A Successful Multipronged Approach to Reducing Infectious Complications to Zero Following Colon Surgery

Lael King; Nancy Robinson; Nancy Khardori

For 3 years (2015-2017) our level one trauma, teaching hospital with a bed capacity of 525 experienced less than optimal outcomes for colon surgical procedures. Since 2015 the report from the National Healthcare Safety Network for our institution showed us in the lowest 25^th percentile amongst similar acuity hospitals. The standardized infection ratio was greater than 2 every year from 2015 to 2017.

Multiple variables could be leading to this unfavorable outcomes profile associated with our colon surgeries.

The infection preventionists directly observed the process in the operating rooms during colon surgeries. The focus was around maintaining sterility including consistently changing gown and gloves before anastomosis, and isolating the closing instruments. Upon review of prior cases it was found that cefoxitin was the default antimicrobial agent in the perioperative setting unless contraindicated. After review of the colon surgical cases since 2015, it was recognized that the use of cefoxitin was associated with infectious complications and in cases using a combination of ceftriaxone and metronidazole no infections occurred. It was decided to make the change within the operating room carts to have ceftriaxone and metronidazole as the default antibiotic in place of cefoxitin. 

The focus around sterility did not lead to a significant reduction in infections, still maintaining standardized infections ratios over 2 in 2017. The antimicrobial intervention was the last to be instituted in December 2017. As of 10 months post intervention (October 2018) there have been no reportable infections in this patient population. Currently the standardized infection ratio for our institution is 0, placing us amongst top rated colon surgery hospitals.

The initial approach of vigilance around sterility although useful, did not impact the incidence of post colon surgical infections. The association of infected cases with the use of the “workhorse standard of care” systemic antimicrobial therapy led us to make the change to ceftriaxone and metronidazole. As shown in the results, this simple intervention resulted in a 100% reduction in infections following colon surgeries.