OBJECTIVE To compare the effects of different skin preparation solutions on surgical-site infection rates. DESIGN Three skin preparations were compared by means of a sequential implementation design. Each agent was adopted as the preferred modality for a 6-month period for all general surgery cases. Period 1 used a povidone-iodine scrub-paint combination (Betadine) with an isopropyl alcohol application between these steps, period 2 used 2% chlorhexidine and 70% isopropyl alcohol (ChloraPrep), and period 3 used iodine povacrylex in isopropyl alcohol (DuraPrep). Surgical-site infections were tracked for 30 days as part of ongoing data collection for the National Surgical Quality Improvement Project initiative. The primary outcome was the overall rate of surgical-site infection by 6-month period performed in an intent-to-treat manner. SETTING Single large academic medical center. PATIENTS All adult general surgery patients. RESULTS The study comprised 3,209 operations. The lowest infection rate was seen in period 3, with iodine povacrylex in isopropyl alcohol as the preferred preparation method (3.9%, compared with 6.4% for period 1 and 7.1% for period 2; P = .002). In subgroup analysis, no difference in outcomes was seen between patients prepared with povidone-iodine scrub-paint and those prepared with iodine povacrylex in isopropyl alcohol, but patients in both these groups had significantly lower surgical-site infection rates, compared with rates for patients prepared with 2% chlorhexidine and 70% isopropyl alcohol (4.8% vs 8.2%; P = .001). CONCLUSIONS Skin preparation solution is an important factor in the prevention of surgical-site infections. Iodophor-based compounds may be superior to chlorhexidine for this purpose in general surgery patients.

Summary Background Antimicrobial treatment in critically ill patients can either be started as soon as infection is suspected or after objective data confirm an infection. We postulated that delaying antimicrobial treatment of patients with suspected infections in the surgical intensive care unit (SICU) until objective evidence of infection had been obtained would not worsen patient mortality. Methods We did a 2-year, quasi-experimental, before and after observational cohort study of patients aged 18 years or older who were admitted to the SICU of the University of Virginia (Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was used: patients suspected of having an infection on the basis of clinical grounds had blood cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a conservative strategy was used, with antimicrobial treatment started only after objective findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses were by intention to treat. Findings Admissions to the SICU for the first and second years were 762 and 721, respectively, with 101 patients with SICU-acquired infections during the aggressive year and 100 patients during the conservative year. Compared with the aggressive approach, the conservative approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%]; p=0.015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0.0095), and a shorter mean duration of therapy (12.5 days [SD 10.7] vs 17.7 [28.1]; p=0.0080). After adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation (APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the aggressive therapy group compared with the conservative therapy group was 2.5 (95% CI 1.5−4.0). Interpretation Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected SICU-acquired infections does not worsen mortality and might be associated with better outcomes and use of antimicrobial drugs.

Among critically ill surgical patients, caloric provision across a wide acceptable range does not appear to be associated with major outcomes, including infectious complications. The optimum target for caloric provision remains elusive.

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Background: Obese patients are at higher than normal risk for postoperative infections such as pneumonia and surgical site infections, but the relation between obesity and infections acquired in the intensive care unit (ICU) is unclear. Our objective was to describe the relation between body mass index (BMI) and site-specific ICU-acquired infection risk in adults. Methods: Secondary analysis of a large, dual-institutional, prospective observational study of critically ill and injured surgical patients remaining in the ICU for at least 48 h. Patients were classified into BMI groups according to the National Heart, Lung and Blood Institute guidelines: Յ 18.5 kg/m 2 (underweight), 18.5-24.9 kg/m 2 (normal), 25-29.9 kg/m 2 (overweight), 30.0-39.9 kg/m 2 (obese), and Ն 40.0 kg/m 2 (severely obese). The primary outcomes were the number and site of ICU-acquired U.S. Centers for Disease Control and Preventiondefined infections. Multivariable logistic and Poisson regression were used to determine age-, sex-, and severity-adjusted odds ratios (ORs) and incidence rate ratios associated with differences in BMI. Results: A total of 2,037 patients had 1,436 infection episodes involving 1,538 sites in a median ICU length of stay of 9 days. After adjusting for age, sex, and illness severity, severe obesity was an independent risk factor for catheter-related (OR 2.2; 95% confidence interval [CI] 1.5, 3.4) and other blood stream infections (OR 3.2; 95% CI 1.9, 5.3). Cultured organisms did not differ by BMI group. Conclusion: Obesity is an independent risk factor for ICU-acquired catheter and blood stream infections. This observation may be explained by the relative difficultly in obtaining venous access in these patients and the reluctance of providers to discontinue established venous catheters in the setting of infection signs or symptoms.