BackgroundOral antiseptics reduce nosocomial infections and ventilator-associated pneumonia in critically ill medical and surgical patients intubated for prolonged periods. However, the role of oral antiseptics given before and after planned surgery is not clear. The aim of this systematic review and meta-analysis is to determine the effect of oral antiseptics (chlorhexidine or povidone–iodine) when administered before and after major elective surgery.MethodsSearches were conducted of the MEDLINE, EMBASE and Cochrane databases. The analysis was performed using the random-effects method and the risk ratio (RR) with 95 % confidence interval (CI).ResultsOf 1114 unique identified articles, perioperative chlorhexidine was administered to patients undergoing elective surgery in four studies. This identified 2265 patients undergoing elective cardiac surgery, of whom 1093 (48.3 %) received perioperative chlorhexidine. Postoperative pneumonia and nosocomial infections were observed in 5.3 and 20.2 % who received chlorhexidine compared to 10.4 and 31.3 % who received a control preparation, respectively. Oral perioperative chlorhexidine significantly reduced the risk of postoperative pneumonia (RR = 0.52; 95 % CI 0.39–0.71; p < 0.01) and overall nosocomial infections (RR = 0.65; 95 % CI 0.52–0.81; p < 0.01), with no effect on in-hospital mortality (RR = 1.01; 95 % CI 0.49–2.09; p = 0.98).ConclusionsPerioperative oral chlorhexidine significantly decreases the incidence of nosocomial infection and postoperative pneumonia in patients undergoing elective cardiac surgery. There are no randomised controlled studies of this simple and cheap intervention in patients undergoing elective non-cardiac surgery.Trial RegistrationThis systematic review was registered with the International prospective register of systematic reviews (PROSPERO). The registration number is CRD42015016063.

OBJECTIVE We sought to evaluate the frequency of, and factors associated with, the use of 3 evidence-based interventions: antenatal corticosteroids for fetal lung maturity, progesterone for prevention of recurrent preterm birth, and magnesium sulfate for fetal neuroprotection. STUDY DESIGN A self-administered survey was conducted from January through May 2011 among obstetricians from 21 hospitals that included 30 questions regarding their knowledge, attitudes, and practice of the 3 evidence-based interventions and the 14-item short version of the Team Climate for Innovation survey. Frequency of use of each intervention was ascertained from an obstetrical cohort of women between January 2010 and February 2011. RESULTS A total of 329 obstetricians (74% response rate) who managed 16,946 deliveries within the obstetrical cohort participated in the survey. More than 90% of obstetricians reported that they incorporated each intervention into routine practice. Actual frequency of administration in women eligible for the treatments was 93% for corticosteroids, 39% for progesterone, and 71%formagnesiumsulfate. Provider satisfaction with quality of treatment evidence was 97% for corticosteroids, 82% for progesterone, and 57% for magnesium sulfate. Obstetricians perceived that barriers to treatment were most frequent for progesterone (76%), 30% for magnesium sulfate, and 17% for corticosteroids. Progesterone use was more frequent among patients whose provider reported the quality of the evidence was above average to excellent compared with poor to average (42% vs 25%, respectively; P < .001), and they were satisfied with their knowledge of the intervention (41%vs 28%; P = .02), and was less common among patients whose provider reported barriers to hospital or pharmacy drug delivery (31% vs 42%; P = .01). Corticosteroid administration was more common among patients who delivered at hospitals with 24 hours a day–7 days a week maternal-fetal medicine specialist coverage (93% vs 84%; P = .046), CONCLUSION Obstetricians in Maternal-Fetal Medicine Units Network hospitals frequently use these evidence-based interventions; however, progesterone usewas found to be related to their assessment of evidence quality. Neither progesterone nor the other interventions were associated with overall climate of innovation within a hospital as measured by the Team Climate for Innovation. National Institutes of Health Consensus Conference Statements may also have an impact on use; there is such a statement for antenatal corticosteroids but not for progesterone for preterm prevention or magnesium sulfate for fetal neuroprotection.

Background: Evidence-based interventions may reduce mortality in surgical patients. This study documented the prevalence of sepsis, adherence to guidelines in its management, and timing of source control in general surgical patients presenting as an emergency.Methods: Patients aged 16 years or more presenting with emergency general surgery problems were identified over a 7-day period and then screened for sepsis compliance (using the Sepsis Six standards, devised for severe sepsis) and the timing of source control (whether radiological or surgical). Exploratory analyses examined associations between the mode (emergency department or general practitioner) and time of admission, adherence to the sepsis guidelines, and outcomes (complications or death within 30 days).Results: Of a total of 5067 patients from 97 hospitals across the UK, 911 (18⋅0 per cent) fulfilled the criteria for sepsis, 165 (3⋅3 per cent) for severe sepsis and 24 (0⋅5 per cent) for septic shock. Timely delivery of all Sepsis Six guidelines for patients with severe sepsis was achieved in four patients. For patients with severe sepsis, 17⋅6-94⋅5 per cent of individual guidelines within the Sepsis Six were delivered. Oxygen was the criterion most likely to be missed, followed by blood cultures in all sepsis severity categories. Surgery for source control occurred a median of 19⋅8 (i.q.r. 10⋅0-35⋅4) h after diagnosis. Omission of Sepsis Six parameters did not appear to be associated with an increase in morbidity or mortality. Conclusion:Although sepsis was common in general surgical patients presenting as an emergency, adherence to severe sepsis guidelines was incomplete in the majority. Despite this, no evidence of harm was apparent. * Members of the UK National Surgical Research Collaborative are co-authors of this study and can be found under the heading Collaborators Paper accepted 25 October 2016Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.10432 IntroductionGeneral surgical patients presenting as an emergency account for over 7 per cent of hospital episodes in the USA and 14 000 ICU admissions per year in the UK 1 -3 . Sepsis is prevalent in this patient group. Early diagnosis of severe sepsis and initiation of goal-directed therapy can reduce mortality, irrespective of the need for surgery 4,5 . This evidence was used to develop a care bundle known as the Sepsis Six for managing patients with severe sepsis (Table 1) 6,7 . These standards have been endorsed by many professional organizations, including the Society of Critical Care Medicine, the European Society of Intensive Care Medicine and the Royal Colleges of Surgeons of England and Ireland 1,2,8,9 . Complete application of these interventions is thought to be associated with as much as a one-third reduction in mortality from sepsis, although uptake is uncertain amongst surgical patients presenting as an emergency 4,6 .The main aims of the present study were to assess adherence to the Sepsis Six guidelines and identify the timing of source control in general su...

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