Another of my favourite guitarists succumbed to sepsis following surgery just before Xmas, with the sad passing of Rick Parfitt following shoulder surgery, spookily the day after his band Status quo performed their final electric gig (which I was at). The other was Rory Gallagher, who died a few years ago now of MRSA. Surgical procedures are normally carried out under what should be the most controllable of conditions, yet there are variations in practice, a paucity of quality studies on even the most basic of interventions (such as pre-op bathing) and even when there is good evidence, it is ignored. However I do also wonder if we have been missing something. A paper that suggests no difference between Chlorhexidine (CHG) and Povidone Iodine (PI) for pre-surgical skin prep (both aqueous) recently piqued my interest. It was an RCT (non-blinded) undertaken in clean-contaminated upper gastrointestinal or hepatobiliary–pancreatic open surgery, however that wasn’t the aspect that I became interested in. Continue reading
The WHO guideline for SSI prevention was launched as if it were the iPhone8. I immediately went looking for what I think is the intervention with the strongest evidence: pre-op nasal mupirocine and CHX bathing, see why here. After an interesting read I’m pleased that the guideline is clear, but I missed an evaluation on feasibility and the evidence for simplification is turned around.
This is a guest post by Dr Gabriel Birgand (bio below), a researcher at Imperial College London…
Surveillance is an essential component in any infection control programme. In UK, the surveillance of infections associated with some procedures (e.g. certain orthopaedic procedures) is mandated by Public Health England. This surveillance requires time and represents either a full time job (i.e. dedicated nurses doing the data collection and follow-up of patients undergoing surgery) or additional work (i.e. surveillance of catheter-associated urinary tract infection by infection control nurses). This process is time-consuming, expensive and dependent on the rigour of the person in charge of the surveillance. Despite proven value, the involved nature of the method makes these manual HCAI surveillance systems difficult cumbersome to deliver. Moreover, hospitals often struggle to recruit and retain nursing staff dedicated to surveillance meaning that reporting is frequently incorporated into other posts, which interrupts other clinical duties and may reduce the detail of reporting.
I am always interested in compliance. What makes staff implement an intervention reliably? What makes a patient follow the advice they’ve been given? A new retrospective cohort study purports to look at what factors influence compliance with preoperative regimes aimed at preventing surgical site infection (SSI). The authors were of the opinion that socio-economic group would be a major factor in whether individuals would be compliant with measures that are likely to reduce the risk of SSI, since this has been demonstrated to be the case in chronic health issues such as asthma. Disappointingly the authors stated that the method of determining at adherence is described elsewhere with the accompanying reference to an 4-minute abstract given at a paediatric orthopaedic conference in Toronto in 2013 which, if you weren’t there, you’ve missed it. However they do provide a small amount of detail and of the 2-5 protocol tasks they only mention bathing and decolonisation of those screened.
So I’m really quite interested in seasonality of infections. I first became interested in it when looking at increases in E. coli bacteraemia for ARHAI (report here) because of Jennie Wilson’s excellent paper showing seasonality of gram negative bacteraemia, echoed by similar observations and conjecture on warmer weather, more infection. This is true in hospitals as well as the community. Why would this be? We have tussled with increasing E. coli bacteraemia in the UK for a few years now. Goes up every summer, does not return to the baseline, goes up again next summer etc., etc.. Other countries have also reported this. I have heard some suggest this is due to longer hours of daylight leading to more barbeques and more sexual activity. Given that the majority of infections in the UK are >70 years of age, my senior years have no fears for me then.