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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

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Surgical site infections incidence impact evidence based interventions l.jpg

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


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SURGICAL SITE INFECTIONS EVIDENCE-BASED INTERVENTIONSImpact

  • 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


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EPIDEMIOLOGY EVIDENCE-BASED INTERVENTIONSSSI Rates Vary

  • Patient population

  • Size of hospital

  • Experience of the surgeon

  • Methods used for surveillance


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EPIDEMIOLOGY EVIDENCE-BASED INTERVENTIONSSSI Rates by Procedures


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Factors Affecting SSI EVIDENCE-BASED INTERVENTIONS

  • Patient characteristics

  • Preoperative

  • Intraoperative

  • Postoperative


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Patient Characteristics EVIDENCE-BASED INTERVENTIONS

  • Diabetes

  • Smoking/nicotine

  • Corticosteroids

  • Malnutrition

  • Prolonged preoperative stay

  • Colonization with S. aureus


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Preoperative EVIDENCE-BASED INTERVENTIONS

  • Antiseptic showering

  • Hair removal

  • Patient OR skin prep

  • Surgeon hand/forearm antisepsis

  • Colonized surgical personnel

  • Hyperglycemic control

  • Antimicrobial prophylaxis


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Intraoperative EVIDENCE-BASED INTERVENTIONS

  • OR environment

  • Surgical attire and drapes

  • Asepsis and surgical technique

  • Perioperative transfusion

  • Supplemental oxygen

  • Normothermia


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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


Postoperative l.jpg
Postoperative 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

  • Incision care

  • Discharge planning


Cdc guideline prevention of ssi categorizing recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Categorizing 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 (*)


Cdc guideline prevention of ssi preoperative patient ia recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative (Patient) – IA Recommendations

  • When possible, identify and treat all infections remote to surgical site before elective surgery

  • Don’t remove hair unless it will interfere with the operation

  • If hair removed, do immediately before surg., preferably with electric clippers


Cdc guideline prevention of ssi preoperative patient recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative (Patient) - Recommendations


Cdc guideline prevention of ssi preoperative patient recommendations14 l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative (Patient) - Recommendations


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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


Cdc guideline prevention of ssi preoperative surg team recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative (Surg Team) - Recommendations


Cdc guideline prevention of ssi preoperative infected colonized surg personnel recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative (Infected Colonized Surg Personnel)Recommendations


Cdc guideline prevention of ssi intraoperative ventilation recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Intraoperative (Ventilation) Recommendations


Cdc guideline prevention of ssi intraoperative surg attire drapes recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Intraoperative (Surg. Attire/Drapes) - Recommendations


Cdc guideline prevention of ssi intraoperative asepsis surg technique recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Intraoperative (Asepsis/Surg Technique) - Recommendations


Cdc guideline prevention of ssi intraoperative cleaning disinfecting recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Intraoperative (Cleaning/Disinfecting) Recommendations


Cdc guideline prevention of ssi intraoperative recommendations l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Intraoperative - Recommendations


Cdc guidelines prevention of ssi postoperative incision care recommendations l.jpg
CDC GUIDELINES: PREVENTION OF SSI 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 2001Postoperative (Incision Care) - Recommendations


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CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative 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)

  • Don’t routinely use vancomycin for antimicrobial prophylaxis (IB)


Cdc guideline prevention of ssi preoperative antimicrobial prophylaxis25 l.jpg
CDC GUIDELINE: PREVENTION OF SSI 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 2001Preoperative 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)


Antimicrobial prophylaxis l.jpg
Antimicrobial prophylaxis 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

  • Surgical incision = break in body’s 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


Antimicrobial prophylaxis27 l.jpg
Antimicrobial prophylaxis 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

  • 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


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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


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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



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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


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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



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Classen DC The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286


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Timing of Prophylactic Antibiotic Administration and antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Subsequent 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; 326:281

http://uptodateonline.com/application/topic/print.asp?file=bact_inf/20831&type=A&selectedTitle=1~3811/04/2003


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Classen DC The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286


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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


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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 Jun;51(6):1389-96


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Adherence to local hospital guidelines for surgical antimicrobial prophylaxis: a multicentre audit in Dutch hospitals

Van Kasteren ME, et al. J. Antimicrob Chemother 2003 Jun;51(6):1389-96


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Classen DC The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286


Slide42 l.jpg

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


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Classen DC The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286


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Impact of Surgical Site Infections antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286

  • 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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Preoperative (Patient) – IB Recommendations

  • Control serum bld glucose in all diabetic pts., avoid hyperglycemia perioperatively

  • Encourage tobacco cessation, abstain 30 days before surgery

  • Don’t 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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Preoperative (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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Preoperative (Surg Team) – IB Recommendations

  • Keep nails short, don’t 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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Preoperative (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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286No 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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Preoperative 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 SSI antibiotics and the risk of surgical-wound infection. NEJM 1992; 326(5):282-286Preoperative (Patient) - Recommendations


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