SURGICAL SITE INFECTIONS

1
SURGICAL SITE INFECTIONS INCIDENCE, IMPACT,
EVIDENCE-BASED INTERVENTIONS
Gary A. Roselle, M.D.

• Program Director for Infectious Diseases
  Department of Veterans Affairs
  VA Central Office, Washington, DC
• Chief, Medical Service
  Cincinnati VA Medical Center
• Professor of Medicine
  Univ. of Cincinnati College of Medicine

2
SURGICAL SITE INFECTIONSImpact

• SSIs are associated with substantial morbidity
  and mortality
• ? post-op hospital LOS by 7-10 days
• Hosp. charges ? 2,000 4,500 in pts. with SSI
• Death is directly related to SSI in over 75 of
  pts. with SSI who die in the post-op period

3
EPIDEMIOLOGYSSI Rates Vary

• Patient population
• Size of hospital
• Experience of the surgeon
• Methods used for surveillance

4
EPIDEMIOLOGYSSI Rates by Procedures
5
Factors Affecting SSI

• Patient characteristics
• Preoperative
• Intraoperative
• Postoperative

6
Patient Characteristics

• Diabetes
• Smoking/nicotine
• Corticosteroids
• Malnutrition
• Prolonged preoperative stay
• Colonization with S. aureus

7
Preoperative

• Antiseptic showering
• Hair removal
• Patient OR skin prep
• Surgeon hand/forearm antisepsis
• Colonized surgical personnel
• Hyperglycemic control
• Antimicrobial prophylaxis

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Intraoperative

• OR environment
• Surgical attire and drapes
• Asepsis and surgical technique
• Perioperative transfusion
• Supplemental oxygen
• Normothermia

9
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
10
Postoperative

• Incision care
• Discharge planning

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CDC GUIDELINE PREVENTION OF SSICategorizing
Recommendations

• IA Strongly recommended for implementation and
  supported by well-designed experimental,
  clinical or epidemiological studies
• IB Strongly recommended for implementation and
  supported by some experimental, clinical, or
  epidemiological studies and strong theoretical
  rationale
• II Suggested for implementation and supported by
  suggestive clinical or epidemiological studies
  or theoretical rationale
• No recommendation unresolved issues. Practices
  for which insufficient evidence or no consensus
  regarding efficacy exists
• Practices required by federal regulation denoted
  with an asterisk ()

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Patient) IA Recommendations

• When possible, identify and treat all infections
  remote to surgical site before elective surgery
• Dont remove hair unless it will interfere with
  the operation
• If hair removed, do immediately before surg.,
  preferably with electric clippers

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Patient) - Recommendations
14
CDC GUIDELINE PREVENTION OF SSIPreoperative
(Patient) - Recommendations
15
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
16
CDC GUIDELINE PREVENTION OF SSIPreoperative
(Surg Team) - Recommendations
17
CDC GUIDELINE PREVENTION OF SSIPreoperative
(Infected Colonized Surg Personnel)Recommendation
s
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CDC GUIDELINE PREVENTION OF SSIIntraoperative
(Ventilation) Recommendations
19
CDC GUIDELINE PREVENTION OF SSIIntraoperative
(Surg. Attire/Drapes) - Recommendations
20
CDC GUIDELINE PREVENTION OF SSIIntraoperative
(Asepsis/Surg Technique) - Recommendations
21
CDC GUIDELINE PREVENTION OF SSIIntraoperative
(Cleaning/Disinfecting) Recommendations
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CDC GUIDELINE PREVENTION OF SSIIntraoperative -
Recommendations
23
CDC GUIDELINES PREVENTION OF SSIPostoperative
(Incision Care) - Recommendations
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CDC GUIDELINE PREVENTION OF SSIPreoperative
Antimicrobial Prophylaxis

• Administer prophylactic antimicrobial agent only
  when indicated, select it based on efficacy
  against the most common pathogens causing SSI for
  a specific operation (IA)
• Administer initial dose IV, timed such that a
  bactericidal concentration of the drug is
  established in serum and tissues when incision
  made. Maintain therapeutic levels throughout the
  operation and few hours after incision is closed
  in OR (IA)
• Dont routinely use vancomycin for antimicrobial
  prophylaxis (IB)

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CDC GUIDELINE PREVENTION OF SSIPreoperative
Antimicrobial Prophylaxis

• Before elective colorectal surg, prepare colon
  using enemas and cathartic agents, administer
  nonabsorbable oral antimicrobial agents in
  divided doses day before surg, and give the IV
  antimicrobial as previously described (IA)
• High-risk C-section, administer prophylactic
  antimicrobial agent immediately after the
  umbilical cord is clamped (IA)

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Antimicrobial prophylaxis

• Surgical incision break in bodys defense
  against infection
• Bacteria colonizing the skin gain access to deep,
  usually protected tissue
• High levels of tissue antibiotic when the skin
  breaks may kill these bacteria

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Antimicrobial prophylaxis

• Animal studies show need for high levels of
  antibiotic at time of incision
• Timing is critical
• first giving antibiotic after skin open is too
  late
• Duration is critical
• need to maintain levels during operation
• may need to redose during operation
• Once skin closed, antibiotics not effective
• do not continue after operation

28
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
29
Table 20.1.1 Meta-analyses examining antibiotic
prophylaxis (Cont.)
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
30
Kreter B, et al. Thorac Cardiovasc Surg 1992
104590-9
31
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
32
Table 20.1.2. Systematic reviews of antibiotic
prophylaxis (Cont.)
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
33
Mittendorf et al. Am J Obstet Gynecol
19931691119-24
34
Classen DC The timing of prophylactic
administration of antibiotics and the risk of
surgical-wound infection. NEJM 1992
326(5)282-286
35
Timing of Prophylactic Antibiotic Administration
and Subsequent Rates of SSIs
Early denotes 2-24 hrs before incision
preoperative 0-2 hours before incision
perioperative within 3 hrs after incision and
postoperative more than 3 hrs after
incision. Odds ratio determined by
logistic-regression analysis Adapted from
Classen, DC, Evans, RS, Pestotnik, SL, et al, N
Engl J Med 1992 326281
http//uptodateonline.com/application/topic/print.
asp?filebact_inf/20831typeAselectedTitle138
11/04/2003
36
Classen DC The timing of prophylactic
administration of antibiotics and the risk of
surgical-wound infection. NEJM 1992
326(5)282-286
37
Optimizing the timing of antimicrobial
prophylaxis in surgery an intervention study

• 3 surgical departments in Holland
• University Hospital
• Intervention undertaken in two departments
• First dose of antibiotics written one hour before
  incision (was studied)
• Department A 39 - 69
• Department B 64 - 80

Gyssens IC, et al J Antimicrob Chemother. 1996
Aug 38(2)301-8
38
Adherence to local hospital guidelines for
surgical antimicrobial prophylaxis a multicentre
audit in Dutch hospitals

• 13 Dutch hospitals
• Prospective audit of medical records
• Compared reality to local guidelines
• January 2000 January 2001
• 1763 procedures reviewed

Van Kasteren ME, et al. J. Antimicrob Chemother
2003 Jun51(6)1389-96
39
Adherence to local hospital guidelines for
surgical antimicrobial prophylaxis a multicentre
audit in Dutch hospitals
Van Kasteren ME, et al. J. Antimicrob Chemother
2003 Jun51(6)1389-96
40
(No Transcript)
41
Classen DC The timing of prophylactic
administration of antibiotics and the risk of
surgical-wound infection. NEJM 1992
326(5)282-286
42
Shojania KG, et al. Eds. Making Health Care
Safer A Critical Analysis of Patient Safety
Practices. Evidence Report/Technology Assessment
43 (Prepared by Univ of CA at San
Francisco-Stanford Evidence-based Practice Center
under Contract 290-97-0013), AHRQ Publ.
01-E058, Rockville, MD Agency for Healthcare
Research and Quality. July 2001
43
Classen DC The timing of prophylactic
administration of antibiotics and the risk of
surgical-wound infection. NEJM 1992
326(5)282-286
44
Impact of Surgical Site Infections

• 2-5 clean thoracic and orthopedic surgery
• 20 intra-abdominal surgery
• may underestimate infections which develop after
  discharge
• 500,000 per year
• Prolong hospital stay by 7 days

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Patient) IB Recommendations

• Control serum bld glucose in all diabetic pts.,
  avoid hyperglycemia perioperatively
• Encourage tobacco cessation, abstain 30 days
  before surgery
• Dont withhold necessary bld products as means to
  prevent SSI
• Night before, pts to bathe with antiseptic agent
• Thoroughly cleanse surgical site before doing
  antiseptic skin prep
• Use appropriate antiseptic agent for skin prep

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Patient) II Recommendations

• Keep preoperative hospital stay short
• Apply preop antiseptic skin prep in concentric
  circles moving toward periphery

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Surg Team) IB Recommendations

• Keep nails short, dont wear artificial nails
• Preop surg scrub at least 2 to 5 min (up to
  elbows) using appropriate antiseptic
• After surg scrub, hands up and away from body,
  dry hands with sterile towel, don sterile gown
  and gloves

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Surg Team) IB Recommendations

• Clean under each fingernail prior to 1st surg
  scrub of the day
• Do not wear hand or arm jewelry

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CDC GUIDELINE PREVENTION OF SSINo
Recommendations (Unresolved Issues)

• Wearing of nail polish by surgical team
• Taper or discontinue systemic steroids before
  surgery
• Preoperatively, apply mupirocin to nares of pt.
• Provide measures that enhance wound space
  oxygenation

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CDC GUIDELINE PREVENTION OF SSIPreoperative
Infected (Colonized Surg Personnel) - IB

• Surg/ personnel to promptly report signs and
  symptoms of transmissible infections to their
  supervisor and employee health
• Develop well-defined policies concerning
  personnel who have potentially transmissible
  infections
• Cx draining skin lesions and exclude person from
  duty til infection R/O or has resolved
• Do not routinely exclude colonized personnel
  unless linked epidemiologically to dissemination

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CDC GUIDELINE PREVENTION OF SSIPreoperative
(Patient) - Recommendations