Impact of a bundle on surgical site infections after hip arthroplasty: A cohort study in Italy (2012-2019)

Background: Surgical site infections (SSIs) are an extremely serious complication of hip arthroplasty, estimated to affect up to nearly 3% of procedures. In Italy, SSIs are monitored through a national surveillance system (Sistema Nazionale Sorveglianza delle Infezioni del Sito Chirurgico, SNICh). Several studies suggest bundled interventions are effective in reducing SSI rates in orthopaedic surgery. Materials and methods: A bundled intervention was implemented in 2012 in 34 out of the 49 hospitals of the North-West of Italy participating in SNICh. A cohort study was conducted between January 1st, 2012 and December 31st, 2019 to evaluate the impact of the intervention on SSI rates after hip arthroplasty. The four elements of the bundle are: appropriate preoperative shower, preoperative hair removal, perioperative normothermia, antibiotic prophylaxis. Data on compliance with the bundle and the occurrence of infection were collected. Results: In total, 18,791 procedures were included in the study. Full bundle compliance was achieved in 27.9% of procedures. The percentage of fully compliant procedures significantly increased over time from introduction of the bundled intervention (R-2 0.799, p-value 0.003). Multivariable analysis found a significant association between full bundle compliance and reduced SSI rate, with a reduction of the odds of infection of 31% (95% CI 0.5-0.96; p 0.026). Conclusion: Results of this study support bundled interventions as an effective implementation strategy for infection prevention and control practices in hip replacement surgery. This simple bundle protocol could be easily implemented in settings with limited resources.