Decreasing Surgical Site Infection Rates After Benign Hysterectomy: Effects of a Bundled Approach

INTRODUCTION: Hysterectomy is one of the most frequently performed surgeries on reproductive-aged individuals, and surgical site infections are one of the most common complications, leading to increased patient morbidity and health care costs. Though a bundled approach is recommended for infection prevention, including by ACOG for hysterectomy, the optimal bundle is yet to be defined. OBJECTIVE: To evaluate the effectiveness of a hysterectomy-specific infection prevention bundle on surgical site infection rates for patients with benign pathologies. METHODS: This is a retrospective pre-post evaluation of an infection prevention bundle that was implemented in phases throughout 2019. Notable practice changes included the bundle itself, switching from povidone-iodine to chlorhexidine vaginal preparation, preoperative home chlorhexidine bathing materials, and standardization of preoperative metronidazole. The bundle also included tight glycemic control and abdominal chlorhexidine preparation; however, these were previously standard practice. Pre-intervention period was calendar year 2018. 2019 was excluded as the intervention period. Surgical volume decreases due to COVID-19 did not resolve until March 2021. Therefore, the post-intervention period was March 1, 2021, to February 28, 2022. Patients 18 years or older who underwent benign hysterectomy via any route were included. Patients who underwent cesarean or gravid hysterectomy, had malignancy or borderline tumors, or had unrecognized bowel injury or concomitant abdominoplasty were excluded. RESULTS: 981 patients were included, 506 pre-bundle and 475 post-bundle. Cohorts had similar demographics including body mass index, age, American Society of Anesthesiologists physical status, prior surgeries, smoking status, diabetes, and hypertension. Pre-intervention cohort had a higher rate immunosuppressed patients 9% (43/506) vs 5% (25/475), p=0.047. Surgical approach of vaginal, total abdominal, supracervical abdominal, total laparoscopic, and supracervical laparoscopic hysterectomies was similar in both cohorts. Cohorts had no difference in placement of sub-urethral slings, sacrocolpopexy mesh, concomitant bowel procedures, perioperative glucose control, transfusion rates, or blood loss. There was a significant reduction in overall surgical site infections 3.56% (18/506) pre-bundle vs 0.84% (4/475) post-bundle, p=0.004, resulting in the post-intervention group having a 77% absolute or 23% relative risk reduction (OR 0.23, 95% CI=0.08–0.68). Most notably, there was a significant reduction in type 3 infections (intrabdominal or vaginal cuff abscesses) 1.58% (8/506) pre-bundle vs 0% (0/475) post-bundle, p=0.005. The post-intervention group was also less likely to be readmitted to the hospital for surgery-related reasons (OR 0.22, 95% CI=0.07, 0.65). Importantly, there were no readmissions due to infection post-bundle, compared to 11 pre-bundle 2.17% (11/506) pre-bundle vs 0% (0/475) post-bundle, p=0.001. No change was observed in emergency room visits, and there was no clinically significant difference in length of stay (0.45 vs 0.28 days, p=0.029). CONCLUSIONS: Implementation of hysterectomy infection prevention bundle was associated with significant reduction in surgical site infection and readmission rates for patients with benign pathology.Figure 1Table 1Table 2