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Colorectal bundles for surgical site infection prevention: A systematic review and meta-analysis

Published online by Cambridge University Press:  11 May 2020

Aurora E. Pop-Vicas ,
Cybele Abad ,
Kelsey Baubie ,
Fauzia Osman ,
Charles Heise  and
Nasia Safdar
Aurora E. Pop-Vicas*
Affiliation:
Infectious Disease Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
Cybele Abad
Affiliation:
Section of Infectious Diseases, Department of Medicine, Medical City Hospital, Pasig City, Philippines University of the Philippines, Philippine General Hospital, Manila, Philippines
Kelsey Baubie
Affiliation:
Research, William S Middleton Memorial Veterans’ Hospital, Madison, Wisconsin, United States
Fauzia Osman
Affiliation:
Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
Charles Heise
Affiliation:
Section of Colon and Rectal Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
Nasia Safdar
Affiliation:
Infectious Disease Division, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States Research, William S Middleton Memorial Veterans’ Hospital, Madison, Wisconsin, United States
*
Author for correspondence: Aurora E. Pop-Vicas, E-mail: popvicas@medicine.wisc.edu
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Abstract

Objective:

In colorectal surgery, the composition of the most effective bundle for prevention of surgical site infections (SSI) remains uncertain. We performed a meta-analysis to identify bundle interventions most associated with SSI reduction.

Methods:

We systematically reviewed 4 databases for studies that assessed bundles with ≥3 elements recommended by clinical practice guidelines for adult colorectal surgery. The main outcome was 30-day postoperative SSI rate (overall, superficial, deep, and/or organ-space).

Results:

We included 40 studies in the qualitative review, and 35 studies (54,221 patients) in the quantitative review. Only 3 studies were randomized controlled trials. On meta-analyses, bundles were associated with overall SSI reductions of 44% (RR, 0.57; 95% CI, 0.48–0.65); superficial SSI reductions of 44% (RR, 0.56; 95% CI, 0.42–0.75); deep SSI reductions of 33% (RR, 0.67; 95% CI, 0.46–0.98); and organ-space SSI reductions of 37% (RR, 0.63; 95% CI, 0.50–0.81). Bundle composition was heterogeneous. In our meta-regression analysis, bundles containing ≥11 elements, consisting of both standard of care and new interventions, demonstrated the greatest SSI reduction. Separate instrument trays, gloves with and without gown change for wound closure, and standardized postoperative dressing change at 48 hours correlated with the highest reductions in superficial SSIs. Mechanical bowel preparation combined with oral antibiotics, and preoperative chlorhexidine showers correlated with highest organ-space SSI reductions.

Conclusions:

Preventive bundles emphasizing guideline-recommended elements from both standard of care as well as new interventions were most effective for SSI reduction following colorectal surgery. High clinical-bundle heterogeneity and low quality for most observational studies significantly limit our conclusion.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 41 , Issue 7 , July 2020 , pp. 805 - 812
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Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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References

Merkow, RP, Ju, MH, Chung, JW, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA 2015;313:483–495.CrossRefGoogle ScholarPubMed
Zimlichman, E, Henderson, D, Tamir, O, et al. Healthcare-associated infections: a meta-analysis of costs and financial impact on the US healthcare system. JAMA Intern Med 2013;173:2039–2046.CrossRefGoogle Scholar
Tanner, J, Khan, D, Aplin, C, Ball, J, Thomas, M, Bankart, J. Postdischarge surveillance to identify colorectal surgical site infection rates and related costs. J Hosp Infect 2009;72:243–250.CrossRefGoogle Scholar
Hubner, M, Diana, M, Zanetti, G, Eisenring, MC, Demartines, N, Troillet, N. Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon. Arch Surg 2011;146:1240–1245.CrossRefGoogle ScholarPubMed
Ban, KA, Minei, JP, Laronga, C, et al. American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update. J Am Coll Surg 2017;224:59–74.CrossRefGoogle Scholar
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, Group, P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264–269.CrossRefGoogle ScholarPubMed
Horan, TC, Gaynes, RP, Martone, WJ, Jarvis, WR, Emori, TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992;13:606–608.CrossRefGoogle ScholarPubMed
Downs, SH, Black, N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of healthcare interventions. J Epidemiol Commun Health 1998;52:377–384.CrossRefGoogle Scholar
Gilham, B. Case Study Research Methods. London: Continuum; 2000.Google Scholar
Morgan, SJ, Pullon, SRH, Macdonald, LM, McKinlay, EM, Gray, BV. Case study observational research: a framework for conducting case study research where observation data are the focus. Qual Health Res 2017;27:1060–1068.CrossRefGoogle ScholarPubMed
Mays, N, Pope, C. Qualitative research: observational methods in health care settings. BMJ 1995;311(6998):182–184.CrossRefGoogle ScholarPubMed
Anthony, T, Murray, BW, Sum-Ping, JT, et al. Evaluating an evidence-based bundle for preventing surgical site infection: a randomized trial. Arch Surg 2011;146:263–269.CrossRefGoogle ScholarPubMed
Kwaan, MR, Weight, CJ, Carda, SJ, et al. Abdominal closure protocol in colorectal, gynecologic oncology, and urology procedures: a randomized quality improvement trial. Am J Surg 2016;211:1077–1083.CrossRefGoogle ScholarPubMed
Ruiz-Tovar, J, Llavero, C, Morales, V, Gamallo, C. Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with triclosan-coated sutures and mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery. Surg Endosc 2018;32:3495–3501.CrossRefGoogle ScholarPubMed
Albert, H, Bataller, W, Masroor, N, et al. Infection prevention and enhanced recovery after surgery: a partnership for implementation of an evidence-based bundle to reduce colorectal surgical site infections. Am J Infect Control. 2019; 47:718–719.CrossRefGoogle ScholarPubMed
Benlice, C GE. Using NSQIP data for quality improvement: the Cleveland Clinic SSI experience. Semin Colon Rectal Surg 2016;27:74–82.CrossRefGoogle Scholar
Bull, A, Wilson, J, Worth, LJ, et al. A bundle of care to reduce colorectal surgical infections: an Australian experience. J Hosp Infect 2011;78:297–301.CrossRefGoogle Scholar
Cima, R, Dankbar, E, Lovely, J, et al. Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program–driven multidisciplinary single-institution experience. J Am Coll Surg 2013;216:23–33.CrossRefGoogle ScholarPubMed
Connolly, TM, Foppa, C, Kazi, E, Denoya, PI, Bergamaschi, R. Impact of a surgical site infection reduction strategy after colorectal resection. Colorect Dis 2016;18:910–918.CrossRefGoogle ScholarPubMed
Crolla, RM, van der Laan, L, Veen, EJ, Hendriks, Y, van Schendel, C, Kluytmans, J. Reduction of surgical site infections after implementation of a bundle of care. PLoS One 2012;7(9):e44599.CrossRefGoogle Scholar
DeHaas, D, Aufderheide, S, Gano, J, Weigandt, J, Ries, J, Faust, B. Colorectal surgical site infection reduction strategies. Am J Surg 2016;212:175–177.CrossRefGoogle ScholarPubMed
Elia-Guedea, M, Cordoba-Diaz de Laspra, E, Echazarreta-Gallego, E, Valero-Lazaro, MI, Ramirez-Rodriguez, JM, Aguilella-Diago, V. Colorectal surgery and surgical site infection: is a change of attitude necessary? Int J Colorect Dis 2017;32:967–974.CrossRefGoogle ScholarPubMed
Gorgun, E, Rencuzogullari, A, Ozben, V, et al. An effective bundled approach reduces surgical site infections in a high-outlier colorectal unit. Dis Colon Rectum 2018;61:89–98.CrossRefGoogle Scholar
Hedrick, TL, Heckman, JA, Smith, RL, Sawyer, RG, Friel, CM, Foley, EF. Efficacy of protocol implementation on incidence of wound infection in colorectal operations. J Am Coll Surg 2007;205:432–438.CrossRefGoogle ScholarPubMed
Hedrick, TL, Turrentine, FE, Smith, RL, et al. Single-institutional experience with the surgical infection prevention project in intra-abdominal surgery. Surg Infect (Larchmt) 2007;8:425–435.CrossRefGoogle ScholarPubMed
Hewitt, DB, Tannouri, SS, Burkhart, RA, et al. Reducing colorectal surgical site infections: a novel, resident-driven, quality initiative. Am J Surg 2017;213:36–42.CrossRefGoogle ScholarPubMed
Jaffe, TA, Meka, AP, Semaan, DZ, et al. Optimizing value of colon surgery in Michigan. Ann Surg 2017;265:1178–1182.CrossRefGoogle ScholarPubMed
Liau, KH, Aung, KT, Chua, N, et al. Outcome of a strategy to reduce surgical site infection in a tertiary-care hospital. Surg Infect (Larchmt) 2010;11:151–159.CrossRefGoogle ScholarPubMed
Lutfiyya, W, Parsons, D, Breen, J. A colorectal “care bundle” to reduce surgical site infections in colorectal surgeries: a single-center experience. Perm J 2012;16(3):10–16.Google ScholarPubMed
Pastor, C, Artinyan, A, Varma, MG, Kim, E, Gibbs, L, Garcia-Aguilar, J. An increase in compliance with the Surgical Care Improvement Project measures does not prevent surgical site infection in colorectal surgery. Dis Colon Rectum 2010;53:24–30.CrossRefGoogle Scholar
Perez-Blanco, V, Garcia-Olmo, D, Maseda-Garrido, E, Najera-Santos, MC, Garcia-Caballero, J. Evaluation of a preventive surgical site infection bundle in colorectal surgery. Cir Esp 2015;93:222–228.Google ScholarPubMed
Russell, TA, Chung, H, Riad, C, et al. Sustaining improvement: implementation and spread of a surgical site infection bundle. Am Surg 2018;84:1665–1669.CrossRefGoogle ScholarPubMed
Tanner, J, Kiernan, M, Hilliam, R, et al. Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery. Ann R Coll Surg Engl 2016;98:270–274.CrossRefGoogle ScholarPubMed
Vu, JV, Collins, SD, Seese, E, et al. Evidence that a regional surgical collaborative can transform care: surgical site infection prevention practices for colectomy in Michigan. J Am Coll Surg 2018;226:91–99.CrossRefGoogle ScholarPubMed
Weiser, MR, Gonen, M, Usiak, S, et al. Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections. Br J Surg 2018;105:1680–1687.CrossRefGoogle ScholarPubMed
Wick, EC, Galante, DJ, Hobson, DB, et al. Organizational culture changes result in improvement in patient-centered outcomes: implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg 2015;221:669–677.CrossRefGoogle ScholarPubMed
Wick, EC, Hobson, DB, Bennett, JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg 2012;215:193–200.CrossRefGoogle ScholarPubMed
Berenguer, CM, Ochsner, MG Jr, Lord, SA, Senkowski, CK. Improving surgical site infections: using National Surgical Quality Improvement Program data to institute Surgical Care Improvement Project protocols in improving surgical outcomes. J Am Coll Surg 2010;210:737–741.CrossRefGoogle ScholarPubMed
Reames, BN, Krell, RW, Campbell, DA Jr, Dimick, JB. A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program. JAMA Surg 2015;150:208–215.CrossRefGoogle ScholarPubMed
Yamamoto, T, Morimoto, T, Kita, R, et al. The preventive surgical site infection bundle in patients with colorectal perforation. BMC Surg 2015;15:128.CrossRefGoogle ScholarPubMed
Forbes, SS, Stephen, WJ, Harper, WL, et al. Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and postintervention study. J Am Coll Surg 2008;207:336–341.CrossRefGoogle ScholarPubMed
Mammo, D, Peeples, C, Grodsky, M, Honaker, D, Wasvary, H. The Colectomy Improvement Project: do evidence-based guidelines improve institutional colectomy outcomes? Am Surg 2016;82:830–834.CrossRefGoogle ScholarPubMed
Ohman, KA, Wan, L, Guthrie, T, et al. Combination of oral antibiotics and mechanical bowel preparation reduces surgical site infection in colorectal surgery. J Am Coll Surg 2017;225:465–471.CrossRefGoogle ScholarPubMed
Bell, BP. Adherence to the Centers for Disease Control and Prevention (CDC) infection definitions and criteria is needed to ensure accuracy, completeness, and comparability of infection information. Centers for Disease Control and Prevention website. http://www.cdc/gov/nhsn/pdfs/cms/nhsn-reporting-signed.pdf. Accessed March 8, 2019.Google Scholar
Ghuman, A, Chan, T, Karimuddin, AA, Brown, CJ, Raval, MJ, Phang, PT. Surgical site infection rates following implementation of a colorectal closure bundle in elective colorectal surgeries. Dis Colon Rectum 2015;58:1078–1082.CrossRefGoogle ScholarPubMed
Keenan, JE, Speicher, PJ, Nussbaum, DP, et al. Improving outcomes in colorectal surgery by sequential implementation of multiple standardized care programs. J Am Coll Surg 2015;221:404–414.CrossRefGoogle ScholarPubMed
Kobayashi, M, Inoue, Y, Mohri, Y, Miki, C, Kusunoki, M. Implementing a standard protocol to decrease the incidence of surgical site infections in rectal cancer surgery. Surg Today 2010;40:326–333.CrossRefGoogle ScholarPubMed
Rumberger, LK, Vittetoe, D, Cathey, L, Bennett, H, Heidel, RE, Daley, BJ. Improving outcomes in elective colorectal surgery: a single-institution retrospective review. Am Surg 2016;82:325–330.CrossRefGoogle ScholarPubMed
Tillman, M, Wehbe-Janek, H, Hodges, B, Smythe, WR, Papaconstantinou, HT. Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes? J Surg Res 2013;184:150–156.CrossRefGoogle ScholarPubMed
Waits, SA, Fritze, D, Banerjee, M, et al. Developing an argument for bundled interventions to reduce surgical site infection in colorectal surgery. Surgery 2014;155:602–606.CrossRefGoogle ScholarPubMed
Keenan, JE, Speicher, PJ, Thacker, JK, Walter, M, Kuchibhatla, M, Mantyh, CR. The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings. JAMA Surg 2014;149:1045–1052.CrossRefGoogle ScholarPubMed
Bert, F, Giacomelli, S, Amprino, V, et al. The “bundle” approach to reduce the surgical site infection rate. J Eval Clin Pract 2017;23:642–647.CrossRefGoogle ScholarPubMed
Global guidelines on the prevention of surgical site infection. World Health Organizaiton website. http://apps.who.int/iris/bitstream/10665/250680/1/9789241549882-eng.pdf?ua=1. Published 2016. Accessed September 12, 2019.Google Scholar
Surgical site infection: prevention and treatment of surgical site infection (NICE Clinical Guideline 125). National Institute for Health and Clinical Excellence (NICE) website. https://www.nice.org.uk/guidance/ng125/chapter/Recommendations#antiseptics-and-antibiotics-before-wound-closure. Published 2019. Accessed September 12, 2019.Google Scholar
Septimus, E, Yokoe, DS, Weinstein, RA, Perl, TM, Maragakis, LL, Berenholtz, SM. Maintaining the momentum of change: the role of the 2014 updates to the compendium in preventing healthcare-associated infections. Infect Control Hosp Epidemiol 2014;35:460–463.CrossRefGoogle ScholarPubMed
Ariyo, P, Zayed, B, Riese, V, et al. Implementation strategies to reduce surgical site infections: a systematic review. Infect Control Hosp Epidemiol 2019;40:287–300.CrossRefGoogle ScholarPubMed
Zywot, A, Lau, CSM, Stephen Fletcher, H, Paul, S. Bundles prevent surgical site infections after colorectal surgery: meta-analysis and systematic review. J Gastrointest Surg 2017;21:1915–1930.CrossRefGoogle ScholarPubMed
Berrios-Torres, SI, Umscheid, CA, Bratzler, DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–791.Google Scholar
Pouralizadeh, M, Khankeh, H, Ebadi, A, Dalvandi, A. factors influencing nursing students’ clinical judgment: a qualitative directed content analysis in an Iranian context. J Clin Diagn Res 2017;11(5):JC01–JC04.Google Scholar
Ju, MH, Ko, CY, Hall, BL, Bosk, CL, Bilimoria, KY, Wick, EC. A comparison of 2 surgical site infection monitoring systems. JAMA Surg 2015;150:51–57.CrossRefGoogle ScholarPubMed
Bordeianou, L, Cauley, CE, Antonelli, D, et al. Truth in reporting: how data capture methods obfuscate actual surgical site infection rates within a health care network system. Dis Colon Rectum 2017;60:96–106.CrossRefGoogle ScholarPubMed
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