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Prevention of Surgical Site Infections: Considerations in Measuring Effectiveness

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Title: Prevention of Surgical Site Infections: Considerations in Measuring Effectiveness


1
Prevention of Surgical Site Infections
Considerations in Measuring Effectiveness
Michele L. Pearson, MD Division of Healthcare
Quality Promotion National Center for Infectious
Diseases
2
Objectives
  • Provide overview of epidemiology of surgical site
    infections (SSI)
  • Discuss SSI prevention strategies
  • Highlight current surveillance systems for SSI
  • Provide overview of HICPAC/CDC process for
    developing recommendations for prevention
    healthcare-associated infections

3
Public Health Importance of Surgical Site
Infections
  • In U.S., gt40 million inpatient surgical
    procedures each year 2-5 complicated by
    surgical site infection
  • SSIs second most common nosocomial infection (24
    of all nosocomial infections)
  • Prolong hospital stay by 7.4 days
  • Cost 400-2,600 per infection (TOTAL 130-845
    million/year)

4
CDC Definition of Surgical Site Infections
SSI level classification Incisional SSI
- Superficial incisional skin and subcutaneous
tissue - Deep incisional involving deeper
soft tissue Organ/Space SSI - Involve
any part of the anatomy (organs and spaces),
other than the incision, opened or
manipulated during operations
5
Cross Section of Abdominal Wall Depicting CDC SSI
Classifications
6
Source of SSI Pathogens
  • Endogenous flora of the patient
  • Operating theater environment
  • Hospital personnel (MDs/RNs/staff)
  • Seeding of the operative site from distant focus
    of infection (prosthetic device, implants)

7
Microbiology of SSIs
1986-1989 (N16,727)
1990-1996 (N17,671)
8
Microbiology of SSIs
  • Unusual pathogens
  • Rhizopus oryzea - elastoplast adhesive
    bandage
  • Clostridium perfringens - elastic bandages
  • Rhodococcus bronchialis - colonized health
    care personnel
  • Legionella dumoffii and pneumophila - tap
    water
  • Pseudomonas multivorans - disinfectant
    solution
  • Cluster of unusual SSI pathogens ? formal
    epidemiologic investigation

9
Pathogenesis of SSI
  • Relationship equation
    Dose of bacterial contamination x
    Virulence Resistance of
    host

    SSI Risk

10
SSI Risk Factors
  • Age
  • Obesity
  • Diabetes
  • Malnutrition
  • Prolonged preoperative stay
  • Infection at remote site
  • Systemic steroid use
  • Nicotine use
  • Hair removal/Shaving
  • Duration of surgery
  • Surgical technique
  • Presence of drains
  • Inappropriate use of antimicrobial prophylaxis

11
Perioperative Preventive Measures
12
Role of Antimicrobial Prophylaxis (AP) in
Preventing SSI
  • Refers to very brief course of an antimicrobial
    agent initiated just before the operation begins
  • Should be viewed as an adjunctive preventive
    measure
  • Appropriately administered AP associated with a
    5-fold decrease in SSI rates

13
Importance of Timing of Surgical Antimicrobial
Prophylaxis (AP)
  • Prospective study of 2,847 elective clean and
    clean-contaminated procedures
  • Early AP (2-24 hrs before incision) 3.8 Postop
    AP (3-24 hrs after incision) 3.3 Periop AP
    (lt 3 hrs after incision) 1.4 Preop AP (lt2 hrs
    before incision) 0.6

Classen, 1992 (NEJM 326281-286)
14
Impact of Prolonged Surgical Prophylaxis
  • DESIGN Prospective
  • POPULATION CABG patients (N2641)
  • Group 1 pts who received lt 48 hours of AP
  • Group 2 pts who received gt 48 hrs of AP

15
Impact of Prolonged Surgical AP
  • OUTCOMES
  • Incidence of SSI
  • Isolation of a resistant pathogen
  • RESULTS 43 of patients received AP gt 48 hr
  • SSI Incidence
  • lt48 hrs group 8.7 (131/1502) vs
  • gt48 hrs group 8.8 (100/1139), p1.0
    Antimicrobial resistant pathogen
  • OR 1.6 (95 CI 1.1-2.6)

16
Enhanced Perioperative Glucose Control in
Diabetic Patients
  • DESIGN Prospective, sequential study
  • POPULATION Diabetic patients undergoing cardiac
    surgery (N2467) during 1987-1997
  • Controls pts who received intermittent subQ
    insulin (SQI)
  • Treated pts who received continuous
    intravenous (IV) insulin

Furnary AP Ann Thorac Surg, 2000
17
Enhanced Perioperative Glucose Control in
Diabetic Patients
  • OUTCOMES
  • Blood glucose lt200 mg/dl in first two days
    postop
  • Incidence of deep sternal SSI
  • RESULTS
  • SQI group 2.0 (19/968) vs
  • IVI group 0.8 (12/1499), p0.01

Furnary AP Ann Thorac Surg, 2000
18
Supplemental Perioperative O2
  • DESIGN Randomized controlled trial, double
    blind
  • POPULATION Colorectal surgery (N500)
  • INTERVENTION 30 vs 80 inspired oxygen during
    and up to hours after surgery
  • RESULTS SSI incidence 5.2 (80 O2) vs 11.2
    (30 O2), p0.01

Greif, R, et al , NEJM, 2000
19
Pre-operative Antiseptic Showers/Baths
Most studies examine effects on skin colony
counts antiseptic showering decreases colony
counts Few studies examine effect on SSI
rates No Shower Shower Cruse, 1973
2.3 1.3 Ayliffe, 1983 4.9
5.4 Rooter, 1988 2.4 2.6
20
Pre-operative Shaving/Hair Removal
Seropian, 1971 Method of hair removal Razor
5.6 SSI rates Depilatory 0.6 SSI rates No
hair removal 0.6 SSI rates Timing of hair
removal Shaving immediately before 3.1 SSI
rates Shaving ? 24 hours before 7.1 SSI
rates Shaving gt24 hours before 20 SSI rates
21
Pre-operative Shaving/Hair Removal
Multiple studies show - Clipping
immediately before operation associated with
lower SSI risk than shaving or clipping the
night before operation
22
Surgical Attire
  • Scrub suits
  • Cap/hoods
  • Shoe covers
  • Masks
  • Gloves
  • Gowns

23
Surgical Technique
  • Removing devitalized tissue
  • Maintaining effective hemostasis
  • Gently handling tissues
  • Eradicating dead space
  • Avoiding inadvertent entries into a viscus
  • Using drains and suture material appropriately

24
Parameters for Operating Room Ventilation
  • Temperature 68o-73oF, depending on normal
    ambient temp
  • Relative humidity 30-60
  • Air movement from clean to less clean
    areas
  • Air changes gt15 total per hour gt3 outdoor
    air per hour


American Institute of Architects, 1996
25
Role of Laminar Air Flow (Ultraclean Air) in
Preventing SSI
  • Most studies involve only orthopedic operations
  • Lidwell et al 8,000 total hip and knee
    replacements
    ultraclean air SSI rate ?3.4 to 1.6
    antimicrobial prophylaxis (AP) SSI rate
    ?3.4 to 0.8
    ultraclean air AP SSI
    rate ?3.4 to 0.7

26
Status of SSI Surveillance
27
CDC Surveillance Systems
NNIS DSN NaSH
Nosocomial infections in critical care and surgical patients Bloodstream and vascular access infections in dialysis outpatients Exposure to bloodborne pathogens TB skin testing and exposure Vaccine history, receipt, and adverse events
1999-2004
1996-present
1970-2004
28
Characteristics of NNIS Hospitals, 2000
  • 300 hospitals
  • 58 are MAJOR TEACHING
  • 10 are Graduate Teaching
  • 15 are Limited Teaching
  • 16 are Non Affiliated Hospitals
  • Bed Size
  • Median 360 beds
  • No facilities lt 100 beds

29
Variables Collected in Surgical Patient
Component, NNIS
  • Age
  • Sex
  • ASA score
  • Wound class
  • Trauma-related
  • Type of anesthesia
  • Emergency vs elective
  • Duration of surgery
  • Length of postoperative stay
  • Infection site (skin/soft tissue, organ space)
  • Pathogen
  • Mortality
  • Hospital demographics (bed-size, affiliation)

30
SSI Risk Index
  • From the U.S. National Nosocomial Infections
    Surveillance (NNIS) system
  • American Society of Anesthesiologists (ASA) score
  • 1 to 5, from 1normal, healthy to 5patient
    not expected to survive for 24 hours with OR
    without operation
  • Wound Class
  • Clean, clean-contaminated, contaminated, dirty
  • Duration of surgery

31
Surgical Site Infection (SSI) Rates By Risk
Category,
NNIS System, 1986-1999
16
Low risk
12
Medium
8
SSIs per 100 operations
low risk
Medium
high risk
4
High risk
0
1992
1993
1994
1995
1996
1997
1998
1999
1986-90
Years
32
SSI Definitions Period of Surveillance
  • Infection occurs within 30 days after the
    operative procedure if no implant is left in
    place or within 1 year if implant is in place and
    the infection appears to be related to the
    operative procedure

33
Challenges to Surveillance for SSIs
34
What Is NHSN?
Integration of CDCs three patient and healthcare
personnel surveillance systems
  • NNIS
  • NaSH
  • DSN

35
NHSN Premises
  • Maintain the goals of predecessor systems
  • Minimize data collection and manual data entry
    burden
  • Streamline existing surveillance protocols
  • Increase capacity for capturing electronic data
    (e.g., Laboratory information systems, operating
    room, pharmacy, clinical, administrative
    databases)
  • Extensible web-based application

36
Priority Areas for NHSN Development
  • Inclusion of process measures linked to outcomes
  • Surgical prophylaxis
  • Central line insertion practices
  • Completion of HCP Safety Component
  • NaSH ? NHSN
  • Influenza pilot vaccine coverage and use of
    antiviral medications

37
How do we develop policy?
38
Healthcare Infection Control Practices Advisory
Committee (HICPAC)
39
Healthcare Infection Control Practices Advisory
CommitteeMISSION
  • Advise the US Secretary of Health and the
    Director of CDC regarding the practice of
    infection control and strategies for
    surveillance, prevention and control of
    antimicrobial resistance, and related adverse
    events in healthcare settings

40
CDC/HICPAC GUIDELINE SCOPE
  • TARGET AUDIENCE
  • clinicians
  • infection control professionals
  • public health officials
  • regulators
  • TARGET SETTINGS
  • Inpatient
  • Outpatient
  • Home care
  • Long term care

41
Ranking Scheme for HICPAC Recommendations (2001)
  • CATEGORY IA. Strongly recommended for all
    hospitals and strongly supported by well-designed
    experimental or epidemiologic studies.
  • CATEGORY IB. Strongly recommended for all
    hospitals and viewed as effective by experts in
    the field and a consensus of HICPAC based on
    strong rationale and suggestive evidence, even
    though definitive scientific studies may not have
    been done.
  • CATEGORY IC. Required for implementation, as
    mandated by federal or state regulation or
    standard. CATEGORY II. Suggested for
    implementation in many hospitals. Recommendations
    may be supported by suggestive clinical or
    epidemiologic studies, a strong theoretical
    rationale, or definitive studies applicable to
    some but not all hospitals.
  • NO RECOMMENDATION UNRESOLVED ISSUE. Practices
    for which insufficient evidence or consensus
    regarding efficacy exists.

42
CDC/HICPAC GuidelineRATING SYSTEM
  • CATEGORY EVIDENCE PRACTICE
  • IA/IB STRONG RECOMMENDED
  • IC LACKING REQUIRED BY REGULATION
  • II GOOD SUGGESTED
  • NO REC INSUFFICIENT UNRESOLVED
  • CONTRADICTORY

43
Challenges/Issues
  • Subject matter experts vs. methodologic experts
  • Resources for systematic reviews
  • Limited randomized trials
  • User needs vs available science (e.g., expansion
    to non-hospital settings)

44
Healthcare Infection Control Practices Advisory
CommitteeGUIDELINE FORMAT
  • PART I Provides review and synthesis of
    available research on guideline topic and
    established scientific rationale for
    recommendations
  • PART II Provides summary of practice
    recommendations
  • PART III Provides performance indicators for
    institutions to monitor success in
    implementing recommended practices

45
Summary
  • Prevention of SSI require a multifaceted approach
    targeting pre-, intra-, and postoperative factors
  • Current surveillance systems do collect data on
    perioperative processes
  • Increasing shift of surgical procedures to
    outpatient settings and decrease in postoperative
    length of stay complicate surveillance efforts
  • Incidence is generally low so studies would
    require large sample size
  • Some prevention practices (e.g. hand hygiene)
    would be difficult to study using traditional
    randomized controlled trial research design

46
PREVENTION IS PRIMARY!
Protect patientsprotect healthcare
personnel promote quality healthcare! Division
of Healthcare Quality Promotion
47
Division of Healthcare Quality Promotion (DHQP)
website
To obtain HICPAC guidelines visit the
  • http//www.cdc.gov/ncidod/hip/default.htm
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