Intra-operative vancomycin: to randomize or not

Today we discussed a recent paper published by our orthopedic surgeons on using powdered vancomycin in the wounds of spinal surgery to prevent surgical site infections (SSI). Two years ago I already had a post on the topic. The powder is spread deep in the wounds, on the bone and metal, before fascia and skin are closed. Yet, none of the 3 guidelines addressing prevention of surgical site infections that appeared recently recommends this intervention; WHO (2016) didn’t even include the intervention, CDC (2017) said “don’t do it”, and NICE (2019) acknowledged that the procedure is widely used without strong supporting evidence and recommended: stop doing it and do a trial. Continue reading

An empty gut before surgery?

We Dutch, we love gut decontamination. Not only in critically ill patients, but also in those undergoing elective colorectal  surgery. A decontaminated gut is a safe gut, and that feeling was based on data from Dutch studies. A new study from Finland, published in Lancet, now questions whether our gut feeling was correct. Continue reading

What does good surgical wound closure look like?

I love and hate SSI prevention in equal measure. On the one hand, we have good evidence and strong guidelines around SSI prevention – but on the other hand, implementing these interventions to prevent SSI can be enormously tricky in practice. One key factor in preventing SSI is creating a well-closed wound in theatre. Surprisingly, there’s precious little data on how to measure what a well-closed surgical wound looks like. This qualitative study presents some potential indicators to measure good surgical wound closure in order to prevent SSI.

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Preventing S. aureus SSI: Who does what? (part 2)

A month ago I blogged on the practices of pre-operative (or better peri-operative) treatment of nasal S. aureus carriage to prevent S. aureus surgical site infection (SSI) in orthopaedic or cardiothoracic surgery patients. The issue brought forward was that a “treat-all” (thus “screen none”) strategy is more feasible, more effective and cheaper than the “screen & treat” strategy. The latter strategy, is associated with less mupirocin exposure and thus less selective pressure for mupirocin-resistance genes. There was a poll with 2 questions. What is your current practice for patients undergoing orthopaedic or cardiothoracic surgery and what do you think the strategy should be, with 3 options for each question; “do nothing”, “screen & treat”, or “treat all”. Today the results. Continue reading

Preventing S. aureus SSI: Who does what?

Pre-operative (or better peri-operative) treatment of nasal S. aureus carriage is one of the most – if not the most – effective infection prevention measure. A large double-blind randomized controlled trial convincingly confirmed the meta-analysis results of previously performed smaller studies: 5 days of nasal mupirocin ointment together with chlorhexidine showering reduced the incidence of deep-seated S. aureus surgicial site infection (SSI) with 80% among S. aureus carriers undergoing orthopaedic or cardiothoracic surgery. Eight years after publication of these findings I (and others) still have the feeling that many hospitals have not implemented this measure. Continue reading

SSIs – time to de-invest in laminar flow?

Laminar flow is a very embedded technology for the prevention of SSI in some types of surgery (especially hip and knee arthroplasty). However, it seems from a recent Lancet ID review that this widely adopted practice is way ahead of the evidence supporting it: the bottom line finding of the review is we should stop wasting time and money on laminar flow theatres for some procedures, and focus on basic prevention initiatives (especially getting antibiotic prophylaxis right) in all surgical categories.

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Agent Orange in spinal surgery

This week I learned from an orthopaedic surgeon that randomized trials were something that could be of use in “pharmaceutical sciences”, but that it is well-known that in the “surgical science” retrospective analyses are better for deriving evidence. We came to this when discussing the benefits of powdered vancomycin in the wounds of spinal surgery. Apparently this is something “all spinal orthopaedics do”, because it works so good. Continue reading