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Infection Control for the OB/GYN Surgeon. Gonzalo Bearman, MD, MPH Assistant Professor of Internal Medicine & Epidemiology Associate Hospital Epidemiologist. Outline. Nosocomial Infections are a significant cause of morbidity and mortality

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infection control for the ob gyn surgeon

Infection Control for the OB/GYN Surgeon

Gonzalo Bearman, MD, MPH

Assistant Professor of Internal Medicine & Epidemiology

Associate Hospital Epidemiologist

outline
Outline
  • Nosocomial Infections are a significant cause of morbidity and mortality
  • There has been increased public interest in nosocomial infections
  • Shifting paradigm
    • Many infections are preventable
  • SSI and OB/GYN
    • Surveillance data
    • Risk factors
    • Modifiable risk factors- modifiable interventions
  • BSI and OB/GYN
    • Surveillane
    • Risk reduction strategies
  • Proliferation of drug resistant nosocomial pathogens
    • Hand Hygeiene and Contact precautions
slide3

“11,600 patients got infections in Pa. hospitals “

7/13/2005

"The consequences clearly are huge," says Marc Volavka, executive director of the Pennsylvania Health Care Cost Containment Council, an independent state agency that published the data. "Everyone is paying the bill."

shifting vantage points on nosocomial infections
Shifting Vantage Points on Nosocomial Infections

Many infections are inevitable, although some can be prevented

Each infection is potentially preventable unless proven otherwise

Gerberding JL. Ann Intern Med 2002;137:665-670.

nosocomial infections
Nosocomial Infections
  • 5-10% of patients admitted to acute care hospitals acquire infections
    • 2 million patients/year
    • ¼ of nosocomial infections occur in ICUs
    • 90,000 deaths/year
    • Attributable annual cost: $4.5 – $5.7 billion
      • Cost is largely borne by the healthcare facility not 3rd party payors

Weinstein RA. Emerg Infect Dis 1998;4:416-420.

Jarvis WR. Emerg Infect Dis 2001;7:170-173.

nosocomial infections1
Nosocomial Infections
  • 70% are due to antibiotic-resistant organisms
  • Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection

Burke JP. New Engl J Med 2003;348:651-656.

Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

attributable costs of nosocomial infections
Attributable Costs of Nosocomial Infections

Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. 2003:36.

major sites of nosocomial infections
Major Sites of Nosocomial Infections
  • Urinary tract infection
  • Bloodstream infection
  • Pneumonia (ventilator-associated)
  • Surgical site infection
national nosocomial infections surveillance system nnis
National Nosocomial Infections Surveillance System (NNIS)
  • NNIS is the only national system for tracking HAIs
  • Voluntary reporting system has approximately 300 hospitals
  • The NNIS database uses standardized definitions of HAI’s to:
    • Describe the epidemiology of HAIs
    • Describe antimicrobial resistance associated with HAIs
    • Produce aggregated HAI rates suitable for interhospital comparison

http://www.cdc.gov/ncidod/hip/SURVEILL/NNIS.HTM

nnis ssi surveillance 1992 2004
NNIS- SSI Surveillance 1992-2004

Am J Infect Control 2004;32:470-85

slide14

NNIS- SSI Surveillance 1992-2004

Am J Infect Control 2004;32:470-85

slide15

NNIS- SSI Surveillance 1992-2004

Am J Infect Control 2004;32:470-85

hospital morbidity due to post operative infections in obstetrics and gynecology
Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology
  • Post operative infections prospectively surveyed from 1997-1998 in tertiary care medical center, Bahrain
    • Definition of postoperative infection:
      • Fever
      • Purulent discharge from wound
        • With or without a positive microbiologic culture
      • Re-admissions for wound infections were not included in the study

Saudi Medical Journal 2000: Vol 21 (3) 270-273

slide17

Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology

Saudi Medical Journal 2000: Vol 21 (3) 270-273

slide18

Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology

Genitourinary flora is a significant source of contamination during surgery

Saudi Medical Journal 2000: Vol 21 (3) 270-273

risk factors for surgical site infections following cesarean section
Risk Factors for Surgical Site Infections Following Cesarean Section
  • OBJECTIVE: To identify risk factors associated with surgical-site infections (SSIs) following cesarean sections.
  • DESIGN: Prospective cohort study.
  • SETTING: High-risk obstetrics and neonatal tertiary-care center in upstate New York.
  • METHODS:
        • Prospective surgical-site surveillance was conducted using methodology of the National Nosocomial Infections Surveillance System.
        • Infections were identified on admission, within 30 days following the cesarean section, by readmission to the hospital or by a postdischarge survey.
        • Multiple logistic-regression analysis used for risk factor identification

Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7

slide20

Risk Factors for Surgical Site Infections Following Cesarean Section

Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7

summary ssi s in ob gyn
Summary: SSI’s in OB/GYN
  • NNIS- SSIs are reported to occur in 1%-7% of OB/GYN surgeries
  • SSI are typically caused by maternal cutaneous or endometrial/vaginal flora
  • When an exogenous source is the cause of SSI in the obstetrical patient, S.aureus is frequently implicated
preventing surgical site infections

Preventing Surgical Site Infections

Focus on modifiable risk factors

sources of ssis
Sources of SSIs
  • Endogenous: patient’s skin or mucosal flora
    • Increased risk with devitalized tissue, fluid collection, edema, larger inocula
  • Exogenous
    • Includes OR environment/instruments, OR air, personnel
  • Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection
    • May occur days to weeks following the procedure
  • Most infections occur due to organisms implanted during the procedure
slide24

Up to 20% of skin-associated bacteria in skin appendages (hair follicles, sebaceous glands) & are not eliminated by topical antisepsis. Transection of these skin structures by surgical incision may carry the patient's resident bacteria deep into the wound and set the stage for subsequent infection.

Downloaded from: Principles and Practice of Infectious Diseases

© 2004 Elsevier

risk factors for ssi
Risk Factors for SSI
  • Duration of pre-op hospitalization

* increase in endogenous reservoir

  • Pre-op hair removal

* esp if time before surgery > 12 hours

* shaving>>clipping>depilatories

  • Duration of operation

*increased bacterial contamination

* tissue damage

* suppression of host defenses

* personnel fatigue

slide26
SCIP
  • A national partnership of organizations to improve the safety of surgical care by reducing post-operative complications through a national campaign
  • Goal: reduce the incidence of surgical complications by 25 percent by the year 2010
  • Initiated in 2003 by the Centers for Medicare & Medicaid Services (CMS) & the Centers for Disease Control & Prevention (CDC)
    • Steering committee of 10 national organizations
    • More than 20 additional organizations provide technical expertise

Putting risk reduction guidelines into practice

scip steering committee organizations
SCIP Steering Committee Organizations
  • Agency for Healthcare Research and Quality
  • American College of Surgeons
  • American Hospital Association
  • American Society of Anesthesiologists
  • Association of periOperative Registered Nurses
  • Centers for Disease Control and Prevention
  • Centers for Medicare & Medicaid Services
  • Department of Veterans Affairs
  • Institute for Healthcare Improvement
  • Joint Commission on Accreditation of Healthcare Organizations
slide29

Monetary incentives for promoting quality and compliance with SSI risk reduction guidelines:

March 12, 2005

In recent years, the healthcare industry has placed a stronger emphasis on reducing medical errors, monitoring everything from how long doctors sleep to whether or not their handwriting is legible.Now one organization is not only recognizing the hospitals that follow patient safety and clinical guidelines, but rewarding them for doing so. Anthem Blue Cross and Blue Shield recently gave a total of $6 million to 16 Virginia hospitals as part of the company's new Quality-In-Sights Hospital Incentive Program (Q-HIP).

http://www.richmond.comID=15

slide30

Infection Rate

Downloaded from: Principles and Practice of Infectious Diseases

process indicators duration of antimicrobial prophylaxis
Process Indicators:Duration of Antimicrobial Prophylaxis

Prophylactic antimicrobials should be discontinued within 24 hrs after the end of surgery

Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

process indicators timing of first antibiotic dose
Process Indicators:Timing of First Antibiotic Dose

Infusion should begin within 60 minutes of the incision

Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

nosocomial bloodstream infections 1995 2002
Nosocomial Bloodstream Infections, 1995-2002

N= 24,847

52 BSI/10,000 admissions

Edmond M. SCOPE Project.

nosocomial bloodstream infections 1995 20021
Nosocomial Bloodstream Infections, 1995-2002

Obstetrics and Gynecology

  • Proportion of all BSI 0.9% (n=209)
    • E.coli (33%)
    • S.aureus (11.7%)
    • Enterococci (11.7)

In obstetrics, BSIs are uncommon. However, the principal pathogen is E.coli and not coagulase negative staphylococci.

The source is typically genitourinary

N= 24,847

52 BSI/10,000 admissions

Edmond M. SCOPE Project.

nosocomial bloodstream infections1
Nosocomial Bloodstream Infections
  • 12-25% attributable mortality
  • Risk for bloodstream infection:
risk factors for nosocomial bsis
Risk Factors for Nosocomial BSIs
  • Heavy skin colonization at the insertion site
  • Internal jugular or femoral vein sites
  • Duration of placement
  • Contamination of the catheter hub
prevention of nosocomial bsis
Prevention of Nosocomial BSIs
  • Coated catheters
    • In meta-analysis C/SS catheter decreases BSI (OR 0.56, CI95 0.37-0.84)
    • M/R catheter may be more effective than C/SS
    • Disadvantages: potential for development of resistance; cost (M/R > C/SS > uncoated)
  • Use of heparin
    • Flushes or SC injections decreases catheter thrombosis, catheter colonization & may decrease BSI
prevention of nosocomial bsis1
Prevention of Nosocomial BSIs
  • Limit duration of use of intravascular catheters
    • No advantage to changing catheters routinely
  • Change CVCs to PICCs when possible
  • Maximal barrier precautions for insertion
    • Sterile gloves, gown, mask, cap, full-size drape
    • Moderately strong supporting evidence
  • Chlorhexidine prep for catheter insertion
slide41
30%-40% of all Nosocomial Infections are Attributed to Cross Transmission- Implication For The Spread Drug Resistant Pathogens
slide42

NNIS: Selected antimicrobial resistant pathogens associated with HAIs

Fig 1. Selected antimicrobial-resistant pathogens associated with nosocomial infections in ICU patients, comparison of resistance rates from January through December 2003 with 1998 through 2002, NNIS System.

Am J Infect Control 2004;32:470-85

antimicrobial resistant pathogens of ongoing concern
Antimicrobial Resistant Pathogens of Ongoing Concern
  • Vancomycin resistant enterocci
    • 12% increase in 2003 when compared to 1998-2002
  • MRSA
    • 12% increase in 2003 when compared to 1998-2002
    • Increased reports of Community-Acquired MRSA
  • Cephalosporin and Imipenem resistant gram negative rods
    • Klebsiella pneumonia
    • Pseudomonas aeruginosa

Am J Infect Control 2004;32:470-85

transfer of vre via hcw hands
Transfer of VRE via HCW Hands
  • 16 transfers (10.6%) occurred in 151 opportunities.
  • 13 transfers occurred in rooms of unconscious patients who were unable to spontaneously touch their immediate environment

Duckro et al. Archive of Int Med. Vol.165,2005

the inanimate environment is a reservoir of pathogens
The inanimate environment is a reservoir of pathogens

X represents a positive Enterococcus culture

The pathogens are ubiquitous

~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

slide46
Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units.
  • Outbreak of 7 cases of skin and soft tissue infections due to a strain of CA-MRSA.
    • All patients were admitted to the labor and delivery, nursery, or maternity units during a 3-week period.
    • Genetic fingerprinting showed that the outbreak strain was closely related to the USA 400 strain that includes the midwestern strain MW2

Emerg Infect Dis. 2005 Jun;11(6):808-13.

slide48
Epidemic of Staphylococcus aureus nosocomial infections resistant to methicillin in a maternity ward
  • Seventeen cases were recorded over a nine-week period (two cases per week).
    • All were skin and soft tissue infections
  • Pulsed field gradient gel electrophoresis confirmed the clonal character of the strain.
  • No definite risk factors were determined by a case-control study.
  • Environmental factors were considered key in the persistence of this MRSA outbreak.

Pathol Biol (Paris). 2001 Feb;49(1):16-22.

the inanimate environment is a reservoir of pathogens1
The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, C.diff CNS and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

the inanimate environment is a reservoir of pathogens2
The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

the inanimate environment is a reservoir of pathogens3
The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

alcohol based hand hygiene solutions
Alcohol based hand hygiene solutions

Easy to use

Quick

Very effective antisepsis due to bactericidal properties of alcohol

hand hygiene
Hand Hygiene
  • Single most important method to limit cross transmission of nosocomial pathogens
  • Multiple opportunities exist for HCW hand contamination
    • Direct patient care
    • Inanimate environment
  • Alcohol based hand sanitizers are ubiquitous
    • USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES
slide54

Contact Precautions for drug resistant pathogens.

Gowns and gloves must be worn upon entry into the patient’s room

conclusion
Conclusion
  • Nosocomial Infections are a significant causes of morbidity and mortality
  • There has been increased public interest in nosocomial infections- this will likely result in greater compliance with IC guidelines
  • Shifting paradigm
    • Many infections are preventable
  • SSI and OB/GYN
    • 1-7 % of all OB/GYN procedures (NNIS)
    • Increased scrutiny of compliance with risk reduction intervention
      • Preoperative antibiotics: choice, timing, discontinuation;
  • BSI and OB/GYN
    • BSI is less common than in Medicine/Surgical services
    • Risk reduction strategies should include appropriate use and prompt removal of invasive devices
  • Proliferation of drug resistant nosocomial pathogens
    • Importance of Hand Hygiene and Contact precautions