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Multicenter Study
. 2023 Apr 1;109(4):737-751.
doi: 10.1097/JS9.0000000000000277.

Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study

Josep M Badia  1   2 , Nares Arroyo-Garcia  1   2 , Ana Vázquez  3 , Alexander Almendral  4 , Aina Gomila-Grange  5 , Domenico Fraccalvieri  6 , David Parés  7   8 , Ana Abad-Torrent  9 , Marta Pascual  10 , Alejandro Solís-Peña  11 , Mireia Puig-Asensio  12   13 , Miguel Pera  10 , Francesc Gudiol  4 , Enric Limón  4   14 , Miquel Pujol  4   13   15   16 ; Members of the VINCat Colorectal Surveillance Team; VINCat Program*
Affiliations
Multicenter Study

Leveraging a nationwide infection surveillance program to implement a colorectal surgical site infection reduction bundle: a pragmatic, prospective, and multicenter cohort study

Josep M Badia et al. Int J Surg. .

Abstract

Background: Bundled interventions usually reduce surgical site infection (SSI) when implemented at single hospitals, but the feasibility of their implementation at the nationwide level and their clinical results are not well established.

Materials and methods: Pragmatic interventional study to analyze the implementation and outcomes of a colorectal surgery care bundle within a nationwide quality improvement program. The bundle consisted of antibiotic prophylaxis, oral antibiotic prophylaxis (OAP), mechanical bowel preparation, laparoscopy, normothermia, and a wound retractor. Control group (CG) and Intervention group (IG) were compared. Overall SSI, superficial (S-SSI), deep (D-SSI), and organ/space (O/S-SSI) rates were analyzed. Secondary endpoints included microbiology, 30-day mortality, and length of hospital stay.

Results: A total of 37 849 procedures were included, 19 655 in the CG and 18 194 in the IG. In all, 5462 SSIs (14.43%) were detected: 1767 S-SSI (4.67%), 847 D-SSI (2.24%), and 2838 O/S-SSI (7.5%). Overall SSI fell from 18.38% (CG) to 10.17% (IG), odds ratio (OR) of 0.503 [0.473-0.524]. O/S-SSI rates were 9.15% (CG) and 5.72% (IG), OR of 0.602 [0.556-0.652]. The overall SSI rate was 16.71% when no measure was applied and 6.23% when all six were used. Bundle implementation reduced the probability of overall SSI (OR: 0.331; CI 95 : 0.242-0.453), and also O/S-SSI rate (OR: 0.643; CI 95 : 0.416-0.919). In the univariate analysis, all measures except normothermia were associated with a reduction in overall SSI, while only laparoscopy, OAP, and mechanical bowel preparation were related to a decrease in O/S-SSI. Laparoscopy, wound retractor, and OAP decreased overall SSI and O/S-SSI in the multivariate analysis.

Conclusions: In this cohort study, the application of a specific care bundle within a nationwide nosocomial infection surveillance system proved feasible and resulted in a significant reduction in overall and O/S-SSI rates in the elective colon and rectal surgery. The OR for SSI fell between 1.5 and 3 times after the implementation of the bundle.

Trial registration: ClinicalTrials.gov NCT04129177.

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Conflict of interest statement

The authors declare no conflict of interest. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Figures

None
Graphical abstract
Figure 1
Figure 1
Aggregate colorectal SSI, and superficial, deep, and organ/space-SSI rates during the period of the study (2011–2020). SSI, surgical site infection.
Figure 2
Figure 2
Aggregate colorectal surgical site infection rates according to hospital size.
Figure 3
Figure 3
Colorectal SSI rates according to compliance with the elements included in the bundle. SSI, surgical site infection.
Figure 4
Figure 4
Relationship between the implementation of the elements of the bundle throughout the entire study period (covering the Control Group and the Intervention Group) and the evolution of the overall SSI rates. The most marked decrease in SSI occurred in 2016, the first year of the dissemination of the bundle. SSI, surgical site infection.
Figure 5
Figure 5
Relationship between compliance with the elements of the bundle and the evolution of overall SSI rates in the Intervention Group period (2016–2020). The information collected on compliance in 2020 may have been affected by the coronavirus disease 2019 pandemic. SSI, surgical site infection.
Figure 6
Figure 6
Multivariate analysis of the effect of the measures of the bundle on overall surgical site infection rates.
Figure 7
Figure 7
Multivariate analysis of the effect of the measures of the bundle on organ/space-surgical site infection rates.
See this image and copyright information in PMC

References

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