To assess the influence of postdischarge infection surveillance on risk-adjusted surgical-site infection rates for coronary artery bypass graft (CABG) procedures.

Prospective surveillance of surgical-site infections after CABG.

Tertiary-care referral hospital.

Data on surgical-site infections were collected for 1,324 CABG procedures during 27 months. They were risk adjusted and analyzed according to the surgical surveillance protocol of the National Nosocomial Infections Surveillance (NNIS) System of the Centers for Disease Control and Prevention, with and without postdischarge data.

Data were available for 96% of the patients. Of the 88 surgical-site infections, 28% were identified prior to discharge and 72% postdischarge. More chest than harvest-site infections were identified (46% vs 11%) prior to discharge, and more harvest-site than chest infections were identified in the outpatient setting (42% vs 14%). The surgical-site infection rate for patients stratified under risk index 1, calculated without postdischarge surveillance, was 2.9%; when compared with that of the NNIS System, the P value was .29. When postdischarge surveillance was included, the surgical-site infection rate was 4.9% and statistically significant when compared with that of the NNIS System (P = .007). For patients stratified under risk index 2, the rates with and without postdischarge surveillance were 11.7% and 10.0%, respectively; when compared with the NNIS System rates, the P values were .000008 and .0006, respectively.

Only 28% of the surgical-site infections would have been detected if surveillance had been limited to hospital stay. Postdischarge surveillance identified more surgical-site infections among risk index 1 patients. Hospitals with comprehensive postdischarge surveillance after CABG procedures are likely to record higher surgical-site infection rates than those that do not perform such surveillance.

To take into account the proportion of patients lost to follow-up when calculating surgical-site infection (SSI) rates.

A multicenter SSI monitoring network in Basse-Normandie, France, using the definitions for SSI of the National Nosocomial Infections Surveillance System of the Centers for Disease Control and Prevention.

Between January 1, 1998, and December 31, 1999, 3,705 patients were operated on in 25 units of 10 institutions.

Of the patients, 41.2% (range, 5.1% to 95.5%) were seen 30 days or more after their operation. The global SSI attack rate was 2.19% (95% confidence interval, 1.72% to 2.66%). With the use of the Kaplan–Meier method, the incidence rate was 3.11% (95% confidence interval, 3.06% to 3.16%). The difference between the attack rate and the Kaplan–Meier incidence rate for each unit varied according to the percentage of patients seen on or after day 30 postoperatively and the number of SSIs diagnosed in patients seen on or after day 30.

Practice guidelines are needed for the international monitoring for postdischarge SSIs and the calculation of SSI rates. The proportion of patients seen 30 days after their operation is a major quality criterion for SSI monitoring and should be routinely given in monitoring reports, oral communications, and publications to compare results obtained by different teams.

To develop a new, simple, and practical risk index for patients undergoing coronary artery bypass graft (CABG) surgery, to develop a preoperative risk index that is predictive of surgical-site infection (SSI), and to compare the new risk indices with the National Nosocomial Infections Surveillance (NNIS) System risk index.

Potential risk factor and infection data were collected prospectively and analyzed by multivariate analysis. Two new risk indices were constructed and then compared with the NNIS System risk index for predictive power for SSI.

Alfred Hospital is a 350-bed, university-affiliated, tertiary-care referral center. The cardiothoracic unit performs approximately 650 CABG procedures per year.

All patients undergoing CABG surgery within the cardiothoracic unit at Alfred Hospital between December 1, 1996, and September 29, 2000, were included.

Potential risk factor data were complete for 2,345 patients. There were 199 SSIs. Obesity (odds ratio [OR], 1.78; 95% confidence interval [CI95], 1.24 to 2.55), peripheral or cerebrovascular disease (OR, 1.64; CI95, 1.16 to 2.33), insulin-dependent diabetes mellitus (OR, 2.29; CI95, 1.15 to 4.54), and a procedure lasting longer than 5 hours (OR, 1.75; CI95,1.18 to 2.58) were identified as independent risk factors for SSI. With the use of a different combination of these risk factors, two risk indices were constructed and compared using the Goodman-Kruskal nonparametric correlation coefficient (G). Risk index B had the highest G value (0.3405; CI95, 0.2245 to 0.4565), compared with the NNIS System risk index G value (0.3142; CI95, 0.1462 to 0.4822). The G value for risk index A constructed from preoperative variables only, was 0.3299 (CI95 0.2039 to 0.4559).

Two new risk indices have been developed. Both indices are as predictive as the NNIS System risk index. One of the new risk indices can also be applied preoperatively.

To describe an outbreak of mediastinitis in heart transplant recipients.

Retrospective and contemporaneous cohort study.

Urban tertiary-care university hospital with a large cardiac transplantation program.

Heart transplant recipients.

Modifications of donor harvest technique; procedures aimed at decreasing skin and mucosal bacterial colonization; strict aseptic technique in the intensive care unit; and aggressive policing of established infection control practices.

In April 1999, mediastinitis rates among heart transplant recipients increased abruptly from a baseline of 6 cases per 100 procedures to sequential quarterly rates of 22, 31, and 50 cases per 100 procedures, whereas infection rates in other cardiac operations were unchanged. Bacteria causing these infections were multidrug-resistant "nosocomial" organisms. The epidemic occurred 2 months after a change in the United Network for Organ Sharing organ allocation algorithm. This change resulted in an increase in the duration of preoperative hospitalization from a median of 52 to 79 days (P = .008) and may have promoted prolonged hospitalization of patients with high illness severity. Aggressive multidisciplinary interventions were temporally associated with a return to preoperative mediastinitis rates without changing length of hospitalization prior to transplantation.

Changes in organ allocation for transplant that prolong waiting time in the hospital and alter illness acuity may lead to increased rates of postoperative infection. Measures to limit bacterial colonization may be a helpful countervailing strategy.

Few studies have been conducted in Vietnam on the epidemiology of healthcare-associated infections or antimicrobial use. Thus, we sought to determine the prevalence of and risk factors for surgical-site infections (SSIs) and to document antimicrobial use in surgical patients in a large healthcare facility in Vietnam.

We conducted a point-prevalence survey of SSIs and antimicrobial use at Cho Ray Hospital, Ho Chi Minh City, a 1,250-bed inpatient facility. All patients on the 11 surgical wards and 2 intensive care units who had surgery within 30 days before the survey date were included.

Of 391 surgical patients, 56 (14.3%) had an SSI. When we compared patients with and without SSIs, factors associated with infection included trauma (relative risk [RR], 2.65; 95% confidence interval [CI95], 1.60 to 4.37; P < .001), emergency surgery (RR, 2.74; CI95, 1.65 to 4.55; P < .001), and dirty wounds (RR, 3.77; CI95, 2.39 to 5.96; P < .001). Overall, 198 (51%) of the patients received antimicrobials more than 8 hours before surgery and 390 (99.7%) received them after surgery. Commonly used antimicrobials included third-generation cephalosporins and aminoglycosides. Thirty isolates were identified from 26 SSI patient cultures; of the 25 isolates undergoing antimicrobial susceptibility testing, 22 (88%) were resistant to ceftriaxone and 24 (92%) to gentamicin.

Our data show that (1) SSIs are prevalent at Cho Ray Hospital; (2) antimicrobial use among surgical patients is widespread and inconsistent with published guidelines; and (3) pathogens often are resistant to commonly used antimicrobials. SSI prevention interventions, including appropriate use of antimicrobials, are needed in this population.

The primary objective of this study was to evaluate fluorescent readout results of Attest 1291 Biological Indicators (Bis) (3M Health Care, St. Paul, MN) and Attest 1296 BI test packs (containing Attest 1292 Bis) using full and fractional cycles compared with the growth data when prolonged incubation (7 days) was included. Gravity displacement and vacuum-assisted steam sterilization cycles were evaluated. A secondary objective of this study was to evaluate the new automated rapid fluorescent reader (Attest 290 Auto Reader).

The rapid readout Bis for gravity displacement and vacuum-assisted steam autoclave cycles at 132° C were processed using full (4 minutes) and four fractional cycles that provided 30% to 80% positive results for growth after 24 hours of incubation (48 hours of incubation for Attest 1292 Bis from the Attest 1296 test packs). Sixty of each type of BI were tested for each cycle (300 of each BI type in total).

For all full steam sterilization cycles, results of the rapid fluorescent readout and the 24-hour, 48-hour, and 7-day growth tests were negative for all Attest 1291 and 1292 Bis tested. For all fractional cycles, the 24- and 48-hour growth results for the Attest 1291 and 1292 Bis, respectively, were the same as the 7-day growth results. The fractional cycle data indicated that fluorescent rapid readout was a more sensitive indicator than growth. There were rare (0.9%) false-negative results for Bis under fractional cycle conditions and these all correlated with short fractional cycle exposure times.

The fluorescent rapid readout results of the 1291 Bis and 1296 BI test packs reliably predict both 24- and 48-hour and 7-day growth. These data support the value of rapid readout Bis for sterilizer monitoring for both the vacuum-assisted and the gravity displacement steam sterilization cycles. The new automated reader requires less manipulation of the BI and makes monitoring user friendly and less prone to user errors.

To evaluate the lethality profile of an infrared radiation (IR) prototype sterilizer.

Simulated use and D value tests were conducted with Bacillus subtilis spores American Type Culture Collection–9372. A spore suspension (1.06 ± 0.03 × 106) in 5% bovine serum albumin was air dried on stainless steel instruments. IR cycles were completed and the instruments were immersed in tryptic soy broth for 120 hours at 37°C. Direct enumeration of survivors was performed to evaluate IR death. Instrument loads contained carriers laden with spores (1.06 ± 0.3 × 106). The spores were seeded on tryptic soy agar and survivors were counted after 120 hours of incubation at 37°C.

All instruments exposed to IR (n = 50) were culture negative. In contrast, all unprocessed instruments (n = 30) showed B. subtilis growth. The prototype's D value was 0.56, and the death rate's slope was -1.76 (r = -0.99741; P < .0001). The 10-6 sterility assurance level was reached after 8 minutes and 40 seconds of exposure, from cold start.

IR destroys B. subtilis spores. Instrument sterilization with IR may provide another technology for infection control.

Skin preparation is an important factor in reducing the rate of blood culture contamination. We assessed blood culture contamination rates associated with the use of skin antisepsis kits containing either 2% alcoholic chlorhexidine gluconate or 2% alcoholic tincture of iodine.

Prospective, blinded clinical trial.

Tertiary-care teaching hospital.

Adult patients in medical wards, the medical intensive care unit, and the cardiac intensive care unit who needed paired, percutaneous blood cultures.

House officers, medical students, and healthcare technicians drew the blood for cultures. We prepared sacks containing all of the necessary supplies, including two different types of antiseptic kits. In each sack, one kit contained 2% chlorhexidine in 70% isopropyl alcohol and the other contained 2% tincture of iodine in ethyl alcohol and 70% isopropyl alcohol. Each patient received chlorhexidine at one site and tincture of iodine at the other.

Four (0.9%) of 430 blood culture sets from 215 patients were contaminated. The contamination rate when using alcohol and chlorhexidine (1 of 215, 0.5%) did not differ significantly from the contamination rate when using tincture of iodine (3 of 215,1.4%; P = .62, McNemar test). There was an 87% probability that the two interventions differed by less than 2% in their rate of contamination.

Both of these antiseptic kits were highly effective for skin preparation prior to drawing blood for cultures. The use of these kits may have contributed to the low contamination rate observed in this study.