18, 95% CI: 1.46-6.89, p = 0.003), pre-operative anemia (hemoglobin <12.5 g/dL) (OR: 4.61, 95% CI: 2.37-8.98, p = < 0.0001), leukocytosis (white blood cell count ≥10,100/mm3) (OR: 0.04, 95% CI: 0.02-0.11, p < 0.0001), thrombocytosis (thrombocytes ≥450,000/mm3) (OR: 39.35, 95% CI: 10.69-144.86, p < 0.0001), peritoneal contamination (OR: 4.11, 95% CI: 2.12-7.97, p < 0.0001).
Conclusion:
In addition to other known risk factors (male gender, age over 60 years, pre-operative anemia, leukocytosis, gross peritoneal contamination), this study identified thrombocytosis as a new risk factor for SSI after colon resection.
... Sepsis is a common complication observed after colectomy surgery among elderly persons (20). An implication of this scenario is surgical site infections, where K. pneumoniae is one of the most likely organisms to be encountered (21). These infections are successfully treated by antibiotic therapy, however the presence of resistant or multidrug resistant strains can be associated with bloodstream bacterial dissemination (22). ...
We report a fatal bacteremia caused by Klebsiella pneumoniae in a 60–70-year-old patient from Brazil. The genomic analysis of three isolates (from blood culture, nasal and anal swabs) showed that the bacteremia was caused by a KPC-2 producing extensively drug-resistant K64-ST11 hypermucousviscous K. pneumoniae (hmKP) harboring several virulence and antimicrobial resistance genes. Although the isolates did not present virulence markers associated with hypervirulent K. pneumoniae (hvKP), they showed invasion and toxicity to epithelial Hep-2 cells; resistance to cell microbicidal mechanisms; and blood and human serum survival, evidencing their pathogenic potential. This study highlights the risk of infection caused by hmKp strains not characterized as hvKP as well as the clinical implications and difficulty of treatment, especially in elderly or immunocompromised patients.
