Last data update: May 13, 2024. (Total: 46773 publications since 2009)
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Query Trace: Berrios-Torres S[original query] |
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Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017
Berrios-Torres SI , Umscheid CA , Bratzler DW , Leas B , Stone EC , Kelz RR , Reinke CE , Morgan S , Solomkin JS , Mazuski JE , Dellinger EP , Itani KMF , Berbari EF , Segreti J , Parvizi J , Blanchard J , Allen G , Kluytmans Jajw , Donlan R , Schecter WP . JAMA Surg 2017 152 (8) 784-791 Importance: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. Objective: To provide new and updated evidence-based recommendations for the prevention of SSI. Evidence Review: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. Findings: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. Conclusions and Relevance: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety. |
Surgical site infection research opportunities
Itani KMF , Dellinger EP , Mazuski J , Solomkin J , Allen G , Blanchard JC , Kelz R , Berrios-Torres SI . Surg Infect (Larchmt) 2017 18 (4) 401-408 Much has been done to identify measures and modify risk factors to decrease the rate of surgical site infection (SSI). Development of the Centers for Disease Control and Prevention (CDC) Core recommendations for the prevention of SSI revealed evidence gaps in six areas: Parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, antiseptic prophylaxis, and non-parenteral antimicrobial prophylaxis. Using a modified Delphi process, seven SSI content experts identified nutritional status, smoking, obesity, surgical technique, and anemia as additional areas for SSI prevention research. Post-modified Delphi process Staphylococcus aureus colonization and SSI definition and surveillance were also deemed important topic areas for inclusion. For each topic, research questions were developed, and 10 were selected as the final SSI research questions. |
Introduction to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infections
Solomkin JS , Mazuski J , Blanchard JC , Itani KMF , Ricks P , Dellinger EP , Allen G , Kelz R , Reinke CE , Berrios-Torres SI . Surg Infect (Larchmt) 2017 18 (4) 385-393 Surgical site infection (SSI) is a common type of health-care-associated infection (HAI) and adds considerably to the individual, social, and economic costs of surgical treatment. This document serves to introduce the updated Guideline for the Prevention of SSI from the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The Core section of the guideline addresses issues relevant to multiple surgical specialties and procedures. The second procedure-specific section focuses on a high-volume, high-burden procedure: Prosthetic joint arthroplasty. While many elements of the 1999 guideline remain current, others warrant updating to incorporate new knowledge and changes in the patient population, operative techniques, emerging pathogens, and guideline development methodology. |
Future research opportunities in peri-prosthetic joint infection prevention
Berbari E , Segreti J , Parvizi J , Berrios-Torres SI . Surg Infect (Larchmt) 2017 18 (4) 409-412 Peri-prosthetic joint infection (PJI) is a serious complication of prosthetic joint arthroplasty. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSI). Recently, the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) published the Guideline for Prevention of Surgical Site Infection. This targeted update applies evidence-based methodology in drafting recommendations for potential strategies to reduce the risk of SSI both across surgical procedures and specifically in prosthetic joint arthroplasty. A panel of PJI content experts identified nine PJI prevention research opportunities based on both evidence gaps identified through the guideline development process (transfusion, immunosuppressive therapy, anticoagulation, orthopedic space suit, and biofilm) and expert opinion (anesthesia, operative room environment, glycemic control, and Staphylococcus aureus nasal screening and decolonization. This article offers a road map for PJI prevention research. |
Introduction to the Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee Guideline for Prevention of Surgical Site Infection: Prosthetic Joint Arthroplasty Section
Segreti J , Parvizi J , Berbari E , Ricks P , Berrios-Torres SI . Surg Infect (Larchmt) 2017 18 (4) 394-400 Peri-prosthetic joint infection (PJI) is a severe complication of total joint arthroplasty that appears to be increasing as more of these procedures are performed. Numerous risk factors for incisional (superficial and deep) and organ/space (e.g., PJI) surgical site infections (SSIs) have been identified. A better understanding and reversal of modifiable risk factors may lead to a reduction in the incidence of incisional SSI and PJI. The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recently updated the national Guideline for Prevention of Surgical Site Infection. The updated guideline applies evidence-based methodology, presents recommendations for potential strategies to reduce the risk of SSI, and includes an arthroplasty-specific section. This article serves to introduce the guideline development process and to complement the Prosthetic Joint Arthroplasty section with background information on PJI-specific economic burden, epidemiology, pathogenesis and microbiology, and risk factor information. |
Evidence-based update to the U.S. Centers for Disease Control and Prevention and Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection: developmental process
Berrios-Torres SI . Surg Infect (Larchmt) 2016 17 (2) 256-61 Recommendations in the "Guideline for Prevention of Surgical Site Infection, 1999" were based on experts' selective interpretation of the scientific evidence. Effective 2009, the U.S. Centers for Disease Control and Prevention (CDC) and its Healthcare Infection Control Practices Advisory Committee (HICPAC) updated their guideline development process. This is a narrative summary of the updated process focusing on key changes and challenges specific to the Guideline for Prevention of Surgical Site Infection. The guideline development process now incorporates evidence-based methodology and provides explicit links between the evidence and the recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. There is also participation by professional surgical societies, an updated guideline structure (core and procedure-specific sections), additional planned related manuscripts (introductions to the guideline and research opportunities), and new proposed venues for publication. The new CDC and HICPAC "Guideline for the Prevention of Surgical Site Infection" represents a substantial advancement from recommendations for infection control practices based on expert opinion to evidence-based practices. The new structure is meant to facilitate future updates, in particular, those addressing specialty or procedure-specific surgical site infection prevention questions. Increased presence by the surgical community through the professional surgical societies' engagement in the guideline development process, lead authorship of related manuscripts, and proposed publication in the surgical literature not only increase adherence by the surgical community, but also promote an ongoing collaboration with public health and other partners in a multidisciplinary approach to SSI prevention. |
Surgical site infection risk factors and risk stratification
Florschutz AV , Fagan RP , Matar WY , Sawyer RG , Berrios-Torres SI . J Am Acad Orthop Surg 2015 23 Suppl S8-s11 Preoperative identification of the risk factors for surgical site infection and patient risk stratification are essential for deciding whether surgery is appropriate, educating patients on their individual risk of complications, and managing postoperative expectations. Early identification of these factors is also necessary to help guide both patient medical optimization and perioperative care planning. Several resources are currently available to track and analyze healthcare-associated infections, including the Centers for Disease Control and Prevention's National Healthcare Safety Network. In addition, the Centers for Disease Control and Prevention and the American Academy of Orthopaedic Surgeons are exploring collaborative opportunities for the codevelopment of a hip and/or knee arthroplasty national quality measure for periprosthetic joint infection. |
Medicare reimbursement attributable to periprosthetic joint infection following primary hip and knee arthroplasty
Yi SH , Baggs J , Culler SD , Berrios-Torres SI , Jernigan JA . J Arthroplasty 2015 30 (6) 931-8 e2 This study estimated Medicare reimbursement attributable to periprosthetic joint infection (PJI) across the continuum of covered services four years following hip or knee arthroplasty. Using 2001-2008 Medicare claims data, total and annual attributable reimbursements were assessed using generalized linear regression, adjusting for potential confounders. Within one year following arthroplasty, 109 (1.04%) of 10,418 beneficiaries were diagnosed with PJI. Cumulative Medicare reimbursement in the PJI arm was 2.2-fold (1.9-2.6, P<.0001) or $53,470 ($39,575-$68,221) higher than that of the non-PJI arm. The largest difference in reimbursement occurred the first year (3.2-fold); differences persisted the second (2.3-fold) and third (1.9-fold) follow up years. PJI following hip or knee arthroplasty appears costly to Medicare, with cost traversing several years and health care service areas. |
Surgical site infection surveillance following ambulatory surgery
Rhee C , Huang SS , Berrios-Torres SI , Kaganov R , Bruce C , Lankiewicz J , Platt R , Yokoe DS . Infect Control Hosp Epidemiol 2015 36 (2) 225-8 We assessed 4045 ambulatory surgery patients for surgical site infection (SSI) using claims-based triggers for medical chart review. Of 98 patients flagged by codes suggestive of SSI, 35 had confirmed SSIs. SSI rates ranged from 0 to 3.2% for common procedures. Claims may be useful for SSI surveillance following ambulatory surgery. Infect Control Hosp Epidemiol 2014;00(0):1-4. |
Strategies to prevent surgical site infections in acute care hospitals: 2014 update
Anderson DJ , Podgorny K , Berrios-Torres SI , Bratzler DW , Dellinger EP , Greene L , Nyquist AC , Saiman L , Yokoe DS , Maragakis LL , Kaye KS . Infect Control Hosp Epidemiol 2014 35 (6) 605-27 Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates "Strategies to Prevent Surgical Site Infections in Acute Care Hospitals," published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates. |
A polymicrobial outbreak of surgical site infections following cardiac surgery at a community hospital in Florida, 2011-2012
Nguyen DB , Gupta N , Abou-Daoud A , Klekamp BG , Rhone C , Winston T , Hedberg T , Scuteri A , Evans C , Jensen B , Moulton-Meissner H , Torok T , Berrios-Torres SI , Noble-Wang J , Kallen A . Am J Infect Control 2014 42 (4) 432-5 We describe an outbreak of 22 sternal surgical site infections following cardiac surgery, including 4 Gordonia infections. Possible operation room environmental contamination and suboptimal infection control practices regarding scrub attire may have contributed to the outbreak. |
Activity of commonly used antimicrobial prophylaxis regimens against pathogens causing coronary artery bypass graft and arthroplasty surgical site infections in the United States, 2006-2009
Berrios-Torres SI , Yi SH , Bratzler DW , Ma A , Mu Y , Zhu L , Jernigan JA . Infect Control Hosp Epidemiol 2014 35 (3) 231-9 BACKGROUND: Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens. METHODS: Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime), beta-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity. RESULTS: There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitive Staphylococcus aureus (23%), methicillin-resistant S. aureus (18%), coagulase-negative staphylococci (17%), and Enterococcus species (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures), beta-lactam (12%), and extended-spectrum (8%) regimens was 41%-45%, 47%-96%, and 81%-96%, respectively. CONCLUSION: Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens. |
Improved risk adjustment in public reporting: coronary artery bypass graft surgical site infections
Berrios-Torres SI , Mu Y , Edwards JR , Horan TC , Fridkin SK . Infect Control Hosp Epidemiol 2012 33 (5) 463-9 OBJECTIVE: The objective was to develop a new National Healthcare Safety Network (NHSN) risk model for sternal, deep incisional, and organ/space (complex) surgical site infections (SSIs) following coronary artery bypass graft (CABG) procedures, detected on admission and readmission, consistent with public reporting requirements. PATIENTS AND SETTING: A total of 133,503 CABG procedures with 4,008 associated complex SSIs reported by 293 NHSN hospitals in the United States. METHODS: CABG procedures performed from January 1, 2006, through December 31, 2008, were analyzed. Potential SSI risk factors were identified by univariate analysis. Multivariate analysis with forward stepwise logistic regression modeling was used to develop the new model. The c-index was used to compare the predictive power of the new and NHSN risk index models. RESULTS: Multivariate analysis independent risk factors included ASA score, procedure duration, female gender, age, and medical school affiliation. The new risk model has significantly improved predictive performance over the NHSN risk index (c-index, 0.62 and 0.56, respectively). CONCLUSIONS: Traditionally, the NHSN surveillance system has used a risk index to provide procedure-specific risk-stratified SSI rates to hospitals. A new CABG sternal, complex SSI risk model developed by multivariate analysis has improved predictive performance over the traditional NHSN risk index and is being considered for endorsement as a measure for public reporting. |
Outbreak of Pseudomonas aeruginosa surgical site infections after arthroscopic procedures: Texas, 2009
Tosh PK , Disbot M , Duffy JM , Boom ML , Heseltine G , Srinivasan A , Gould CV , Berrios-Torres SI . Infect Control Hosp Epidemiol 2011 32 (12) 1179-86 SETTING: Seven organ/space surgical site infections (SSIs) that occurred after arthroscopic procedures and were due to Pseudomonas aeruginosa of indistinguishable pulsed-field gel electrophoresis (PFGE) patterns occurred at hospital X in Texas from April 22, 2009, through May 7, 2009. OBJECTIVE: To determine the source of the outbreak and prevent future infections. DESIGN: Infection control observations and a case-control study. METHODS: Laboratory records were reviewed for case finding. A case-control study was conducted. A case patient was defined as someone who underwent knee or shoulder arthroscopy at hospital X during the outbreak period and subsequently developed organ/space SSI due to P. aeruginosa. Cultures of environmental and surgical equipment samples were performed, and selected isolates were analyzed by PFGE. Surgical instrument reprocessing practices were reviewed, and surgical instrument lumens were inspected with a borescope after reprocessing to assess cleanliness. RESULTS: The case-control study did not identify any significant patient-related or operator-related risk factors. P. aeruginosa grew from 62 of 388 environmental samples. An isolate from the gross decontamination sink had a PFGE pattern that was indistinguishable from that of the case patient isolates. All surgical instrument cultures showed no growth. Endoscopic evaluation of reprocessed arthroscopic equipment revealed retained tissue in the lumen of both the inflow/outflow cannulae and arthroscopic shaver handpiece. No additional cases occurred after changes in instrument reprocessing protocols were implemented. After this outbreak, the US Food and Drug Administration released a safety alert about the concern regarding retained tissue within arthroscopic shavers. CONCLUSIONS: These SSIs were likely related to surgical instrument contamination with P. aeruginosa during instrument reprocessing. Retained tissue in inflow/outflow cannulae and shaver handpieces could have allowed bacteria to survive sterilization procedures. |
Current practice in Staphylococcus aureus screening and decolonization
Diekema D , Johannsson B , Herwaldt L , Beekmann S , Jernigan J , Kallen A , Berrios-Torres S , Polgreen P . Infect Control Hosp Epidemiol 2011 32 (10) 1042-4 We surveyed infectious disease physicians to determine their preoperative Staphylococcus aureus screening and decolonization practices. Sixty percent reported preoperative screening for S. aureus. However, specific screening and decolonization practices are highly variable, are focused almost exclusively on methicillin-resistant S. aureus, and do not include testing for mupirocin or chlorhexidine resistance. |
Improving risk-adjusted measures of surgical site infection for the National Healthcare Safety Network
Mu Y , Edwards JR , Horan TC , Berrios-Torres SI , Fridkin SK . Infect Control Hosp Epidemiol 2011 32 (10) 970-86 BACKGROUND: The National Healthcare Safety Network (NHSN) has provided simple risk adjustment of surgical site infection (SSI) rates to participating hospitals to facilitate quality improvement activities; improved risk models were developed and evaluated. METHODS: Data reported to the NHSN for all operative procedures performed from January 1, 2006, through December 31, 2008, were analyzed. Only SSIs related to the primary incision site were included. A common set of patient- and hospital-specific variables were evaluated as potential SSI risk factors by univariate analysis. Some ific variables were available for inclusion. Stepwise logistic regression was used to develop the specific risk models by procedure category. Bootstrap resampling was used to validate the models, and the c-index was used to compare the predictive power of new procedure-specific risk models with that of the models with the NHSN risk index as the only variable (NHSN risk index model). RESULTS: From January 1, 2006, through December 31, 2008, 847 hospitals in 43 states reported a total of 849,659 procedures and 16,147 primary incisional SSIs (risk, 1.90%) among 39 operative procedure categories. Overall, the median c-index of the new procedure-specific risk was greater (0.67 [range, 0.59-0.85]) than the median c-index of the NHSN risk index models (0.60 [range, 0.51-0.77]); for 33 of 39 procedures, the new procedure-specific models yielded a higher c-index than did the NHSN risk index models. CONCLUSIONS: A set of new risk models developed using existing data elements collected through the NHSN improves predictive performance, compared with the traditional NHSN risk index stratification. |
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