Comparison of two bundles for reducing surgical site infection in colorectal surgery: multicentre cohort study
Authors: Flores-Yelamos Miriam , Gomila-Grange Aina , Badia Josep M , Almendral Alexander , Vázquez Ana , Parés David , Pascual Marta , Limón Enric , Pujol Miquel , Juvany Montserrat ,   members of the VINCat Colorectal Surveillance Team, Fraccalvieri Domenico , Abad-Torrent Ana , Solís-Peña Alejandro , Puig-Asensio Mireia , López Lucrecia , Piriz Marta , Hernández Mercè , Castellana Dolors , González Elisa Montiu , Pardo Graciano García , Villaró Francesc Feliu , Fatsini Josep Rebull , Spaneda Marie France Domènech , Galí Marta Conde , Pérez-Hita Anna Oller , Martín Lydia , Lerida Ana , Biondo Sebastiano , Martínez Emilio Jiménez , Galindo Nieves Sopena , Ausàs Ignasi Camps , Ferrer Carmen , Salas Luis , Vidal Rafael Pérez , Rubio Dolors Mas , de la Red Irene García , Castillo Mª Angels Iruela , Gil Eva Palau i , Martínez José Antonio , Navarro M Blanca Torralbo , López Maria , Porta Carol , Amat Alex Smithson , Escudero Guillen Vidal , de la Fuente Redondo José Carlos , Espés Montse Rovira , Fidalgo Arantxa Mera , Almazán Luis Escudero , Raya Monserrat Ortega , Moya Mª Carmen Álvarez , Diaz-Brito Vicens , Palafox Laura Grau , Gómez Yésika Angulo , Codina Anna Besolí , Ricard Carme Autet , López Carlota Hidalgo , Lerma-Chippirraz Elisabeth , López Demelza Maldonado , Blancas David , Rubio Esther Moreno , Aguilera Roser Ferrer i , Iftimie Simona , Castro-Salomó Antoni , Enguídanos Rosa Laplace , Serra Maria Carmen Sabidó , Ros Núria Bosch , Solchaga Virginia Pomar , Garcia Laura Lázaro , Ribas Angeles Boleko , Luque Jordi Palacín , Moise Alexandra Lucía , Palomares Mª Carmen Fernández , Sopeña Santiago Barba , Huertas Eduardo Sáez , Estada Sara Burges , Leris Josep María Tricas , Ruiz Eva Redon , Brugués Montse , Aced Susana Otero , Esteve Maria Cuscó , Vargas-Machuca Francisco José , de Gracia García Ramírez Mª , Bellés Ana Maria Ciscar , Díez Elena Vidal , Morón Mariló Marimón , Sáez Marisol Martínez , Farguell Josep , Saballs Mireia , Franco Montserrat Vaqué , Garcia Leonor Invernón , Enguídanos Rosa Laplace , Marrugat Meritxell Guillemat , Conde Ana Coloma 
Published: August 2024

Abstract

Background
There is controversy regarding the maximum number of elements that can be included in a surgical site infection prevention bundle. In addition, it is unclear whether a bundle of this type can be implemented at a multicentre level.

Methods
A pragmatic, multicentre cohort study was designed to analyse surgical site infection rates in elective colorectal surgery after the sequential implementation of two preventive bundle protocols. Secondary outcomes were to determine compliance with individual measures and to establish their effectiveness, duration of stay, microbiology and 30-day mortality rate.

Results
A total of 32 205 patients were included. A 50% reduction in surgical site infection was achieved after the implementation of two sequential sets of bundles: from 18.16% in the Baseline group to 10.03% with Bundle-1 and 8.19% with Bundle-2. Bundle-2 reduced superficial-surgical site infection (OR 0.74 (95% c.i. 0.58 to 0.95); P = 0.018) and deep-surgical site infection (OR 0.66 (95% c.i. 0.46 to 0.93); P = 0.018) but not organ/space-surgical site infection (OR 0.88 (95% c.i. 0.74 to 1.06); P = 0.172). Compliance increased after the addition of four measures to Bundle-2. In the multivariable analysis, for organ/space-surgical site infection, laparoscopy, oral antibiotic prophylaxis and mechanical bowel preparation were protective factors in colonic procedures, while no protective factors were found in rectal surgery. Duration of stay fell significantly over time, from 7 in the Baseline group to 6 and 5 days for Bundle-1 and Bundle-2 respectively (P &lt; 0.001). The mortality rate fell from 1.4% in the Baseline group to 0.59% and 0.6% for Bundle-1 and Bundle-2 respectively (P &lt; 0.001). There was an increase in Gram-positive bacteria and yeast isolation, and reduction in Gram-negative bacteria and anaerobes in organ/space-surgical site infection.

Conclusions
The addition of measures to create a final 10-measure protocol had a cumulative protective effect on reducing surgical site infection. However, organ/space-surgical site infection did not benefit from the addition. No protective measures were found for organ/space-surgical site infection in rectal surgery. Compliance with preventive measures increased from Bundle-1 to Bundle-2.