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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 6-11

Effect of colon care bundle on surgical site infections in colorectal surgery


Department of General and Minimal Invasive Surgery, Division of Colorectal, Sheri Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

Date of Submission27-Apr-2020
Date of Acceptance12-May-2020
Date of Web Publication30-May-2020

Correspondence Address:
Nisar Ahmad Chowdri
Department of General and Minimal Invasive Surgery, Division of Colorectal, Sheri Kashmir Institute of Medical Sciences, Srinagar - 190 011, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2666-0784.285441

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  Abstract 


Objectives: Surgical site infection (SSI) has been recognized as the third most common health-care-associated infection. Colorectal surgeries are consistently associated with higher SSI (4%–45%) relative to other surgeries. SSI not only increases morbidity but also causes severe economic impact throughout the world. The aim of the present study was to study the effect of colon care bundle on SSI and identify the risk factors involved in SSI in colorectal surgeries. Methods: Two hundred and seventy patients who underwent elective colorectal surgery between July 2015 and June 2017 were included in the study. Patients were assigned to bundle care group (n = 150) and control group (n = 122). In the colon care bundle group, patients received aseptic cleaning of skin with chlorhexidine (night before and morning), clipping of hair before surgery, nonabsorbable oral antimicrobial agents, maintenance of normothermia during surgery, and high-inspired oxygen intra- and postoperatively. Both groups received parenteral antibiotics for 24 h. SSI was defined as per the Centers for Disease Control and Prevention. Patients were followed for 30 days postoperatively. Results: Both groups were comparable with respect to age, gender, comorbidities, obesity, and other variables. SSI in the colon care bundle group (8.7%; n = 13) was less than in the control group (18.9%; n = 23), which was statistically significant (P = 0.014); however, effect on deep and organ/space infection was not statistically significant. The incidence of SSI increases with age and superficial SSIs were more common than deep or organ/space infection in both groups. SSIs were more common in wounds of rectal surgeries than colon surgeries (46% vs. 15%, P = 0.926). SSIs were more common in patients with diabetes mellitus (39.1% vs. 23.1%), patients with increased body mass index (BMI) (43.5% vs. 38.5%), patients with decreased serum albumin (69.6% vs. 53.8%), smokers (60.9% vs. 53.8%), and patients with preoperative chemoradiation (65.2% vs. 61.5%) in both groups (control group vs. bundle group), but did not reach statistical significance. Out of 36 SSIs in two groups, 24 were culture positive with Escherichia coli, followed by Enterococcus faecalis as common organisms. Conclusion: Colon care bundle is an effective method of reducing SSI in colorectal patients. Overall SSI was found to be significantly less in the study group than in controls. On subanalysis, superficial SSI was seen more in the control group. The infections were seen more often in diabetics; smokers; and patients with increased BMI, decreased serum albumin, preoperative chemoradiation, and rectal operations, though statistically not significant. However, efficacy of individual component of care bundle on SSI remains unanswered.

Keywords: Bundle crae, colorectal surgery, surgical site infections


How to cite this article:
Bhat AA, Bhat GA, Chowdri NA, Shah ZA, Parray FQ, Wani RA. Effect of colon care bundle on surgical site infections in colorectal surgery. Indian J Colo-Rectal Surg 2019;2:6-11

How to cite this URL:
Bhat AA, Bhat GA, Chowdri NA, Shah ZA, Parray FQ, Wani RA. Effect of colon care bundle on surgical site infections in colorectal surgery. Indian J Colo-Rectal Surg [serial online] 2019 [cited 2020 Sep 29];2:6-11. Available from: http://www.ijcrsonweb.org/text.asp?2019/2/1/6/285441




  Introduction Top


Surgical site infections (SSIs) are infections of the incision or organ or space that occur after surgery.[1] SSIs are associated with increased morbidity, increased duration of hospitalization, readmission, and excess utilization of health-care resources. As a surgical specialty, colorectal surgery has one of the highest rates of SSI. Colon and rectal surgery is associated with higher SSI rates with a range of 2%–45%.[2],[3] A recent collaborative study by the Joint Commission Center for Transforming Healthcare and the American College of Surgeons (ACS) found a baseline rate of 15.8% among seven US institutions participating in a multidisciplinary effort to reduce the risk of infections after colorectal surgery.[4]

Numerous clinical interventions with varying levels of supporting evidence have been implemented to reduce SSIs among colorectal patients. A recent approach to improving patient outcomes is the use of care bundles. Care bundles were first introduced by the Institute for Healthcare Improvement in 2001 to improve clinical outcomes in the critical care population.[5] Care “bundles” are simple sets of evidence-based practices that, when implemented collectively, improve the reliability of their delivery and improve patient outcomes.[5] The implementation of care bundles can assist in enhancing compliance to evidence-based quality process measures to improve patient care. Care bundles include a set of evidence-based measures (where possible, level 1, randomized controlled trial evidence) that when implemented together have shown to produce better outcomes and have a greater impact than that of the isolated implementation of individual measures.[6] Bundles also help create reliable and consistent care systems in hospital settings since they are simple (three to five elements), clear, and concise.[6] In addition to creating safer patient care environments, the implementation of bundles also promotes multidisciplinary collaboration, since they should be developed collaboratively and consensus obtained with strong clinician engagement and endorsement.[6] Despite major improvements in antibiotics, better anesthesia, superior instruments, earlier diagnosis of surgical problems, and improved techniques for postoperative vigilance, wound infections continue to occur. Although some may view the problem as merely cosmetic, that view represents a shallow understanding of this problem, which causes significant patient suffering, morbidity, and mortality and is a financial burden to the health-care system.

The US Centers for Disease Control and Prevention (CDC) has developed criteria that define SSI as infection related to an operative procedure that occurs at or near the surgical incision within 30 days of the procedure or within a year if prosthetic material is implanted at surgery.[7] SSIs are classified into incisional and organ/space infections and CDC has given criteria for its diagnosis.[8] The former is further classified into superficial and deep SSI [Table 1]. Superficial SSI involves skin and subcutaneous tissue of incision, and deep SSI involves deep tissue such as fascial and muscle layer. Organ or space SSI involves any part of anatomy in organs or spaces other than the incision, which was opened or manipulated during operation.
Table 1: Centers for Disease Control and Prevention criteria for defining surgical site infections[9]

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SSIs in colorectal surgery originate in the majority of cases from contamination of the surgical site with the patient's endogenous flora, with the colonic lumen being the major (>80%) source of bacterial contamination. The higher the number of contaminating bacteria at the surgical site (inoculum), the higher the probability of developing an SSI because the quantity of bacterial contamination may exceed the capacity of the host for clearance.[9],[10]Escherichia coli and Bacteroides fragilis are the most likely organisms to be encountered at the contaminated site. Skin colonization can be a source for a smaller percentage (<20%) of infections and may originate from exogenous sources brought within the sterile field, such as the operating room environment, infected instruments and materials, or members of the surgical team. Staphylococcus species (e.g., Staphylococcus aureus including methicillin-resistant S. aureus and coagulase-negative staphylococci) are responsible for the majority of SSIs caused by skin or operating room environmental contaminants.[11],[12]


  Methods Top


The study was conducted in colorectal division of Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, JK. Two hundred and seventy patients who underwent elective colorectal surgery between July 2015 and June 2017 were included in the study excluding patients operated in emergency settings and age <18 years. A total of 272 patients were prospectively enrolled and were assigned to bundle care group (n = 150) and control group (n = 122) after randomization. Patients in the colon care group received the following elements of colon care bundle:

  1. Preoperative antiseptic skin cleaning with chlorhexidine wipes night before and morning of surgery
  2. Part preparation with clippers on the day of surgery
  3. Nonabsorbable oral antibiotic agent, metronidazole 500 mg TID, 2 days before surgery
  4. Forced warm air gown was used to maintain normothermia between 36°C and 40°C using Bair Hugger warmer during surgery
  5. High fraction of inspired oxygen was given intraoperatively and for four hours postoperatively.


Both groups received parenteral antibiotics intraoperatively and for 24 h after surgery. SSI was defined as per the CDC and patients were followed for 30 days postoperatively. The results were analyzed for continuous variables using Student's independent t-test and Chi-square test or Fisher's exact test whichever appropriate for categorical variables.


  Results Top


Out of 272 patients in the study, 150 were in the bundle group and 122 in the control group. The age distribution in two groups was comparable with mean age (± standard deviation [SD]) of 45.9 (±14.28) years and 46.8 (±14.03) years in the bundle group and control group, respectively. Two groups were comparable with respect to comorbidities and other demographic profiles [Table 2].
Table 2: Characteristics of bundle and control group

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The SSI rate in the bundle group was 8.7% (n = 13) whereas it was 18.9% (n = 23) in the control group, and the difference was statistically significant (P = 0.014) [Table 3]. On subanalysis, it was found that only superficial SSI was more in the control group (12.3%; n = 15) than in the bundle care group (4.75%; n = 7), and the difference was statistically significant (P = 0.021). The deep and organ/space SSI were less in the bundle group as compared to the control group, but did not reached statistical significance. Both the groups showed higher rates of SSI with increasing age, but without statistical significance. SSI rate in rectal surgeries was more than colon surgeries, but without statistical significance. SSIs were more common in patients with diabetes mellitus (39.1% vs. 23.1%, P = 0.539), patients with increased body mass index (BMI) (43.5% vs. 38.5%; P = 0.769), patients with decreased serum albumin <3 g/dl; (69.6% vs. 53.8%, P = 0.345), smokers (60.9% vs. 53.8%, P = 0.681), and patients with preoperative chemoradiation (65.2% vs. 61.5%; P = 0.825) in both the groups (control group vs. bundle group), but did not reach statistical significance [Table 4].
Table 3: Surgical site infection rates in bundle and control group

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Table 4: Surgical site infection rates with respect to different variables

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Out of 36 patients with SSI in two groups, 24 were culture positive. The most common organism found was E. coli (29%; n = 7), followed by Enterococcus faecalis, S. aureus, Klebsiella, and coagulase-negative S. aureus [Figure 1].
Figure 1: Pie chart showing microorganisms isolated from surgical site infection

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  Discussion Top


SSIs remain the leading hospital-acquired infections in surgical patients.[13] Prevention of SSI continues to be a clinical challenge particularly in colorectal surgery, in which risk of SSI may be 15 times that of other types of operation.[14] SSIs in colorectal surgery are associated with significant morbidity, mortality, increased health-care costs, frequently prolonged hospitalization, increased readmission, increased reoperation during the course of treatment, and delay in adjuvant chemoradiotherapy. A study analyzing the impact of SSIs on hospital use and treatment costs using the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS) database found that SSIs extend the length of stay by an average of 9.7 days, while increasing costs by $20,842 per admission.[15]

In an effort to reduce SSIs, many institutions have developed evidence-based standards and implementation of standardized care has been shown to improve outcomes and reduce length of stay.[16],[17],[18] Surgical site infections have become a focus of many institutions as well as the surgical care improvement project (SCIP).[19],[20] SCIP was introduced in 2002 as collaboration between the Centers for Medicare and Medicaid Services and US CDC in hopes of standardizing processes that reduce surgical site infections.[21] These include the use of perioperative hair clipping, perioperative antibiotics, and normothermia in colon and rectal surgery patients.[22] However, despite its introduction and implementation at numerous hospitals across the country, surgical site infections remain a source of morbidity. Consequently, due to the large number of elective colorectal operations performed annually, there remains increased scrutiny on various best-practice methods to reduce SSIs and their associated morbidity.[23],[24] Individual elements of these efforts vary across institutions; however, the overall results are promising in the reduction of overall infection rates.

Preventing SSIs is a multidisciplinary endeavor; involving the entire health team, including nurses, surgical staff, and physicians, is critical. It may involve taking measures at every step of the care process, ranging from preoperative optimization, to the operating room and postoperative care, combined with audit and surveillance of SSI rates and providing feedback, as well as education to health-care personnel when appropriate.

In this study, our primary aim was to investigate the effect of an evidence-based SSI-reduction bundle on colorectal SSIs. The study included 272 patients: 150 were in the bundle group and 122 in the control group; both the groups were comparable with respect to comorbidities and other demographic profiles. The SSI rate in the bundle group was 8.7%, whereas it was 18.9% in the control group, and the difference was statistically significant. On subanalysis of patients who have SSI, it was found that only superficial SSI was more in the control group (12.3%) than in the bundle care group (4.75%), and the difference was statistically significant. The deep and organ/space SSI were less in the bundle group as compared to the control group, but did not reach statistical significance. Decrease in SSI rates after applying bundle care was significant and comparable to literature rates of 5.9%–7%.[25],[26],[27] Zywot et al.[26] in a meta-analysis review involving 17,557 patients showed a SSI risk reduction of 40% (P < 0.001), with 44% for superficial SSI (P < 0.001) and 34% for organ/space (P = 0.048). These results are consistent with our study, which showed decrease in superficial SSI but not in deep or space/organ/space SSI. SSI rate in rectal surgeries was more than colon surgeries, but without statistical significance. Tanner et al.[25] in a systemic review and cohort meta-analysis of 8515 patients showed decrease in SSI rate with SSI rate of 7% in the bundle group and 15.1% in the standard group. The results of this study were consistent with our study. SSIs were more common in patients with diabetes mellitus, patients with increased BMI, decreased serum albumin <3 g/dl, smokers, preoperative chemoradiation in both the groups, but did not reach statistical significance.

Limitations of this study are that a specific cohort from a single institution who underwent colorectal surgery was analyzed and as is the case with all bundled care studies, we are unable to precisely determine which components of the bundle are truly beneficial and which are not. A final comment worthy of consideration is: what comprised the optimal surgical care bundle for decreasing the risk of colorectal SSIs?

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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21.
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26.
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27.
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