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Infection Control for the OB/GYN Surgeon

Infection Control for the OB/GYN Surgeon. Gonzalo Bearman, MD, MPH Assistant Professor of Internal Medicine & Epidemiology Associate Hospital Epidemiologist. Outline. Nosocomial Infections are a significant cause of morbidity and mortality

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Infection Control for the OB/GYN Surgeon

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  1. Infection Control for the OB/GYN Surgeon Gonzalo Bearman, MD, MPH Assistant Professor of Internal Medicine & Epidemiology Associate Hospital Epidemiologist

  2. Outline • Nosocomial Infections are a significant cause of morbidity and mortality • There has been increased public interest in nosocomial infections • Shifting paradigm • Many infections are preventable • SSI and OB/GYN • Surveillance data • Risk factors • Modifiable risk factors- modifiable interventions • BSI and OB/GYN • Surveillane • Risk reduction strategies • Proliferation of drug resistant nosocomial pathogens • Hand Hygeiene and Contact precautions

  3. “11,600 patients got infections in Pa. hospitals “ 7/13/2005 "The consequences clearly are huge," says Marc Volavka, executive director of the Pennsylvania Health Care Cost Containment Council, an independent state agency that published the data. "Everyone is paying the bill."

  4. U.S. News and World Report, July 18, 2005.

  5. Shifting Vantage Points on Nosocomial Infections Many infections are inevitable, although some can be prevented Each infection is potentially preventable unless proven otherwise Gerberding JL. Ann Intern Med 2002;137:665-670.

  6. Nosocomial Infections • 5-10% of patients admitted to acute care hospitals acquire infections • 2 million patients/year • ¼ of nosocomial infections occur in ICUs • 90,000 deaths/year • Attributable annual cost: $4.5 – $5.7 billion • Cost is largely borne by the healthcare facility not 3rd party payors Weinstein RA. Emerg Infect Dis 1998;4:416-420. Jarvis WR. Emerg Infect Dis 2001;7:170-173.

  7. Nosocomial Infections • 70% are due to antibiotic-resistant organisms • Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection Burke JP. New Engl J Med 2003;348:651-656. Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

  8. Attributable Costs of Nosocomial Infections Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. 2003:36.

  9. Major Sites of Nosocomial Infections • Urinary tract infection • Bloodstream infection • Pneumonia (ventilator-associated) • Surgical site infection

  10. Surgical Site Infections in Obstetrics and Gynecology

  11. National Nosocomial Infections Surveillance System (NNIS) • NNIS is the only national system for tracking HAIs • Voluntary reporting system has approximately 300 hospitals • The NNIS database uses standardized definitions of HAI’s to: • Describe the epidemiology of HAIs • Describe antimicrobial resistance associated with HAIs • Produce aggregated HAI rates suitable for interhospital comparison http://www.cdc.gov/ncidod/hip/SURVEILL/NNIS.HTM

  12. National Nosocomial Infections Surveillance System (NNIS)

  13. NNIS- SSI Surveillance 1992-2004 Am J Infect Control 2004;32:470-85

  14. NNIS- SSI Surveillance 1992-2004 Am J Infect Control 2004;32:470-85

  15. NNIS- SSI Surveillance 1992-2004 Am J Infect Control 2004;32:470-85

  16. Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology • Post operative infections prospectively surveyed from 1997-1998 in tertiary care medical center, Bahrain • Definition of postoperative infection: • Fever • Purulent discharge from wound • With or without a positive microbiologic culture • Re-admissions for wound infections were not included in the study Saudi Medical Journal 2000: Vol 21 (3) 270-273

  17. Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology Saudi Medical Journal 2000: Vol 21 (3) 270-273

  18. Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology Genitourinary flora is a significant source of contamination during surgery Saudi Medical Journal 2000: Vol 21 (3) 270-273

  19. Risk Factors for Surgical Site Infections Following Cesarean Section • OBJECTIVE: To identify risk factors associated with surgical-site infections (SSIs) following cesarean sections. • DESIGN: Prospective cohort study. • SETTING: High-risk obstetrics and neonatal tertiary-care center in upstate New York. • METHODS: • Prospective surgical-site surveillance was conducted using methodology of the National Nosocomial Infections Surveillance System. • Infections were identified on admission, within 30 days following the cesarean section, by readmission to the hospital or by a postdischarge survey. • Multiple logistic-regression analysis used for risk factor identification Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7

  20. Risk Factors for Surgical Site Infections Following Cesarean Section Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7

  21. Summary: SSI’s in OB/GYN • NNIS- SSIs are reported to occur in 1%-7% of OB/GYN surgeries • SSI are typically caused by maternal cutaneous or endometrial/vaginal flora • When an exogenous source is the cause of SSI in the obstetrical patient, S.aureus is frequently implicated

  22. Preventing Surgical Site Infections Focus on modifiable risk factors

  23. Sources of SSIs • Endogenous: patient’s skin or mucosal flora • Increased risk with devitalized tissue, fluid collection, edema, larger inocula • Exogenous • Includes OR environment/instruments, OR air, personnel • Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection • May occur days to weeks following the procedure • Most infections occur due to organisms implanted during the procedure

  24. Up to 20% of skin-associated bacteria in skin appendages (hair follicles, sebaceous glands) & are not eliminated by topical antisepsis. Transection of these skin structures by surgical incision may carry the patient's resident bacteria deep into the wound and set the stage for subsequent infection. Downloaded from: Principles and Practice of Infectious Diseases © 2004 Elsevier

  25. Risk Factors for SSI • Duration of pre-op hospitalization * increase in endogenous reservoir • Pre-op hair removal * esp if time before surgery > 12 hours * shaving>>clipping>depilatories • Duration of operation *increased bacterial contamination * tissue damage * suppression of host defenses * personnel fatigue

  26. SCIP • A national partnership of organizations to improve the safety of surgical care by reducing post-operative complications through a national campaign • Goal: reduce the incidence of surgical complications by 25 percent by the year 2010 • Initiated in 2003 by the Centers for Medicare & Medicaid Services (CMS) & the Centers for Disease Control & Prevention (CDC) • Steering committee of 10 national organizations • More than 20 additional organizations provide technical expertise Putting risk reduction guidelines into practice

  27. SCIP Steering Committee Organizations • Agency for Healthcare Research and Quality • American College of Surgeons • American Hospital Association • American Society of Anesthesiologists • Association of periOperative Registered Nurses • Centers for Disease Control and Prevention • Centers for Medicare & Medicaid Services • Department of Veterans Affairs • Institute for Healthcare Improvement • Joint Commission on Accreditation of Healthcare Organizations

  28. SCIP Performance Measures

  29. Monetary incentives for promoting quality and compliance with SSI risk reduction guidelines: March 12, 2005 In recent years, the healthcare industry has placed a stronger emphasis on reducing medical errors, monitoring everything from how long doctors sleep to whether or not their handwriting is legible.Now one organization is not only recognizing the hospitals that follow patient safety and clinical guidelines, but rewarding them for doing so. Anthem Blue Cross and Blue Shield recently gave a total of $6 million to 16 Virginia hospitals as part of the company's new Quality-In-Sights Hospital Incentive Program (Q-HIP). http://www.richmond.comID=15

  30. Infection Rate Downloaded from: Principles and Practice of Infectious Diseases

  31. Process Indicators:Appropriate Antibiotic Prophylaxis

  32. Process Indicators:Duration of Antimicrobial Prophylaxis Prophylactic antimicrobials should be discontinued within 24 hrs after the end of surgery Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

  33. Process Indicators:Timing of First Antibiotic Dose Infusion should begin within 60 minutes of the incision Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

  34. Nosocomial Bloodstream Infections

  35. Nosocomial Bloodstream Infections, 1995-2002 N= 24,847 52 BSI/10,000 admissions Edmond M. SCOPE Project.

  36. Nosocomial Bloodstream Infections, 1995-2002 Obstetrics and Gynecology • Proportion of all BSI 0.9% (n=209) • E.coli (33%) • S.aureus (11.7%) • Enterococci (11.7) In obstetrics, BSIs are uncommon. However, the principal pathogen is E.coli and not coagulase negative staphylococci. The source is typically genitourinary N= 24,847 52 BSI/10,000 admissions Edmond M. SCOPE Project.

  37. Nosocomial Bloodstream Infections • 12-25% attributable mortality • Risk for bloodstream infection:

  38. Risk Factors for Nosocomial BSIs • Heavy skin colonization at the insertion site • Internal jugular or femoral vein sites • Duration of placement • Contamination of the catheter hub

  39. Prevention of Nosocomial BSIs • Coated catheters • In meta-analysis C/SS catheter decreases BSI (OR 0.56, CI95 0.37-0.84) • M/R catheter may be more effective than C/SS • Disadvantages: potential for development of resistance; cost (M/R > C/SS > uncoated) • Use of heparin • Flushes or SC injections decreases catheter thrombosis, catheter colonization & may decrease BSI

  40. Prevention of Nosocomial BSIs • Limit duration of use of intravascular catheters • No advantage to changing catheters routinely • Change CVCs to PICCs when possible • Maximal barrier precautions for insertion • Sterile gloves, gown, mask, cap, full-size drape • Moderately strong supporting evidence • Chlorhexidine prep for catheter insertion

  41. 30%-40% of all Nosocomial Infections are Attributed to Cross Transmission- Implication For The Spread Drug Resistant Pathogens

  42. NNIS: Selected antimicrobial resistant pathogens associated with HAIs Fig 1. Selected antimicrobial-resistant pathogens associated with nosocomial infections in ICU patients, comparison of resistance rates from January through December 2003 with 1998 through 2002, NNIS System. Am J Infect Control 2004;32:470-85

  43. Antimicrobial Resistant Pathogens of Ongoing Concern • Vancomycin resistant enterocci • 12% increase in 2003 when compared to 1998-2002 • MRSA • 12% increase in 2003 when compared to 1998-2002 • Increased reports of Community-Acquired MRSA • Cephalosporin and Imipenem resistant gram negative rods • Klebsiella pneumonia • Pseudomonas aeruginosa Am J Infect Control 2004;32:470-85

  44. Transfer of VRE via HCW Hands • 16 transfers (10.6%) occurred in 151 opportunities. • 13 transfers occurred in rooms of unconscious patients who were unable to spontaneously touch their immediate environment Duckro et al. Archive of Int Med. Vol.165,2005

  45. The inanimate environment is a reservoir of pathogens X represents a positive Enterococcus culture The pathogens are ubiquitous ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

  46. Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units. • Outbreak of 7 cases of skin and soft tissue infections due to a strain of CA-MRSA. • All patients were admitted to the labor and delivery, nursery, or maternity units during a 3-week period. • Genetic fingerprinting showed that the outbreak strain was closely related to the USA 400 strain that includes the midwestern strain MW2 Emerg Infect Dis. 2005 Jun;11(6):808-13.

  47. Emerg Infect Dis. 2005 Jun;11(6):808-13.

  48. Epidemic of Staphylococcus aureus nosocomial infections resistant to methicillin in a maternity ward • Seventeen cases were recorded over a nine-week period (two cases per week). • All were skin and soft tissue infections • Pulsed field gradient gel electrophoresis confirmed the clonal character of the strain. • No definite risk factors were determined by a case-control study. • Environmental factors were considered key in the persistence of this MRSA outbreak. Pathol Biol (Paris). 2001 Feb;49(1):16-22.

  49. The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, C.diff CNS and GNR Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

  50. The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, CNS. C.diff and GNR Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

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