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Charles E. Edmiston Jr., PhD., CIC Professor of Surgery, Pathology, Otolaryngology

Improving Patient Outcome: Reducng the Risk of Surgical Site Infections by Embracing Basic and Innovative Risk Reduction Strategies. Charles E. Edmiston Jr., PhD., CIC Professor of Surgery, Pathology, Otolaryngology

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Charles E. Edmiston Jr., PhD., CIC Professor of Surgery, Pathology, Otolaryngology

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  1. Improving Patient Outcome: Reducng the Risk of Surgical Site Infections by Embracing Basic and Innovative Risk Reduction Strategies Charles E. Edmiston Jr., PhD., CIC Professor of Surgery, Pathology, Otolaryngology and Hospital Epidemiologist - Department of Surgery Medical College of Wisconsin Milwaukee, Wisconsin USA edmiston@mcw.edu

  2. Methicillin-ResistantStaphylococcal aureus (MRSA)

  3. Impact of Medical Injuries During Hospitalization Medical Injuries Major Hazard in Health Care System Safety Indicators d- LOS (p) $- Excess Charges (p) %- Excess Mortality (p) Decubitus ulcer 3.9 (<.001) 10,845.00 (<.001) 7.23 (<.001) Foreign bodies 2.1 (.002) 13,315.00 (<.001) 2.14 ((.04) Pneumothorax (Iatro) 4.4 (<.001) 17,312.00 (<.001) 6.7 (<.001) Postop hemorrhage 3.9 (<.001) 21,431.00 (<.001) 3.0 (<.001) Postop sepsis 10.9 (<.001) 57,727.00 (<.001) 21.9 (<.001) Wound dehiscence 9.4 (<.001) 40,323.00 (<.001) 9.6 (<.001) Infection due to medical care 9.5 (<.001) 38,656.00 (<.001) 4.3 (<.001)… Zhan et al, JAMA 2003;290:1868-1874

  4. CMS Reimbursement Changes Increase Hospital Focus on InfectionsOctober 1, 2008 “…hospitals will not receive additional payment for cases in which one (or more) of the following selected conditions was not present on admission (POA)….” • Serious preventable events – objects left after surgery, air embolism and blood incompatibility • Catheter-associated UTIs • Pressure ulcers • Catheter-associated bloodstream infections’ • Mediastinitis after CABG • Traumatic injuries during hospitalization

  5. How Does it Work After October 1, 2008 “A patient is admitted to a hospital with pneumonia and develops a urinary tract infection or bed sores during the hospitalization, the hospital would currently be paid $6,253, under DRG 89 ("pneumonia with complications"); under the new rule, if there were no other complications, the hospital would be paid $3,705, under DRG 90 ("simple pneumonia") representing a $2,548 (~40%) decrease in reimbursement.” Rosenthal MB. NEJM 2007;357:1573-1675

  6. Proposed Inpatient Reimbursement Rules Proposed “no-pay” conditions: Surgical site infections following elective procedures: Total knee replacement Laparoscopic gastric bypass and gastroenterostomy Ligation and stripping of varicose veins Legionnaire’s disease Glycemic control (diabetic coma, ketoacidosis, hypoglycemic coma, nonketotic hyperosmolar coma) Iatrogenic pneumothorax Ventilator-associated pneumonia Delirium Deep vein thrombosis/pulmonary embolism Staphylococcus aureus septicemia Clostridiumdifficile-associated disease MRSA Wrong Surgery FY 2009 and beyond

  7. Surgical Wound Taskforce • Interdisciplinary – MD, RN, PharmD, PhD, OR personnel • Putting the surgeon on the front-end • Understanding the complexities of the surgical sciences • Collegial – team building

  8. Role of Patient Risk Factors

  9. Possible Risk Factors for Postoperative Wound Infections Host Factors • Diabetes mellitus - SCIP • Estimated prognosis • Nutritional status • Serum albumin • Weight • Presence of other infections • Duration of preoperative stay • Age • Gender • Severity of disease • ASA physical status classification • Immunocompromising disease

  10. Possible Risk Factors for Postoperative Wound Infections Surgery Factors • Emergency vs elective procedure • Hair removal technique - SCIP • Surgeon • Site of surgery • Increased O2 tension • Surgical skin prep - SCIP • Perioperative antibiotics - SCIP • Normothermia - SCIP • Duration of surgery • Drains • Packs & Drapes • Glove puncture • Primary or secondary closure • Operating room environment • Iatrogenic

  11. A More Than Typical Scenario - Total Joint Replacement – What is the Risk? High Risk Patient: Immunosuppressive meds - RA Diabetes Advanced age Prior surgery to same joint Psoriasis Malnourished morbid obesity sAlb<35 low sTransferrin Remote sites of infection Smokers ASA ≥3

  12. Surgical Care Improvement Project (SCIP) Interdisciplinary process –To reduce preventable surgical morbidity and mortality by 25% by the year 2010

  13. Mitigating Risk - Surgical Care Infection Prevention (SCIP) – An Evidence-Based Approach • Timely and appropriate antimicrobial prophylaxis • Glycemic control in cardiac and vascular surgery • Appropriate hair removal • Normothermia in general surgical patients Does the Process Trump the Practice?

  14. Reinventing the Past - Reducing Risk on the Front End

  15. The Skin Antisepsis: Intervention on the Front End and Back End Non SCIP The Preoperative Antiseptic Shower: Does it Make Sense? • Reduce skin colonization • Enhanced residual activity • Cochrane Reports • Eyers PS, et al. Cochrane Database 2006;3: CD003073 • Edwards et al.. Cochrane Database 2006;3: • CD003949.pub 2 • No evidence of benefit associated with preoperative antiseptic shower/scrub • Flawed components • contact time • loss of antiseptic activity (rinse) • concentration

  16. 4% Chlorhexidine Gluconate (CHG) Shower - 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, In press – J Am Coll Surg 2008 (August)

  17. Sample (n) 10-m 30-m 6-hr 2% CHG cloth (30) 3.5 3.5 3.6 4% CHG prep (30) 2.8 2.6 3.1 t-test of mean difference p<0.0001 p<0.0001 p<0.01 Edmiston et al, Am J Infect Control 2007;35:89-96

  18. 2% Chlorhexidine Gluconate (CHG) Impregnated Cloth Application – Skin Surface Concentration (N = 60) CHG Cloth Application Group 1B “Evening (PM)” Group 2B “Morning (AM)” Group 3B “Both (AM and PM)” CHG Concentration (PPM) p<0.05 p <0.001 MIC90 = 4.8 ppm Left Elbow Right Elbow Abdominal Left Knee Right Knee Skin Sites Edmiston et al, In press – J Am Coll Surg 2008 (August)

  19. Community-Associated MRSA in the Elective Surgical Patient Population • 2006 - 57 MRSA from 9 surgical services • 40 HA-MRSA while 17 CA-MRSA (29.8%) • Surgical services – 3 surgical services • General (7): 5-superficial/2-deep incisional • Urology (4): 2-superficial/2-deep incisional • Plastic (4): 3-superficial/1-deep incisional • CT (2): 1-incisional/1-deep • Sensitive to clindamycin, tetracycline, SxT, vancomycin and rifampin • 100% CA-MRSA positive for PVL virulence gene • PFGE – USA300 clones • Prophylactic agent – cefazolin Edmiston et al, Wisconsin Surgical Meeting 2007

  20. Managing the Present – Perioperative Skin Antisepsis and Antimicrobial Prophylaxis

  21. Mean Microbial Counts (Log10) Following Povidone-Iodine (PI) VS Chlorhexidine Gluconate (CG) Surgical Scrub (N=36) Baseline 6.37 6.38 Post-scrub 4.13 2.74 1 hr 4.60 2.41 2 hr 4.32 2.69 3 hr 4.20 2.42 4 hr 5.34 3.02 5 hr 4.86 3.03 6 hr 5.23 2.32 PI CG SG & O 1978;146:63-65

  22. Perioperative Skin Preparation: A Comparison

  23. Let it Dry!

  24. Antimicrobial Prophylaxis

  25. Who Should be Responsible for the Delivery of Antibiotic Prophylaxis? • The surgical staff – ownership is not a priority • Anesthesiology – “recorded but not given” • Pharmacy responsibility – ultimate gatekeeper • Nursing – just another task – PACU may be the key Does SCIP ignore “best practice”

  26. Somewhere in the Midwest: Surgery SCIP Sample Data - Antibiotic within 1 hr of Incision Percent 84 8 12 88 11 13 205 22 43 105 10 16 118 15 19 115 13 22 17 26 21 29 23 99 34 34 27 44 27 41

  27. Does Timing Alone Represent Best Practice?

  28. Somewhere in the Midwest: Surgery SCIP Sample Data - Appropriate Antibiotic Selection Percent 88 8 12 87 11 12 208 24 41 108 11 16 122 15 20 120 13 22 18 27 22 29 27 99 36 34 28 44 31 41

  29. Somewhere in the Midwest: Surgery SCIP Sample Data - Antibiotic Discontinuation within 24 hours Percent 83 7 12 83 10 11 197 22 41 100 10 14 116 15 18 94 13 20 16 27 21 28 19 98 31 34 27 43 11 41

  30. Current Concepts Review - Prevention of Perioperative Infection • Nicholas Fletcher, MD, D’Mitri Sofianos, BS, Marschall Brantling Berkes, BS, and William T. Obremskey, MD, MPH • Vanderbilt Orthopedic Trauma, Nashville, Tennessee • Preoperative antibiotics is associated with reduced rates of surgical site infections. • Antibiotics should be continued for no longer than twenty-four hours after elective surgery or surgical treatment of closed fractures. • Chlorhexidine gluconate is superior to povidone-iodine for preoperative antisepsis for the patient and surgeon. • Closed suction drainage is not warranted in elective total joint replacement. It is associated with an increased relative risk of transfusions. Drains left in situ for more than twenty-four hours are at an increased risk for bacterial contamination. • Rate of postoperative infections associated with occlusive dressings is lower than that associated with nonocclusive dressings. • Management of blood glucose levels, oxygenation, and the temperature of the patient reduces the risk of postoperative infection. JBJS 2007;89:1605

  31. Roux-en-Y Gastric Bypass Is it possible that weight could be a mitigating risk factor in infection?

  32. Perioperative Antimicrobial Prophylaxis in Higher BMI (>40) Patients: Do We Achieve Therapeutic Levels? Percent Serum/Tissue Concentrations Achieving Therapeutic levels at a 2 gm (N = 38) and 3 gm (N = 40) Perioperative Dosing Regimen 2-gma 3-gmb Organism N Serum Tissue N Serum Tissue S. aureus 70 68.6% 27.1% 92 87.5% 68.5% S. epidermidis 110 34.5% 10.9% 156 64.5% 49.6% E. coli 85 75.3% 56.4% 101 92.4% 86.5% Kl. pneumoniae 55 80%65.4% 49 96.8% 98.4% a period covering 2001-2003 b period covering 2005-2007 aEdmiston et al, Surgery 2004;136:738-747 bEdmiston et al., In Press 2009

  33. The SCIP process does not adequately address BMI, redosing and the pharmacokinetics of extended ½-life agents

  34. Embracing the Future: Mitigating Risk in the OR and Impregnated Technology

  35. Late-Onset Vascular Graft Infection Slime-Forming Staphylococcus epidermidis

  36. Edmiston et al., Am J Surg 2006;192:344-354

  37. Antibiotics Antibodies PROTECTION Phagocytes NUTRIENT TRAPPING Glycocalyx Enclosed Microcolony Bacteria ADHERENCE Biomedical Device

  38. Percent Intraoperative Recovery of Airborne Microbial Populations During Vascular Surgery (N=70) Distance from operative field (m): 0.5 - 1.0 4.0 - 5.5 Percent recovery Staphylococcusaureus Misc. gram-negatives Corynebacterium spp Bacillus spp Micrococcus spp Candida (yeast) Coagulase negative staphylococci Edmiston et al, Surgery 2005; 138; 573-582

  39. 3a 3b 4a 5a 9a 11a MSM 7a 7b 1a 1b 1c 1d Edmiston et al, Surgery 2005; 138; 573-582

  40. Impact of Surgical Masks on Prevention of Microbial Nasopharyngeal Shedding in Healthy (N = 22) Individuals and Subjects with Symptoms of Rhinorrhea (N = 8) NS No Mask - Healthy Surgical Mask - Healthy No Mask - Rhinorrhea Surgical Mask - Rhinorrhea cfu/m3 NS p<0.05 p<0.05 90 minutes 180 minutes Test Interval Edmiston et al, Surgery 2005; 138:572-583

  41. Future Surgical Masks Technology will Involve: • Impregnated-antibacterial components • N-95 respiratory inspired technology This technology will reduce the risk of intra-operative microbial nasopharyngeal shedding but not without some increase in cost

  42. 1990;11:629-634 Seabrook & Edmiston, Critical Care Infectious Diseases 2001; 875-888

  43. Is there a Role for Impregnated Technology for Reducing the risk of Healthcare-Associated Infections – What is the Evidence?

  44. Innovative Strategies to Reduce Infection Within the Nosocomial Environment Antibacterial Devices – FDA registered Antiseptic cloth • 2% CHG impregnated • Foley catheters – hydrogel/silver • Ureteral stents – triclosan eluting • Implantable prostheses – antibiotic Urologic devices Central venous catheters • CHG-impregnated ring (cuff) • Silver alone • Silver sulfadiazine • SS/CHG • Minocycline-rifampin Peritoneal catheters • Silver coated • Silver/antibiotics coated Vascular catheters Orthopaedic devices • External fixation pins - silver • Antibiotic impregnated PMM

  45. Impregnated Devices in Orthopaedic Surgery – Management of Infected Total Knee Arthroplasty with Articulating Spacers • Historic infection rates – 1% to 23% (modern rate 1-2%) • Single-stage revision: acute infection, primary debridement = 56% success versus Two-stage revision (chronic): device removal + debridement + insertion of antibiotic-impregnated spacer with delayed reimplantation following 6-weeks of focused IV therapy (mean - 12-weeks) = 88-96% • Local administration of high dose antimicrobial • Washout cycles – 2 to ? (7) • Front-end consideration - Impact of oxacillin resistant (clindamycin sensitive) strains of MRSA on efficacy of antimicrobial prophylaxis Hoffman et al., Clin Orthop Related Res 2005;430:125-131 Cuckler, JM. J Arthroplasty 2005;20:33-36

  46. Efficacy of Antibiotic Impregnation of Inflatable Penile Prostheses in Decreasing Infection • Risk of infection at implantation = 2.1 to 3.7% • Penile prosthesis impregnated with rifampin and minocycline • Retrospective review of 4,205 original implants (2,261 impregnated group & 1,944 non-impregnated penile prosthesis) with a mean follow-up of 12.4 (impregnated group) vs 14.6 (non-imprgenated group) months • Results – infection rate • 60 days: 0.28% vs 1.59% p<0.003 (82% reduction) • 180 days: 0.68% vs 1.61% p<0.005 (58% reduction) • Use of impregnated penile prostheses resulted in significant decrease in infection rate associated with original insertion Carson, CC. J Urology 2004;171:1611-1614

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