title: Surgical site infection reporting: more than meets the agar.
abstract: OBJECTIVE
  Surgical site infection (SSI) rate in pediatric appendicitis is a commonly used hospital quality metric. We hypothesized that surveillance of organ-space SSI (OSI) using cultures alone would fail to capture many clinically-important events.
  
  
  METHODS
  A prospective, multidisciplinary surveillance program recorded 30-day SSI and hospital length of stay (LOS) for patients <18years undergoing appendectomy for perforated appendicitis from 2012 to 2015. Standardized treatment pathways were utilized, and OSI was identified by imaging and/or bacterial cultures.
  
  
  RESULTS
  Four hundred ten appendectomies for perforated appendicitis were performed, and a total of 84 OSIs (20.5%) were diagnosed with imaging. Positive cultures were obtained for 39 (46%) OSIs, whereas 45 (54%) had imaging only. Compared to the mean LOS for patients without OSI (5.2±2.9days), LOS for patients with OSI and positive cultures (13.7±5.4days) or with OSI without cultures (10.4±3.7days) was significantly longer (both p<0.001). The OSI rate identified by positive cultures alone was 9.5%, whereas the clinically-relevant OSI rate was 20.5%.
  
  
  CONCLUSIONS
  Using positive cultures alone to capture OSI would have identified less than half of clinically-important infections. Utilizing clinically-relevant SSI is an appropriate metric for comparing hospital quality but requires agreed upon standards for diagnosis and reporting.
  
  
  METHODS
  II.
  
  
  METHODS
  Diagnostic study.
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Luke R
authors.initials: LR
authors.lastname: Putnam
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Tiffany G
authors.initials: TG
authors.lastname: Ostovar-Kermani
authors.affiliation: Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX.
authors.forename: Andrea
authors.initials: A
authors.lastname: Le Blanc
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Kathryn T
authors.initials: KT
authors.lastname: Anderson
authors.affiliation: Children's Memorial Hermann Hospital, Houston, TX; Department of Infectious Diseases, McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, TX.
authors.forename: Galit
authors.initials: G
authors.lastname: Holzmann-Pazgal
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX.
authors.forename: Kevin P
authors.initials: KP
authors.lastname: Lally
authors.affiliation: Center for Surgical Trials and Evidence-based Practice, Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, TX; Children's Memorial Hermann Hospital, Houston, TX. Electronic address: kuojen.tsao@uth.tmc.edu.
authors.forename: KuoJen
authors.initials: K
authors.lastname: Tsao
mesh_terms: D000362:Agar; D001062:Appendectomy / Q000009:adverse effects*; D001064:Appendicitis / Q000150:complications / Q000601:surgery*; D002648:Child; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000209:etiology / Q000601:surgery; D007902:Length of Stay; D008297:Male; D008828:Microbiological Techniques; D011183:Postoperative Complications / Q000175:diagnosis; D011446:Prospective Studies; D013530:Surgical Wound Infection / Q000175:diagnosis* / Q000453:epidemiology; D013781:Texas / Q000453:epidemiology
chemical_list: D000362:Agar
keywords: Appendicitis; Organ space infection; Quality metric; Surgical site infection; Surveillance