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Prevention of Surgical Site Infections

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  1. Prevention of Surgical Site Infections William A. Rutala, Ph.D., M.P.H. UNC Health Care System and UNC School of Medicine, Chapel Hill, NC

  2. Disclosure This educational activity is brought to you, in part, by Advanced Sterilization Products (ASP) and Ethicon. The speaker receives an honorarium from ASP and Ethicon and must present information in compliance with FDA requirements applicable to ASP.

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

  4. Healthcare-Associated Infections (HAIs) • HAIs are those that develop in the hospital that were neither incubating nor present at the time of admission • 40 million persons hospitalized annually in US; 5% or 2M will develop a HAI • Morbidity and mortality (90,000 deaths); 6th leading cause of death in the US • Variable prolongation of hospital stay • $5-10 billion/year

  5. Impact of Healthcare-Associated Infections

  6. Cost Estimates for Specific Healthcare-Associated Infections 2005 US dollars Anderson DJ, et al. ICHE 2007;28:767-773

  7. Most Prevalent Weinstein RA. Emerg Infect Dis. 1998;4(3):416-420. CDC, NNIS Semiannual Report, Dec 2000.

  8. Surgical Site Infection

  9. Surgical Site Infection SSIs third most common HAI, accounting for 14-16% of HAIs Among surgical patients, SSIs were most common accounting for ~40% of healthcare-associated infections 67% incisional infections (confined to incision) 33% organ/space infections Increase an average of 7 days to each hospitalization Increase >$10,000 (2005 $) to each hospitalization Appropriate preoperative administration of antibiotics and other prevention measures are effective in preventing infection Surgical Site Infections. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/. Odom-Forren J. Nursing2006. 2006;36(6):58-63.

  10. Surgical Site Infection • Advances in infection control practices • Improved operating room ventilation • Sterilization methods • Barriers • Surgical technique • Antimicrobial prophylaxis

  11. Challenges in the Prevention and Management of Surgical Site Infections • Changing population of hospital patients • Increased severity of illness • Increased numbers of surgical patients who are elderly • Increased numbers of chronic, debilitating or immunocompromising underlying diseases • Shorter duration of hospitalization • Increased numbers of prosthetic implant and organ transplant operations performed • Public reporting of infection rates/proportions • Growing frequency of antimicrobial-resistant pathogens • Non-reimbursement for “medical errors”-CMS • Lack of compliance with hand hygiene

  12. SSI: Pathogenesis Risk of surgical site infections = Dose of bacterial contamination x virulence (toxins) Resistance of the host

  13. 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 Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.

  14. SSI: Microbiology (NNIS, 1996)

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

  16. 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.

  17. CDC: SSI Recommendations, 1999 • Definitions • IA: Strongly recommended for all hospitals and strongly supported by experimental or epidemiologic studies • IB: Strongly recommended for all hospitals and viewed as effective by experts • II: Suggested for implementation in many hospitals; suggestive clinical or epidemiologic studies, strong theoretical rationale

  18. 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.

  19. 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.

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

  21. 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

  22. Prevention of SSIs • Preoperative preparation of the patient • Minimize preoperative stay (II) • Identify and treat remote site infections (IA) • Adequately control glucose in diabetics (IB) • Encourage discontinuation of tobacco for 30d (IB). Consider delaying elective procedures in severely malnourished patients (II) • No recommendations to taper or discontinue steroids (Unresolved issue)

  23. 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.

  24. 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.

  25. 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)

  26. Preoperative Showers • Garibaldi R (J Hosp Infect 1988;11(suppl B):5 • Reduction in bacterial counts: Chlorhexidine 9-fold, povidone-iodine 1.3-fold • Cruse and Foord (Arch Surg 1973;107:206) • Clean surgery • SSI rate, no shower = 2.3% • SSI rate, shower with soap = 2.1% • SSI rate, shower with hexachlorophene = 1.3%

  27. Chlorhexidine: Preoperative Showers CDC recommends preoperative showering with antiseptic1 CHG more effective than PI and triclocarban Lower rates of intraoperative wound contamination 1. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278. 2. Garibaldi RA. J Hosp Infect. 1988;11(suppl B):5-9.

  28. Chlorhexidine: Preoperative Showers Patients who had 2 preoperative showers with CHG 24 hours before surgery had reduced rates of wound infection compared to patients who showered with soap. Hayek LJ, et al. J Hosp Infect. 1987;10(2):165-172.

  29. 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

  30. Preoperative Hair Removal • Seropian and Reynolds (Am J Surg 1971;121:251) • SSI rate, razor-shave (microabrasions) = 5.6% • SSI rate, razor-shave >24 hours = 20% • SSI rate, razor-shave within 24 hours = 7.1% • SSI, razor-shave immediately preop = 3.1% • SSI rate, no removal or depilatory = 0.6%

  31. Preoperative Hair Removal • Cruse and Foord (Arch Surg 1973;107:206) • SSI rate, razor-shave = 2.5% • Manual hair clipped = 1.7% • Electric hair clipper = 1.4% • No shave or clip = 0.9%

  32. 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.

  33. Prevention of SSIs • Preoperative preparation of the surgical team • Keep nails short and no artificial nails (IB) • Perform preoperative surgical scrub for 2-5 minutes with antiseptic-alcohol, chlorhexidine, iodophors (IB); new waterless, surgical hand antisepsis with alcohol • Perform preoperative scrub including forearms (IB) • Do not wear hand/arm jewelry (II) • Prohibiting nail polish (No recommendation)

  34. Importance of Our Skin Microorganisms 80% in first 5 cell layers of epidermis When skin is perforated Integrity is compromised  infection risk #1 Function: Protective Barrier

  35. 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

  36. Surgical Hand Antisepsis

  37. 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

  38. Combined Agents

  39. 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

  40. Prevention of SSI • Preoperative preparation of the patient • Use appropriate antiseptic for skin preparation (IB) • Alcohol (70-92%) • Chlorhexidine 4%, 2% or 0.5% in alcohol base • Iodine/iodophors • Apply in concentric circles moving to periphery • Prep area to include incision and any drain sites

  41. 2% CHG/70% IPA vs. 10% PVP-I Randomized, parallel group, open label, healthy human volunteers 55 subjects Microbial samples: right and left abdominal and inguinal sites Efficacy defined as ≥2.0 log10 reduction from baseline CFUs/cm2 on abdominal sites ≥3.0 log10 mean reduction from baseline CFUs/cm2 on inguinal sites Hibbard JS. J Infus Nursing. 2005;28(3):194-207.

  42. 2%CHG/70% IPAvs. 10% PVP-I Abdominal Inguinal P=0.0001 compared to baseline for all results Hibbard JS. J Infus Nursing. 2005;28(3):194-207

  43. 2% CHG/70% IPA for Foot and Ankle Surgery Prospective, randomized trial 125 evaluable patients 40 subjects/group 5 pre-prep baseline Products ChloraPrep® (2% CHG/70% IPA) DuraPrep® (0.7% Iodine/74% IPA) Techni-Care® (3% Chloroxylenol-PCMX) Cultures: hallux, web spaces between toes, and control site Ostrander RV, et al. Bone Joint Surg Am. 2005;87(5):980-985.