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Systematic Reviews Jan 2019Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and...
BACKGROUND
Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and microbiologists mainly recommend functional separation (i.e. aseptic procedures first) without calling for separate operating floors and rooms. However, patients with severe musculoskeletal infections (e.g. joint empyema, spondylodiscitis, deep implant-associated infections) may benefit from the permanent availability of septic operating capacities without delay caused by an ongoing aseptic surgical program. A systematic literature review on the influence of a structural separation of septic and aseptic operating theatres on process and/or outcome quality has not yet been conducted.
METHODS
Systematic literature search in PubMed MEDLINE, Ovid Embase, CINAHL and the Cochrane Library, screening of referenced citations, and assessment of grey literature.
RESULTS
A total of 572 articles were found through the systematic literature search. No head-to-head studies (neither randomised, quasi-randomised nor observational) were identified which examined the impact of structural separation of septic and aseptic operating theatres on process and/or outcome quality.
CONCLUSIONS
This review did not identify evidence in favour nor against architectural separation of septic or aseptic operating theatre. Specifically, there is no evidence of a harmful effect of architectural separation. Unless prospective studies, ideally randomised trials, will be available, it is unjustified to call for abolishing established hospital structures. Future investigations must address patient-centered endpoints, surgical site infections, process quality and hospital economy.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO (International prospective register of systematic reviews): CRD42018086568.
Topics: Asepsis; Cross Infection; Drug Resistance, Multiple; Equipment Contamination; Germany; Hospital Design and Construction; Humans; Infection Control; Operating Rooms; Outcome and Process Assessment, Health Care; Prosthesis-Related Infections; Quality Improvement; Time Factors; Wound Healing
PubMed: 30626433
DOI: 10.1186/s13643-018-0937-9 -
The Journal of Hospital Infection Apr 2019Presurgical hand washing is crucial for preventing surgical site infections (SSIs). Chlorhexidine gluconate (CHG) and povidone-iodine (PI) products have been... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Presurgical hand washing is crucial for preventing surgical site infections (SSIs). Chlorhexidine gluconate (CHG) and povidone-iodine (PI) products have been conventionally used as hand scrubs for presurgical hand preparation. However, waterless hand rub (WHR) products have been developed for operating room staff.
AIM
The aim of this study was to conduct a systematic review and meta-analysis to compare the antiseptic efficacies of WHR, CHG, and PI in surgical settings.
METHODS
PubMed, Embase, and Cochrane Library databases as well as the ClinicalTrials.gov registry were searched for studies published before October 2018. Randomized controlled trials (RCTs) comparing the clinical outcomes of the use of WHRs, CHG, or PI for presurgical hand washing were included. A random effects model was used for meta-analysis. Colony-forming unit (cfu) counts, SSI rates, and preference and compliance were determined to measure efficacies.
FINDINGS
Eleven RCTs involving 5135 participants were included. Residual cfu counts were significantly lower in the WHR and CHG groups than in the PI group. The differences in cfu counts between the WHR and CHG groups were non-significant. No significant differences were observed in the SSI rates between the WHR and traditional hand scrub groups. Moreover, WHRs were considered most favourable and were associated with higher compliance rates than the other products.
CONCLUSION
WHRs and CHG exhibited higher antiseptic efficacies than PI. However, additional studies with consistent outcome measurements and accurate grouping are required to obtain comprehensive results. Moreover, preference, compliance, and the cost determine the selection of hand wash products.
Topics: Anti-Infective Agents, Local; Chlorhexidine; Colony Count, Microbial; Hand Disinfection; Humans; Povidone-Iodine; Preoperative Care; Randomized Controlled Trials as Topic; Surgical Wound Infection; Treatment Outcome
PubMed: 30500384
DOI: 10.1016/j.jhin.2018.11.012 -
American Journal of Perinatology Jan 2019To compare chlorhexidine-alcohol with povidone-iodine solutions for skin antisepsis prior to cesarean delivery for the prevention of surgical site infection. (Comparative Study)
Comparative Study Meta-Analysis
OBJECTIVE
To compare chlorhexidine-alcohol with povidone-iodine solutions for skin antisepsis prior to cesarean delivery for the prevention of surgical site infection.
STUDY DESIGN
Electronic databases MEDLINE, Embase, Scopus, and Clinicaltrials.gov were searched from inception to August 2017. Eligible studies included randomized controlled trials comparing chlorhexidine-alcohol with povidone-iodine skin preparation solutions for women undergoing cesarean delivery. The primary outcome was surgical site infection including superficial or deep wound infection. Meta-analysis was performed, and risk ratios (RRs) with 95% confidence interval (CI) were calculated using the Mantel-Haenszel random effects model. Statistical heterogeneity was assessed using Higgin's .
RESULTS
Of 61 abstracts identified in the primary search, four studies (3,059 women) met the eligibility criteria. The risk of surgical site infection was significantly reduced with chlorhexidine-alcohol (RR: 0.72; 95% CI: 0.52-0.98). No heterogeneity across studies was observed with = 0%. Subgroup analysis of superficial infection only or deep infection only showed no statistically significant difference (RR: 0.76, 95% CI: 0.54-1.08; and RR: 0.50, 95% CI: 0.23-1.10, respectively).
CONCLUSION
Preoperative skin cleansing prior to cesarean delivery with chlorhexidine-alcohol reduces surgical site infection as compared with povidone-iodine solutions.
Topics: Administration, Cutaneous; Anti-Infective Agents, Local; Antisepsis; Cesarean Section; Chlorhexidine; Drug Combinations; Ethanol; Female; Humans; Povidone-Iodine; Pregnancy; Preoperative Care; Surgical Wound Infection
PubMed: 30184558
DOI: 10.1055/s-0038-1669907 -
Surgery Journal (New York, N.Y.) Jul 2016Effective preoperative antisepsis is recognized to prevent surgical site infection (SSI), although the definitive method is unclear. Many have compared chlorhexidine...
Effective preoperative antisepsis is recognized to prevent surgical site infection (SSI), although the definitive method is unclear. Many have compared chlorhexidine (CHG) with povidone-iodine (PVI), but there is emerging evidence for combination usage. To conduct a systematic review and meta-analysis to evaluate if combination skin preparation (1) reduces colonization at the operative site and (2) prevents SSI compared with single-agent use. A literature search of MEDLINE, Embase, and Cochrane Database of Clinical Trials was performed. Comparative, human trials considering the combination use of CHG and PVI, as preoperative antisepsis, to single-agent CHG or PVI use were included. Studies were excluded from meta-analysis if the use or absence of alcohol was inconsistent between study arms. The study was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcome for meta-analysis was surgical site infection. The secondary outcome was colonization at the operative site. Eighteen publications with a combination of CHG and PVI use were identified. Of these, 12/14 inferred promise for combination usage, including four trials eligible for meta-analysis. Only one trial reported SSI as its outcome. The remaining three considered bacterial colonization. Combination preparation had a pooled odds ratio for complete decolonization of 5.62 (95% confidence interval 3.2 to 9.7, < 0.00001). There was no evidence of heterogeneity (Cochran's Q 2.1, 2 , = 0.35). There is emerging, albeit low-quality, evidence in favor of combination CHG and PVI preoperative antisepsis. Further rigorous investigation is indicated.
PubMed: 28824994
DOI: 10.1055/s-0036-1587691 -
The Cochrane Database of Systematic... Jul 2017Platelet transfusions are used to prevent and treat bleeding in people who are thrombocytopenic. Despite improvements in donor screening and laboratory testing, a small... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Platelet transfusions are used to prevent and treat bleeding in people who are thrombocytopenic. Despite improvements in donor screening and laboratory testing, a small risk of viral, bacterial, or protozoal contamination of platelets remains. There is also an ongoing risk from newly emerging blood transfusion-transmitted infections for which laboratory tests may not be available at the time of initial outbreak.One solution to reduce the risk of blood transfusion-transmitted infections from platelet transfusion is photochemical pathogen reduction, in which pathogens are either inactivated or significantly depleted in number, thereby reducing the chance of transmission. This process might offer additional benefits, including platelet shelf-life extension, and negate the requirement for gamma-irradiation of platelets. Although current pathogen-reduction technologies have been proven to reduce pathogen load in platelet concentrates, a number of published clinical studies have raised concerns about the effectiveness of pathogen-reduced platelets for post-transfusion platelet count recovery and the prevention of bleeding when compared with standard platelets.This is an update of a Cochrane review first published in 2013.
OBJECTIVES
To assess the effectiveness of pathogen-reduced platelets for the prevention of bleeding in people of any age requiring platelet transfusions.
SEARCH METHODS
We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 9), MEDLINE (from 1946), Embase (from 1974), CINAHL (from 1937), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 24 October 2016.
SELECTION CRITERIA
We included RCTs comparing the transfusion of pathogen-reduced platelets with standard platelets, or comparing different types of pathogen-reduced platelets.
DATA COLLECTION AND ANALYSIS
We used the standard methodological procedures expected by Cochrane.
MAIN RESULTS
We identified five new trials in this update of the review. A total of 15 trials were eligible for inclusion in this review, 12 completed trials (2075 participants) and three ongoing trials. Ten of the 12 completed trials were included in the original review. We did not identify any RCTs comparing the transfusion of one type of pathogen-reduced platelets with another.Nine trials compared Intercept® pathogen-reduced platelets to standard platelets, two trials compared Mirasol® pathogen-reduced platelets to standard platelets; and one trial compared both pathogen-reduced platelets types to standard platelets. Three RCTs were randomised cross-over trials, and nine were parallel-group trials. Of the 2075 participants enrolled in the trials, 1981 participants received at least one platelet transfusion (1662 participants in Intercept® platelet trials and 319 in Mirasol® platelet trials).One trial included children requiring cardiac surgery (16 participants) or adults requiring a liver transplant (28 participants). All of the other participants were thrombocytopenic individuals who had a haematological or oncological diagnosis. Eight trials included only adults.Four of the included studies were at low risk of bias in every domain, while the remaining eight included studies had some threats to validity.Overall, the quality of the evidence was low to high across different outcomes according to GRADE methodology.We are very uncertain as to whether pathogen-reduced platelets increase the risk of any bleeding (World Health Organization (WHO) Grade 1 to 4) (5 trials, 1085 participants; fixed-effect risk ratio (RR) 1.09, 95% confidence interval (CI) 1.02 to 1.15; I = 59%, random-effect RR 1.14, 95% CI 0.93 to 1.38; I = 59%; low-quality evidence).There was no evidence of a difference between pathogen-reduced platelets and standard platelets in the incidence of clinically significant bleeding complications (WHO Grade 2 or higher) (5 trials, 1392 participants; RR 1.10, 95% CI 0.97 to 1.25; I = 0%; moderate-quality evidence), and there is probably no difference in the risk of developing severe bleeding (WHO Grade 3 or higher) (6 trials, 1495 participants; RR 1.24, 95% CI 0.76 to 2.02; I = 32%; moderate-quality evidence).There is probably no difference between pathogen-reduced platelets and standard platelets in the incidence of all-cause mortality at 4 to 12 weeks (6 trials, 1509 participants; RR 0.81, 95% CI 0.50 to 1.29; I = 26%; moderate-quality evidence).There is probably no difference between pathogen-reduced platelets and standard platelets in the incidence of serious adverse events (7 trials, 1340 participants; RR 1.09, 95% CI 0.88 to 1.35; I = 0%; moderate-quality evidence). However, no bacterial transfusion-transmitted infections occurred in the six trials that reported this outcome.Participants who received pathogen-reduced platelet transfusions had an increased risk of developing platelet refractoriness (7 trials, 1525 participants; RR 2.94, 95% CI 2.08 to 4.16; I = 0%; high-quality evidence), though the definition of platelet refractoriness differed between trials.Participants who received pathogen-reduced platelet transfusions required more platelet transfusions (6 trials, 1509 participants; mean difference (MD) 1.23, 95% CI 0.86 to 1.61; I = 27%; high-quality evidence), and there was probably a shorter time interval between transfusions (6 trials, 1489 participants; MD -0.42, 95% CI -0.53 to -0.32; I = 29%; moderate-quality evidence). Participants who received pathogen-reduced platelet transfusions had a lower 24-hour corrected-count increment (7 trials, 1681 participants; MD -3.02, 95% CI -3.57 to -2.48; I = 15%; high-quality evidence).None of the studies reported quality of life.We did not evaluate any economic outcomes.There was evidence of subgroup differences in multiple transfusion trials between the two pathogen-reduced platelet technologies assessed in this review (Intercept® and Mirasol®) for all-cause mortality and the interval between platelet transfusions (favouring Intercept®).
AUTHORS' CONCLUSIONS
Findings from this review were based on 12 trials, and of the 1981 participants who received a platelet transfusion only 44 did not have a haematological or oncological diagnosis.In people with haematological or oncological disorders who are thrombocytopenic due to their disease or its treatment, we found high-quality evidence that pathogen-reduced platelet transfusions increase the risk of platelet refractoriness and the platelet transfusion requirement. We found moderate-quality evidence that pathogen-reduced platelet transfusions do not affect all-cause mortality, the risk of clinically significant or severe bleeding, or the risk of a serious adverse event. There was insufficient evidence for people with other diagnoses.All three ongoing trials are in adults (planned recruitment 1375 participants) with a haematological or oncological diagnosis.
Topics: Adult; Antisepsis; Blood Platelets; Child; Disease Transmission, Infectious; Furocoumarins; Hemorrhage; Humans; Photosensitizing Agents; Platelet Transfusion; Randomized Controlled Trials as Topic; Riboflavin; Thrombocytopenia; Ultraviolet Rays
PubMed: 28756627
DOI: 10.1002/14651858.CD009072.pub3 -
Platelets Jan 2018The infection of a wound is one of the major contributors to delays in healing and tissue regeneration. As multi-drug resistance to antibiotics is becoming a serious... (Meta-Analysis)
Meta-Analysis Review
The infection of a wound is one of the major contributors to delays in healing and tissue regeneration. As multi-drug resistance to antibiotics is becoming a serious threat, research in this field has focused on finding new agents and strategies to fight infection and additionally to reduce healing times. The topical use of autologous Platelet Rich Plasma (PRP) as a biological accelerator of the healing process, has been safely used as a form of treatment for wounds since the 1990s. Although the presence or absence of leucocytes in PRP preparation was previously neglected, in the last decade more attention has been paid to their role and several studies have been conducted to explore both their immuno-metabolic effects and their antimicrobial properties. In this review, we aim to summarise the literature on the contribution of leucocytes included in PRP preparations in terms of their antimicrobial properties. This should help to inform clinical practice and additional research in this promising field.
Topics: Anti-Infective Agents; Antisepsis; Bacterial Infections; Biomarkers; Blood Platelets; Humans; Leukocytes; Platelet Activation; Platelet-Rich Plasma; Treatment Outcome
PubMed: 28681651
DOI: 10.1080/09537104.2017.1317731 -
Surgical Infections Apr 2017The purpose of the study was to identify patient-specific and procedure-specific risk and protective factors associated with post-operative surgical site infections... (Review)
Review
BACKGROUND
The purpose of the study was to identify patient-specific and procedure-specific risk and protective factors associated with post-operative surgical site infections (SSIs) among surgical spine patients.
METHODS
CINAHL, PubMed, Ovid, Medline, and EBSCO databases were searched for articles within the past 10 years (January 2003-March 2015). The keywords and combinations used in the search included: Spine surgery, post-operative infection, risk factors, orthopedic infections. The search resulted in 842 articles of which 29 met inclusion criteria. This systematic review adheres to preferred reporting items for systematic reviews and meta-analyses guidelines.
RESULTS
Evidence about patient-specific and procedure-specific factors associated with increased risk of post-operative SSIs among patients undergoing orthopedic spinal surgery is inconclusive. Gender (male), age, body mass index, cigarette smoking, diabetes mellitus, a history of infection and alcohol abuse were identified as common patient-specific risk factors. Blood transfusion, implantation, and steroid use were found to increase SSIs in certain studies and associated with no significant difference in other studies. Protective factors include the implementation of pre-operative elements to reduce infection; protocols addressing patient-related factors (smoking, weight, glucose) and operation-related factors (antibiotic prophylaxis, prosthetics, length of operation, and pre-operative cultures); incision drains placed intra-operatively; anterior approach; laminar-flow operating theater, and skin antisepsis using chlorhexidine.
CONCLUSIONS
Interventions focusing on minimizing patient-specific risk factors and operation-specific risk factors and optimizing patient-specific protective factors and operation-specific protective factors are most effective in minimizing the likelihood of a post-operative infection among patients undergoing orthopedic spinal surgical procedures. The studies reviewed provide conflicting evidence relative to risk and protective factors.
Topics: Humans; Protective Factors; Risk Factors; Spinal Diseases; Spinal Injuries; Surgical Wound Infection
PubMed: 28394747
DOI: 10.1089/sur.2016.183 -
Obstetrics and Gynecology May 2017To create evidence-based clinical practice guidelines based on a systematic review of published literature regarding the risks and benefits of available preoperative,... (Review)
Review
OBJECTIVE
To create evidence-based clinical practice guidelines based on a systematic review of published literature regarding the risks and benefits of available preoperative, intraoperative, and postoperative technical steps and interventions at the time of vaginal hysterectomy for benign indications.
DATA SOURCES
We systematically searched the literature to identify studies that compared technical steps or interventions during the preoperative, intraoperative, and postoperative periods surrounding vaginal hysterectomy. We searched MEDLINE, Cochrane Central Register of Controlled Trials, Health Technology Assessments, and ClinicalTrials.gov from their inception until April 10, 2016, using the MeSH term "Hysterectomy, Vaginal" and associated text words. We included comparative studies, single-group studies, and systematic reviews published in English.
METHODS OF STUDY SELECTION
We double-screened 4,250 abstracts, identifying 60 eligible studies. Discrepancies were adjudicated by a third reviewer. We followed standard systematic review methodology and the Grades for Recommendation, Assessment, Development and Evaluation approach to evaluate the evidence and generate guideline recommendations.
TABULATION, INTEGRATION, AND RESULTS
Because of limited literature, only 16 perioperative risks, technical steps, and interventions were identified: obesity, large uteri, prior surgery, gonadotropin-releasing hormone agonists, vaginal antisepsis, bilateral salpingo-oophorectomy, morcellation, apical closure, uterine sealers, hemostatic injectants, hot cone, retractor, cystoscopy, vaginal packing, bladder management, and accustimulation. We organized and reported these as four domains: patient selection, preoperative, intraoperative, and postoperative. We did not identify any patient characteristics precluding a vaginal approach; chlorhexidine or povidone is appropriate for vaginal antisepsis; vasopressin decreases blood loss by 130 cc; tissue-sealing devices decrease blood loss by 44 cc and operative time by 15 minutes with uncertain complication implications; vertical cuff closure results in 1-cm increased vaginal length; either peritoneum or epithelium can be used for colpotomy closure; and routine vaginal packing is not advised.
CONCLUSION
Minimal data exist to guide surgeons with respect to planning and performing a vaginal hysterectomy. This study identifies available information and future areas for investigation.
Topics: Female; Humans; Hysterectomy, Vaginal; Outcome Assessment, Health Care; Postoperative Complications; Randomized Controlled Trials as Topic; Uterine Diseases; Women's Health
PubMed: 28383375
DOI: 10.1097/AOG.0000000000001995 -
International Journal of Surgery... Mar 2017This meta-analysis aims to assess the incidences of surgical site infection of patients who applied preadmission chlorhexidine skin preparation, versus those who applied... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This meta-analysis aims to assess the incidences of surgical site infection of patients who applied preadmission chlorhexidine skin preparation, versus those who applied the traditional skin preparation before undergoing total knee and hip arthroplasty.
METHODS
A systematic search is carried out through Medline (1966-2016.11), PubMed (1966-2016.11), Embase (1980-2016.11), ScienceDirect (1985-2016.11) and the Cochrane Library. Only high quality studies are identified. Meta-analysis is conducted with the use of Stata 11.0 software.
RESULTS
One RCT and five retrospective studies, published between 2010 and 2016, are included in the present meta-analysis. The present meta-analysis indicates that there are significant differences in surgical site infection rate (RD = -0.02, 95% CI: -0.02 to -0.01, P < 0.00001), revision surgery rate (RD = -0.01, 95% CI: -0.01 to -0.01, P < 0.00001) and length of stay (MD = -0.29, 95% CI: -0.48 to -0.11, P = 0.002) between groups.
CONCLUSION
Preoperative chlorhexidine skin preparation appears to reduce the risk of infection, the incidence of revision surgery, and the length of stay for patients undergoing total knee and hip arthroplasty. No adverse effects, such as DVT or PE, appear to be related to chlorhexidine preparation. Due to the limited quality of the evidence currently available, high quality RCTs with better study designs, larger sample sizes and longer follow-ups are needed.
Topics: Anti-Infective Agents, Local; Antisepsis; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Chlorhexidine; Cross Infection; Humans; Incidence; Preoperative Care; Reoperation; Retrospective Studies; Surgical Wound Infection
PubMed: 28189811
DOI: 10.1016/j.ijsu.2017.02.004 -
The Journal of Hospital Infection Mar 2017Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Antiseptic cleaning of the meatal area before and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Antiseptic cleaning of the meatal area before and during catheter use may reduce the risk of CAUTIs.
AIM
To undertake a systematic review of the literature and meta-analysis of studies investigating the effectiveness of antiseptic cleaning before urinary catheter insertion and during catheter use for prevention of CAUTIs.
METHODS
Electronic databases were searched to identify randomized controlled trials. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated and compared across intervention and control groups using DerSimonian-Laird random-effects model. Subgroup analyses were performed. Heterogeneity was estimated using the I statistic.
FINDINGS
In total, 2665 potential papers were identified; of these, 14 studies were eligible for inclusion. There was no difference in the incidence of CAUTIs when comparing antiseptic and non-antiseptic agents (pooled OR 0.90, 95% CI 0.73-1.10; P=0.31), or when comparing different agents: povidone-iodine vs routine care; povidone-iodine vs soap and water; chlorhexidine vs water; povidone-iodine vs saline; povidone-iodine vs water; and green soap and water vs routine care (P>0.05 for all). Comparison of an antibacterial agent with routine care indicated near significance (P=0.06). There was no evidence of heterogeneity (I=0%; P>0.05). Subgroup analyses showed no difference in the incidence of CAUTIs in terms of country, setting, risk of bias, sex and frequency of administration.
CONCLUSIONS
There were no differences in CAUTI rates, although methodological issues hamper generalizability of this finding. Antibacterial agents may prove to be significant in a well-conducted study. The present results provide good evidence to inform infection control guidelines in catheter management.
Topics: Anti-Infective Agents, Local; Antisepsis; Catheter-Related Infections; Catheterization; Humans; Randomized Controlled Trials as Topic; Treatment Outcome; Urinary Tract Infections
PubMed: 27986361
DOI: 10.1016/j.jhin.2016.10.025