_______________________________________________________________ Healthcare-Associated Infections
Trunk and Extremities (away from axilla or perineum) Oxacillin, nafcillin, cefazolin, cephalexin, SMX-TMP, vancomycin Axilla or Perineum Metronidazole/ciprofloxacin, levofloxacin, ceftriaxone For surgical site infections after implantation of a joint pros- thesis, the approach depends on the duration of infection, stability of the implant, antimicrobial susceptibility of the pathogen, and condition of the surrounding soft tissue [183]. In this setting, rifampin has shown excellent activity against adherent staphylococci and may be useful in combination with beta-lactams, glycopeptides, fluoroquinolones, minocycline, trimethoprim, or fusidic acid [184]. Guideline Adherence and Quality Improvement The effect of prevention strategies—primarily the appropriate use of prophylactic antibiotics—on the rate of surgical site infec- tion has been evaluated in several studies, and the results have been conflicting. For example, 56% adherence to this measure significantly reduced the incidence of surgical site infections in one study of patients who had colorectal surgery, with the rate decreasing from 22% to 3.5% [185]. There was no significant difference in the rate of surgical site infection between com- pliant and noncompliant prophylactic antibiotics [185]. In a retrospective review of 605 patients who had colorectal surgery with intestinal anastomosis showed that early administration of antibiotic prophylaxis and a nonstandard antibiotic were significantly associated with a greater risk of surgical site infec- tion [186]. However, the timely administration of prophylactic antibiotics did not improve the rate of surgical site infections among nearly 9,200 elective major surgeries (all types); the rate was 5% for patients who received timely antibiotics compared with 6% for patients who received antibiotic prophylaxis out- side of the recommended time [53]. Other studies have analyzed adherence to the Surgical Care Improvement Project (SCIP) quality measures, with analysis of individual measures as well as groups of measures. Some studies have indicated that an increase in compliance with SCIP measures leads to a decrease in the rate of surgical site infection; the rate decreased from nearly 26% to 16% in one study and in another study, increasing compliance with SCIP measures from 38% to 92% led to a decrease in the rate of superficial surgical site infections from 13% to 8% [52; 187]. Among patients who had laparotomy related to trauma (gunshot wound, stab wound, or blunt trauma), adherence to SCIP measures related to antibiotic prophylaxis resulted in a significantly lower rate of surgical site infection (17% vs 33%) as well as a shorter hospital stay (14 vs 19 days), even after controlling for several factors [188]. However, these data have not been consistent. In a study of nearly 500 patients who had colorectal surgery, compliance with all SCIP measures improved—from 40% to 68%—but
the rate of surgical site infections remained essentially the same (approximately 19%) [54]. In addition, a retrospective review of 60,853 surgeries done over a five-year period at 112 Veterans Administration (VA) hospitals showed that improving adherence to five SCIP measures did not significantly lower the odds of surgical site infection [172]. Many have been critical of the SCIP strategy, noting that the evidence has not indicated that adherence to these quality measures alone has had an effect on reducing the overall risk of surgical site infection [189]. The quality measures do not factor in the skill of the surgeon, and other factors, such as state-of-the-art skin antisepsis and innovative antimicrobial technology, should be included in quality improvement pro- grams [189; 190]. Ways to help increase adherence to effective prevention strate- gies are the use of computerized standard orders for antibiotics, reminders and checklists, and auditing of the rates for indi- vidual physicians, with feedback [31]. A study demonstrated that point-of-care prompts increased compliance with timely antibiotic prophylaxis from 62% to 92%, with a correspond- ing decrease in the incidence of surgical site infections, from 1.1% to 0.7% [191]. In an extensive systematic review, there was moderate strength of evidence for the use of audit and feedback, with or without provider reminder systems, for improving adherence to appropriate timing of prophylactic antibiotics [1]. The IHI how-to guide for the prevention of surgical site infection outlines practical steps to help healthcare professionals ensure that prevention strategies are carried out Pneumonia associated with healthcare facilities is classified in three categories: hospital-acquired, ventilator-associated, and healthcare-associated. Hospital-acquired pneumonia refers specifically to pneumonia that develops 48 hours after hospital admission (usually occurring postoperatively), and ventilator-associated pneumonia refers to pneumonia that develops 48 to 72 hours after tracheal intubation [193]. Healthcare-associated pneumonia develops in individuals in healthcare facilities outside hospitals, such as long-term care facilities and outpatient settings. ( Table 11 ) [192]. PNEUMONIA Hospital-acquired pneumonia, also referred to as post- procedure pneumonia, is not included in most discussions of HAIs because it represents less than 1% of all such infections; although this type of pneumonia is not reportable to NHSN, 23 cases were reported in 2009–2010 [81]. Still, hospital- acquired pneumonia can increase the length of stay by more than 1 week and is associated with increased mortality and financial cost [194]. The rate of ventilator-associated pneumonia is higher than that for hospital-acquired pneumonia, with a reported rate of 1 to 4 cases per 1,000 ventilator-days, and rates as high as 10 cases per 1,000 in some neonatal and surgical populations [20; 195].
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