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1 s2.0 S0196655306000083 Main
1 s2.0 S0196655306000083 Main
Background: In many hospitals, infection of the surgical wound is the most common nosocomial infection. Its presence implies
patient morbidity, a mortality risk, and an increase in procedure costs because of prolonged hospitalization.
Objectives: Our objective was to ascertain the effect of an infection control program, using performance feedback, on wound
infection (WI) rate in abdominal hysterectomy.
Methods: All patients undergoing abdominal hysterectomy in our center (Hospital A. Marcide, Ferrol, Spain) between 1999 and 2004
were prospectively followed up to determine the WI rate. A complete set of parameters, including age, underlying illnesses, cancer,
diabetes mellitus, immunosuppressive therapy, albumin, American Society of Anesthesiologists preoperative assessment score
(ASA) risk, days in hospital presurgery, date of surgery, hygiene and perioperative antimicrobial prophylaxis, type of surgical operation, duration of surgery, surgeon, and WI, were collected in each case. After data collection for 1999 concluded, we communicated
surgical WI rates to surgeons every year. A logistic regression analysis was performed to compare WI rates with those observed in 1999.
Results: A total of 980 females was enrolled in the prospective surveillance: mean age, 50.7 6 10.7 years. Cases included 25.8%
cancer, 4.9% diabetes, 0.5% immunosuppressive therapy, 26.6% ASA 1, 58.4% ASA 2, 13.9% ASA 3. In 9 patients, emergency surgery was performed and, in 971 patients, surgery was scheduled: Total abdominal hysterectomy, 878; subtotal abdominal hysterectomy, 65; Wertheim-Meigs, 37. The factors associated with WI were albumin (OR, 0.97; 95% CI: 0.94-0.99) and antimicrobial
prophylaxis (OR, 0.08; 95% CI: 0.02-0.32). The mean values for albumin and the number of patients with antimicrobial prophylaxis fluctuated from year to year. The WI rate improved from 10.7% (95% CI: 5.8-15.6) in 1999 to 6% (243.9%) in 2004.
Conclusion: Performance feedback of surgical wound infection rates to individual surgeons reduces these rates. (Am J Infect
Control 2006;34:182-7.)
182
METHODS
A prospective study of the surgical wound infection
rate (WI) in all patients undergoing abdominal hysterectomy in our hospital (Hospital A. Marcide, Ferrol,
Spain) between the years 1999 and 2004 was
Rodrguez et al
May 2006
183
RESULTS
A total of 980 females was enrolled in the prospective surveillance. The average age was 50.7 6 10.7
years (range, 21-90 years) and varied between 48.6 6
9.3 years in the year 2000 and 52.7 6 11.2 years in
the year 2001 and was lower in patients with WI,
48.1 6 9 years, compared with 50.9 6 10.8 years in
patients with no WI (P , .05).
Two hundred fifty-three (25.8%) patients were
cancer cases: 534 (54.5%) were myoma cases, 113
184
Rodrguez et al
Vol. 34 No. 4
1999
2000
2001
2002
2003
2004
Total
1
26
7
12
4
9
12
20
8
21
0
13
10
0
0
0
0
15
8
13
16
4
11
6
10
16
26
8
8
11
0
0
0
0
17
12
3
11
4
14
8
10
6
28
2
17
15
7
0
8
0
19
8
8
0
1
5
10
11
0
26
8
6
9
32
9
21
0
0
5
5
0
5
7
7
17
0
20
4
7
18
22
24
29
13
3
2
6
0
5
5
0
3
0
28
9
3
12
19
18
6
23
55
61
42
39
23
51
43
71
30
149
31
54
75
80
51
64
36
14 (25.5)
29 (47.5)
5 (11.9)
10 (25.6)
13 (56.5)
8 (15.7)
15 (34.9)
39 (54.9)
4 (13.3)
84 (56.4)
7 (22.6)
9 (16.7)
13 (17.3)
15 (18.8)
7 (13.7)
15 (23.4)
7 (19.4)
Wound infection,y
n (%)
2
3
3
6
1
2
4
6
5
9
8
3
4
6
6
4
3
(3.6)
(4.9)
(7.1)
(15.4)
(4.3)
(3.9)
(9.3)
(8.5)
(16.7)
(6)
(25.6)
(5.6)
(5.3)
(7.5)
(11.8)
(6.3)
(8.3)
Surgical operations by year, patients with antimicrobial prophylaxis, and number of surgical wound infections.
P , .001.
ovarian cyst removal in 1 [1.5%]); and a WertheimMeigs operation in 37 (4.2%). The frequency of total
hysterectomy fluctuated between 83.3% in 1999 and
94.4% in 2001, and the frequency of subtotal hysterectomy varied between 11.1% in 2000 and 3.5% in 2002
(P , .05). There were no differences between the types
of surgical operation in the WI rates.
The mean duration of surgery was 79.9 6 29.2 minutes for total abdominal hysterectomy and ranged between 85.4 6 33.1 minutes in 1999 and 74.5 6 22.2
in 2003; it was 82.5 6 27.9 minutes for subtotal hysterectomy, ranging from 65.8 6 8 minutes in 2001 to 95.8 6
47.2 minutes in 2002; for the Wertheim-Meigs operation, it was 183.2 6 25.1 minutes and varied between
206.7 6 30.5 minutes in 2001 and 162 6 2.7 minutes
in 2002. There were no significant differences in the
duration of surgery between patients with and without
WI. The duration was greater in patients with perioperative antimicrobial prophylaxis: 102.4 6 45.5 versus
75.8 6 25.3 minutes, respectively (P , .001).
We placed closed drainage in 114 (11.6%) patients
and open drainage in 4 (0.4%). The use of drainage
was more frequent in prolonged surgery (132.2 6
50.8 vs 77.4 6 26.1 minutes, respectively) but was
not associated with any increase in the rate of infection. The number of patients who received antimicrobial prophylaxis was higher among those who had
drainage than among those who did not (80.5% vs
23.7%, respectively).
The number of surgical procedures performed each
year by the surgeons, the characteristics of patients operated, the number of patients receiving perioperative
antimicrobial prophylaxis, and the WI rates by surgeon
Rodrguez et al
May 2006
185
DISCUSSION
Our study, adjusted for the variables that were analyzed, shows that the surveillance and control program
of infection of the surgical wound in abdominal hysterectomies, along with periodic communication of the
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Vol. 34 No. 4
Rodrguez et al
but the number of patients receiving antibiotic prophylaxis in the latter years of the study was not significantly greater than the first year; therefore, we
consider that, apart from slight fluctuations in the intervening years, antibiotic prophylaxis is unlikely to
have contributed to the drop in the infection rate
over this period. We assume that the lower incidence
of infection in 2001 was a result of the administration
of antiobiotic prophylaxis to a greater number of
patients, even when there was no indication for this
according to the services protocol. This in turn may
have been due to an attempt to lower the infection
rate on the part of surgeons after the initial results
had been made known. The upturn in the rate in
2002 may be due to a reverse effect: that of not administering prophylaxis in a larger number of patients in
whom it was indicated, in an attempt to correct the
irregularities in the prophylaxis regime detected the
previous year and made known to the surgeons at
the beginning of that year.
Although there are some randomized, prospective,
double-blind studies whose results support the administration of antibiotic prophylaxis in all abdominal hysterectomy cases,16 something also reflected in the latest
guidelines,17,18 it is not routine practice.7,15 The number
of patients who received prophylaxis varied between
the different surgeons, which undoubtedly contributed
to the differences in the incidence of infection.11
The results revealed that only 2.3% of patients who
received antibiotic prophylaxis suffered an infection,
in spite of having more risk factors, compared with a
10.1% infection rate in those who did not receive it.
For this reason, we decided to apply it to all patients
from the first of January 2005. The practice seems
cost-effective, given that the price of 2 g cefazolin is
1.5 euros because patients suffering an infection extended their hospital stay by some 4 days, increasing
the cost of the procedure considerably.19 The potential
reduction in the infection rate and in the number of
postoperative days hospitalization more than offsets
the cost of prophylaxis, and we do not think that this
widespread application of the measure can have any
significant effect on the development of microbial antibiotic resistance because this is clean-contaminated
surgery, with no great microbial load, and the number
of patients is small.
The incidence of surgical wound infection in our patients is within the values reported in other studies, but
the criteria of wound infection used, the characteristics
of the patients operated on, and the percentage of those
who received antibiotic prophylaxis was different.7,8,20
It is possible that our results may not be able to be universally extrapolated. Every center has to be aware of
its own circumstances and develop an appropriate surveillance and control program. However, other studies
Rodrguez et al
May 2006
187