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Incidence and Consequence of Surgical Site Infections

Incidence and Consequence of Surgical Site Infections. William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill, USA.

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Incidence and Consequence of Surgical Site Infections

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  1. Incidence and Consequence of Surgical Site Infections William A. Rutala, PhD, MPH Director, Hospital Epidemiology, Occupational Health and Safety; Professor of Medicine and Director, Statewide Program for Infection Control and Epidemiology University of North Carolina at Chapel Hill, USA

  2. Disclosure This presentation reflects the techniques, approaches and opinions of the individual presenter. This Advanced Sterilization Products (“ASP”) sponsored presentation is not intended to be used as a training guide.  Before using any medical device, review all relevant package inserts with particular attention to the indications, contraindications, warnings and precautions, and steps for use of the device(s). I am compensated by and presenting on behalf of ASP, and must present information in accordance with applicable FDA requirements. The third party trademarks used herein are trademarks of their respective owners.

  3. TOPICS • Epidemiology of healthcare associated infections (HAI) • Review the morbidity, mortality, national initiatives and economic consequences of SSI • Discuss the risk factors and etiology of SSI • Provide strategies to prevent SSI

  4. HEALTHCARE-ASSOCIATED INFECTIONS IN THE US: IMPACT • 1.7 million infections per year • 98,987 deaths due to HAI • Pneumonia 35,967 • Bloodstream 30,665 • Urinary tract 13,088 • Surgical site infection 8,205 • Other 11,062 • 6th leading cause of death (after heart disease, cancer, stroke, chronic lower respiratory diseases, and accidents)1 1National Center for Health Statistics, 2004

  5. COST ESTIMATES FOR HEALTHCARE-ASSOCIATED INFECTIONS (HAIs) Anderson DJ, et al. ICHE 2007;28:767-773 Costs based on literature review 1985-2005; adjusted to US 2005 dollars

  6. INCREMENTAL HOSPITAL DAYSDUE TO COMMON HAIs

  7. Surgical Site Infection

  8. SSIs: IMPACT • 27,000,000 surgical procedures per year1 • Prevalence • 2-5% of surgical patients develop an SSI2 • 500,000 infections per year2 (~70% superficial, ~30% organ/space)1 • SSIs account for ~22% of nosocomial infections: 2nd most common nosocomial infection (after UTIs)1 • Impact • Each SSI results in 7-10 additional hospital days2 • Patients with SSI have a 2-11 times higher risk of death2 • 77% of deaths among patients with SSI are directly due to SSI2 • ~8,000 deaths due to SSI • Cost (2007 dollars): $11,874 to $34,670 per infection (total = $3.45-$10 bil)3 1Klevens R, et al. Pub Health Rep 2007;122:160 - 2Anderson D, et al ICHE 2008;29 (Suppl 1):S51 – 3http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

  9. SSI: PATHOGENESIS Risk of surgical site infections = Microbial load x Virulence x Tissue injury x Foreign material x Antibiotic resistance ____________________________________________________________ Host resistance x Perioperative antibiotics

  10. SSI: Primary Risk Factors Endogenous microorganisms Skin-dwelling microorganisms Most common source S aureus most common isolate Fecal flora (gnr) when incisions are near the perineum or groin Exogenous microorganisms Surgical personnel (members of surgical team) OR environment (including air) All tools, instruments, and materials

  11. PATHOGENS ASSOCIATED WITH SSIs: NHSN, 2006-2007 Hidron AI, et al. ICHE 2008;29:996-1011

  12. TOPICS • Epidemiology of healthcare associated infections (HAI) • Review the morbidity, mortality, national initiatives and economic consequences of SSI • Discuss the risk factors and etiology of SSI • Provide strategies to prevent SSI

  13. Age-extremes Nutritional status-poor Diabetes-controversial; increased glucose levels in post-op period ↑ risk Smoking-nicotine delays wound healing ↑ risk Obesity>20% ideal body weight Remote infections ↑ risk Endogenous mucosal microorganisms Preoperative nares S. aureus- CT patients Immunosuppressive drugs may ↑ risk Preoperative stay-surrogate for severity of illness SSI: Intrinsic/Patient Risk Factors

  14. Surgical wound classification Intraoperative microbial contamination Antimicrobial prophylaxis Preoperative shaving Preoperative skin preparation Thoroughness of surgical scrub Duration of surgical procedure Surgical attire Sterile draping Traffic-minimize Surgical technique: Poor hemostasis Failure to obliterate dead space Tissue trauma Low abdominal operative site Prolonged hospital admission prior to operation Foreign material Operating room ventilation Instrument sterilization Surgical drains SSI: OPERATION-RELATEDRISK FACTORS

  15. SSI RISK AS A FUNCTION OF WOUND CLASSIFICATION

  16. NATIONAL HEALTHCARE SAFETY NETWORK SSI RISK STRATIFICATION • NHSN surgery stratification: Scale from -1 to 3 (operation specific) • 1 point for ASA score >3 • 1 point for duration of operation >75th percentile • 1 point for contaminated or dirty wound • -1 point for surgery done via a laparoscope • ASA classification • 1 = normal healthy patient • 2 = patient with mild systemic disease • 3 = patient with severe systemic disease • 4 = patient with severe systemic disease that is life threatening • 5 = patient not expected to survive without the operation • 6 = declared brain dead patient whose organs are being removed for donation

  17. SSI RATE, NHSN DATA, 2006-2007

  18. TOPICS • Epidemiology of healthcare associated infections (HAI) • Review the morbidity, mortality, national initiatives and economic consequences of SSI • Discuss the risk factors and etiology of SSI • Provide strategies to prevent SSI

  19. STRATEGIES TO PREVENT SSIsSurgical IP Collaborative-6 Performance Measures • CMS – Surgical Infection Prevention Collaborative (2002) • Deliver antibiotic prophylaxis within 1 hour (2 hours for vancomycin/quinolones) • Use an antibiotic with known effectiveness • Discontinue antibiotics within 24 hours (48 hours for cardiac surgery) • CMS - Surgical Care Improvement Project (2003) • Proper hair removal (clip immediately before surgery) • Control blood glucose post-op days 1 and 2 (<200 mg/dL) • Maintain perioperative normothermia for patients undergoing colorectal surgery Anderson D, et al. ICHE 2008;29(suppl 1):S51-S61

  20. To Reduce the Risk of Surgical Site Infection A simple but realistic approach must be applied with the awareness that the risk of SSIs is influenced by characteristics of the patient, operation, personnel and hospital Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

  21. SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

  22. SSI: CDC Guidelines Patient characteristics/risk factor Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

  23. Risk and Prevention in SSIs Risk Factor-a variable that has a significant independent association with the development of SSI after a specific operation

  24. Age-extremes Nutritional status-poor Diabetes- increased glucose levels in post-op period ↑ risk Smoking-nicotine delays wound healing ↑ risk Obesity>20% ideal body weight Remote infections ↑ risk Endogenous mucosal microorganisms Preoperative nares S. aureus- CT patients Immunosuppressive drugs may ↑ risk Preoperative stay-surrogate for severity of illness SSI: Intrinsic/Patient Risk Factors

  25. A More Than Typical Scenario - Total Joint Replacement – What is the Risk? High Risk Patient: Immunosuppressive meds RA Diabetes Advanced age Prior surgery to same joint Psoriasis Obese Malnourished morbid obesity sAlb<35 low sTransferrin Remote sites of infection Smokers ASA ≥3

  26. SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

  27. SSI: Preoperative IssuesModifiable Risks Glucose control-in diabetic patients Preoperative CHG shower Appropriate hair removal Hand hygiene Skin antisepsis Antimicrobial prophylaxis Normothermia-hypo higher risks Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278. 5 Million lives. Institute for Healthcare Improvement. Available at: http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.

  28. Prevention of SSIs • Preoperative preparation of the patient • Preoperative showers with antiseptic agent at least the night before (IB) • Do not remove hair preoperatively unless it will interfere with the operation (IA) • If hair removed, remove just prior to surgery with electric clippers (IA) • Wash and clean at and around incision site prior to performing antiseptic skin preparation (IB)

  29. Normal Skin Micro-Flora Numbers per square centimeter of skin surface (cfu/cm2). Counts on hands range from 3.9x104 to 4.6x106. Numbers of bacteria that colonize different parts of the body

  30. Microbial Ecology of Skin Surface Scalp 6.0 Log10 cfu/cm2 Axilla 5.5 Log10 cfu/cm2 Abdomen 4.3 Log10 cfu/cm2 Forearm 4.0 Log10 cfu/cm2 Hands 4.0-6.6 Log10 cfu/cm2 Perineum 7.0-11.0 Log10 cfu/cm2 Surgical Microbiology Research Laboratory 2008 – Medical College of Wisconsin

  31. 4% Chlorhexidine Gluconate (CHG) Shower - Mean Skin Surface Concentration (N=60) CHG Shower Group 1A “Evening (PM)” Group 2A “Morning (AM)” Group 3A “Both (AM and PM)” CHG Concentration (PPM) p <0.05 NS P<0.001 MIC90 = 4.8 ppm Left Elbow Right Elbow Abdominal Left Knee Right Knee Skin Sites Edmiston et al, J Am Coll Surg 2008;207:233-239

  32. SSI: Preoperative IssuesModifiable Risks Glucose control-in diabetic patients Preoperative CHG shower Appropriate hair removal Surgical hand antisepsis Skin antisepsis Antimicrobial prophylaxis Normothermia-hypo higher risks Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278. 5 Million lives. Institute for Healthcare Improvement. Available at: http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.

  33. Surgical Hand Antisepsis • Surgical hand scrubs should: • Significantly reduce microorganisms on intact skin • Contain a non-irritating antimicrobial preparation • Have broad-spectrum activity • Be fast-acting and persistent

  34. Surgical Hand Antisepsis • Studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used • One study (AORN J 2001;73:412) found a brushless application of a preparation of 1% CHG plus 61% ethanol yielded lower bacterial counts on the hands of participants than using a sponge/brush to apply 4% CHG

  35. Perioperative Skin Antisepsis?

  36. Study Results • N = 849 surgical patients: 409 Alc-CHG vs 440 PI (ITT) • 1:1 randomization • Patients monitored for 30 days post-op • Overall rate of SSI was significantly reduced in Alc-CHG vs PI groups: 9.5% vs 16.1%, p=0.004 • Significant difference for both superficial incisional site rate: 4.2% A-CHG vs 8.6% PI (p=0.008) and deep incisional: 1% A-CHG vs 3% PI (p=0.05) • No significant adverse events noted during the study in either group • Alc-CHG superior to PI in reducing the risk of SSI in clean-contaminated procedures Darouiche RO, et al. New England Journal of Medicine 2010;362:18-26

  37. SSI: Preoperative IssuesModifiable Risks Glucose control-in diabetic patients Preoperative CHG shower Appropriate hair removal Hand hygiene Skin antisepsis Antimicrobial prophylaxis Normothermia-hypo higher risks Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278. 5 Million lives. Institute for Healthcare Improvement. Available at: http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.

  38. IDSA GUIDELINE • Infusion of the first dose within 60 min of surgical incision • Prophylactic therapy should be discontinued within 24 hrs • Provide additional intraoperative doses if surgery extends beyond 2 half-lives of the initial dose • Provide therapy based on weight (>30% above ideal body weight) or body mass index • Additional measures • Supplemental oxygen administration, perioperative glucose control, aggressive fluid resuscitation, proper intraoperative temperature control

  39. SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

  40. LISTER CARBOLIC ACID SPRAY AS ANTISEPTIC PRECAUTION Wood Engraving - William Watson Cheyne, 1882 - National Library of Medicine

  41. OR Environment • Air • Largest source of airborne microbial contamination is the OR staff • Organisms become airborne as a result of conversation or shedding from the hair or exposed skin • Microbial level directly proportional to the number of people moving about in the room • Improved ventilation associated with decreased SSI

  42. Prevention of SSIs • Intraoperative (Ventilation) • Maintain 15 AC/hr (>3 fresh)*, positive pressure (IB) • Filter all air through appropriate filters (IB) • Introduce air at ceiling and exhaust near floor (IB) • Keep OR doors closed as needed for passage of equipment, personnel, and patients (IB) • Limit the number of OR personnel (IB) • Consider ultraclean air for orthopedic implants (II) *2010 Guideline (FGI, ASHRAE) is 20 AC/hr (>4 fesh)

  43. OR Environment • Ventilation • Three primary design components act to purify the OR air • High-flow ventilation - 15 air changes per hour (3 outside air) • High-efficiency filtration 90-99.97% • Positive pressure relative to adjacent areas (prevents contamination from less clean areas) • Maintain the temperature (68o-73oF [20-23oC]) and relative humidity (30-60%)

  44. OR Environment • Environment as an Exogenous Source of Pathogens • Clean environment minimizes the risk of OR environmental surfaces and floors as a source of infection • Microorganisms isolated from the OR are usually non-pathogens rarely associated with infection • When inanimate sources implicated, the sources have been contaminated solutions, antiseptics, or dressings (not floors, walls or environmental surfaces)

  45. Prevention of SSIs • Intraoperative (Cleaning/disinfection environmental surfaces) • Clean when visibly soiled/contaminated with EPA approved disinfectant before the next operation (IB) • Do not perform special cleaning after contaminated or dirty surgery (IB) • Do not use tacky mats (IB) • Cleaning between surgery if no visible contamination (No recommendation)

  46. OR Environment • Disinfection • OR environment (furniture, lights, equipment) should be damp-dusted with a germicide on a scheduled basis • Exogenous microorganisms can contaminate surgical practice setting • Disinfection is essential to reduce the risk of cross-infection • Disinfection of these surfaces will control airborne microorganisms that might travel on dust and lint

  47. OR Environment • Disinfection • Floors should be cleaned with a low-level disinfectant • For end-of-use cleaning, necessary to clean a 3-to-4 ft perimeter around the operative site (extended as necessary by contamination) • Important to re-establish a clean environment after each operation • For terminal daily cleaning, entire floor is cleaned • Same cleaning procedures performed whether clean or contaminated case

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