Occurrence of fever in the first postoperative week does not help to diagnose infection in clean orthopaedic surgery

Postoperative fever is often misinterpreted as a sign of infection, especially when occurring after the third postoperative day. We assessed the epidemiology of postoperative fever in adult orthopaedic patients and its association with infection. Among 1,073 patients participating in a prospective observational study, 198 (19%) had a postoperative fever (>38°C). Thirteen patients (1.2%) had a surgical site infection and 78 patients (7.3%) had remote bacterial infections during their hospital stay. Including asymptomatic bacteriuria, 174 patients were given antibiotic therapy for a median duration of six days. In multivariate analysis, no clinical parameter was associated with fever, including haematoma (odds ratio 0.9, 95%CI 0.6-1.3), infection (1.6, 0.7-3.7), or antibiotic use (1.6, 0.9-3.0). The maximum temperature on each of the first seven postoperative days did not differ between infected and uninfected patients (Wilcoxon rank-sum tests; p > 0.10). We conclude that fever, even up to the seventh postoperative day, is not substantially helpful to distinguish infection from general inflammation in clean orthopaedic surger

Decolonization of intestinal carriage of extended-spectrum β-lactamase-producing Enterobacteriaceae with oral colistin and neomycin: a randomized, double-blind, placebo-controlled trial

Objectives Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) are an increasingly frequent cause of infections in the community and the healthcare setting. In this study, we aimed to investigate whether intestinal carriage of ESBL-E can be eradicated. Methods We conducted a double-blind, randomized, placebo-controlled, single-centre trial to assess the efficacy of an oral decolonization regimen on intestinal ESBL-E carriage in adult patients with an ESBL-E-positive rectal swab. Fifty-eight patients were allocated 1 : 1 to either placebo or colistin sulphate (50 mg 4×/day) and neomycin sulphate (250 mg 4×/day) for 10 days plus nitrofurantoin (100 mg 3×/day) for 5 days in the presence of ESBL-E bacteriuria. The primary outcome was detection of ESBL-E by rectal swab 28 ± 7 days after the end of treatment. Missing primary outcome data were imputed based on the last available observation. Additional cultures (rectal, inguinal and urine) were taken on day 6 of treatment and on days 1 and 7 post-treatment. The study protocol has been registered with ClinicalTrials.gov (NCT00826670). Results Among 54 patients (27 in each group) included in the primary analysis, there was no statistically significant difference between the groups with regard to the primary outcome [14/27 (52%) versus 10/27 (37%), P = 0.27]. During treatment and shortly afterwards, there was significantly lower rectal ESBL-E carriage in the treatment group: 9/26 versus 19/22 on day 6 of treatment (P < 0.001) and 8/25 versus 20/26 on day 1 post-treatment (P = 0.001). This effect had disappeared by day 7 post-treatment (18/27 versus 17/25, P = 0.92). Liquid stools were more common in the treatment group (7/27 versus 2/29, P = 0.05). Conclusions The regimen used in this study temporarily suppressed ESBL-E carriage, but had no long-term effec

Noninfectious Wound Complications in Clean Surgery: Epidemiology, Risk Factors, and Association with Antibiotic Use

Background: Noninfectious wound complications are frequent and often are confused with and treated as infection. Methods: We assessed the epidemiology, impact, risk factors, and associations with antibiotic use of noninfectious wound complications in clean orthopedic and trauma surgery. We report a single-center, prospective, observational study in an orthopedic department. Results: Among 1,073 adult patients, 630 (59%) revealed clinically relevant postoperative noninfectious wound complications, leading to a significant prolongation of hospital stay (14 vs. 12days; Wilcoxon rank-sum test; p<0.02) compared with patients without complications. The most frequent and severe complications were discharge with dehiscence (n=437; 41%) and hematoma (n=379; 35%). Forty-seven patients (47/630; 7%) underwent reoperation for dehiscence (n=39) or hematoma (n=8). These patients made up 4.3% of the entire study population (47/1,073). In multivariate analysis, an ASA score ≥2 points, age≥60years, surgery duration for ≥90min, implant-related surgery, and poor compliance toward nurses' recommendations were pronounced risk factors for these complications, whereas antibiotic-related parameters had no influence. Staple use was significantly associated with wound discharge but not with hematoma. Conclusions: Wound complications, such as dehiscence with discharge or hematoma after clean orthopedic and trauma surgery, are frequent with an overall incidence of 60%. Although they lead to few surgical reinterventions, they prolong hospital stay by 2days. Few clinical parameters show association with wound complications. Among them, improvements of patient compliance and avoidance of staples use for skin closure are the most promising actions to decrease complication ris

Train-the-trainers in hand hygiene : a standardized approach to guide education in infection prevention and control

Background Harmonization in hand hygiene training for infection prevention and control (IPC) professionals is lacking. We describe a standardized approach to training, using a “Train-the-Trainers” (TTT) concept for IPC professionals and assess its impact on hand hygiene knowledge in six countries.Methods We developed a three-day simulation-based TTT course based on the World Health Organization (WHO) Multimodal Hand Hygiene Improvement Strategy. To evaluate its impact, we have performed a pre-and post-course knowledge questionnaire. The Wilcoxon signed-rank test was used to compare the results before and after training.Results Between June 2016 and January 2018 we conducted seven TTT courses in six countries: Iran, Malaysia, Mexico, South Africa, Spain and Thailand. A total of 305 IPC professionals completed the programme. Participants included nurses (n = 196; 64.2%), physicians (n = 53; 17.3%) and other health professionals (n = 56; 18.3%). In total, participants from more than 20 countries were trained. A significant (p < 0.05) improvement in knowledge between the pre- and post-TTT training phases was observed in all countries. Puebla (Mexico) had the highest improvement (22.3%; p < 0.001), followed by Malaysia (21.2%; p < 0.001), Jalisco (Mexico; 20.2%; p < 0.001), Thailand (18.8%; p < 0.001), South Africa (18.3%; p < 0.001), Iran (17.5%; p < 0.001) and Spain (9.7%; p = 0.047). Spain had the highest overall test scores, while Thailand had the lowest pre- and post-scores. Positive aspects reported included: unique learning environment, sharing experiences, hands-on practices on a secure environment and networking among IPC professionals. Sustainability was assessed through follow-up evaluations conducted in three original TTT course sites in Mexico (Jalisco and Puebla) and in Spain: improvement was sustained in the last follow-up phase when assessed 5 months, 1 year and 2 years after the first TTT course, respectively.Conclusions The TTT in hand hygiene model proved to be effective in enhancing participant’s knowledge, sharing experiences and networking. IPC professionals can use this reference training method worldwide to further disseminate knowledge to other health care workers.peer-reviewe

Correction to : Train-the-trainers in hand hygiene : a standardized approach to guide education in infection prevention and control

Correction to: Antimicrob Resist Infect Control https://doi.org/10.1186/s13756-019-0666-4 The original article [1] contained a misspelling in author, Fernando Bellissimo-Rodrigues’s name which has since been corrected.peer-reviewe

Occurrence of fever in the first postoperative week does not help to diagnose infection in clean orthopaedic surgery

Postoperative fever is often misinterpreted as a sign of infection, especially when occurring after the third postoperative day. We assessed the epidemiology of postoperative fever in adult orthopaedic patients and its association with infection. Among 1,073 patients participating in a prospective observational study, 198 (19%) had a postoperative fever (>38°C). Thirteen patients (1.2%) had a surgical site infection and 78 patients (7.3%) had remote bacterial infections during their hospital stay. Including asymptomatic bacteriuria, 174 patients were given antibiotic therapy for a median duration of six days. In multivariate analysis, no clinical parameter was associated with fever, including haematoma (odds ratio 0.9, 95%CI 0.6-1.3), infection (1.6, 0.7-3.7), or antibiotic use (1.6, 0.9-3.0). The maximum temperature on each of the first seven postoperative days did not differ between infected and uninfected patients (Wilcoxon rank-sum tests; p > 0.10). We conclude that fever, even up to the seventh postoperative day, is not substantially helpful to distinguish infection from general inflammation in clean orthopaedic surgery

Eight-year sustainability of a successful intervention to prevent urinary tract infection: A mixed-methods study

BACKGROUND Data on long-term effects of interventions in infection control are scarce. We aimed to evaluate the 8-year sustainability of a successful intervention to reduce urinary tract infections (UTIs) through restriction of urinary catheter (UC) use in an orthopedic surgical population. METHODS Prospective UTI surveillance from November 2009-January 2010 was conducted to compare the results against the 2-year sustainability assessment performed in 2004. Semistructured staff interviews focused on UC indication, training, insertion techniques, and recall of the former intervention. RESULTS A total of 336 consecutive patients were included (median age, 63 years; range, 16-95 years; 55% women). A UC was placed in 17.6% of patients (operating room [OR], 10.1%; postanesthesia care unit [PACU], 3.6%; surgical wards [SW], 3.9%) compared with 20.0% in 2004 (OR, 15.7%; PACU, 1.0%; SW, 3.7%). The incidence rate of UTI was 2.4 per 1,000 patient-days in 2010 versus 2.6 per 1,000 patient-days in 2004; adjusted incidence rate ratio 0.76; 95% confidence interval, 0.21-2.76; P = .67. The qualitative inquiry demonstrated poor recall of the intervention and knowledge of guidelines except in the OR, where we identified a champion leader. DISCUSSION The intervention effect was sustained with regard to overall UTI rate and UC placement in the OR, but less in the PACU and SW. CONCLUSIONS Continuous leadership of a single opinion leader in a pivotal position can contribute critically to sustainability

Evaluating the probability of previously unknown carriage of MRSA at hospital admission

PURPOSE: We determined the prevalence and risk profile of patients with previously unknown carriage of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission. SUBJECTS AND METHODS: We conducted a 7-month, prospective case-controlled study in adult inpatients admitted to a university hospital with endemic MRSA. Multivariate conditional logistic regression for data sets matched 1:4 was performed to identify the risk profile of newly identified MRSA carriers. RESULTS: Overall, 399 of 12072 screened admissions (prevalence, 3.3%) were found colonized (n = 368, 92%) or infected (n = 31, 8%) with MRSA. In 204 cases (prevalence, 1.7%), MRSA carriage was newly identified. Without screening on admission, 49% (196/399) of MRSA carriers would have been missed. We identified nine independent risk factors for newly identified MRSA carriage at admission (adjusted odds ratio): male sex (1.9); age greater than 75 years (2.0); receipt of fluoroquinolones (2.7), cephalosporins (2.1), and carbapenems (3.2) in the last 6 months; previous hospitalization (1.9) or intravenous therapy (1.7) during the last 12 months; urinary catheter at admission (2.0); and intrahospital transfer (2.4). A risk score (range, 0-13) was calculated by adding points assigned to these variables. On the basis of analysis of 1006 patients included in the case-controlled study, the probability of MRSA carriage was 8% (28/342) in patients with a low score ( or =5). The risk score had good discrimination (c-statistic, 0.73) and showed excellent calibration (P =.88). CONCLUSIONS: On-admission prevalence of previously unknown MRSA carriers was high. Applying the risk score to newly admitted patients with an intermediate or high probability of MRSA carriage could allow a more effective MRSA control strategy

Determinants of Successful Methicillin-Resistant Staphylococcus aureus Decolonization

International audienc

One- vs 2-Stage Bursectomy for Septic Olecranon and Prepatellar Bursitis: A Prospective Randomized Trial

To assess the optimal surgical approach and costs for patients hospitalized with septic bursitis