Transcript Preventing Surgical Site Infections

Preventing Surgical Site
Infections
Donald E. Fry, M.D.
Professor Emeritus of Surgery
University of New Mexico
Prevention of SSIs

Objectives
Reduce the inoculum of bacteria at the
surgical site
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Surgical Site Preparation
Antibiotic Strategies
Optimize the microenvironment of the
surgical site
Enhance the physiology of the host
Hair Removal of the Surgical Site
Razor vs. Clipper
Percent SSI Infection
PM Razor
Discharge
5.2%
30-day Follow up
8.8%
AM Razor
6.4%
10%
PM Clipper
4.0%
7.5%
AM Clipper
1.8%
3.2%
Alexander JW et al: Arch Surg 1983; 118:347-52.
Antiseptic Preparation of the
Surgical Site
Isopropyl alcohol, povidone iodine, and
chlorhexidine are all recommended.*
Choice
Commentary
Isopropyl alcohol
Flammable
Povidone Iodine
Must dry for maximum
antibacterial effect
Chlorhexidine
Colorless; even distribution
at surgical site is an
issue

*Mangram
AJ at al: Am J Infect Control 1999; 27:97-132.
Immunocompromised Surgical Host
Microenvironment of the Surgical Site
Variable
Causation
Effect
Hemoglobin/
Hematoma
Poor Hemostasis
Iron, microbial
proliferation
Dead Tissue
Electrocautery
Ineffective
phagocytosis
Foreign Bodies
Braided Suture
Ineffective
phagocytosis
Dead Space
Obesity; Lack of
Drainage
No
phagocytosis
“The Germ is nothing, the terrain is everything” L. Pasteur (1895)
•
Joseph Lister
• A Surgeon
from Edinburgh
• Introduced the
practice of using
Antiseptics
during surgical
procedures.
• Even
introduced the
aerosolization of
antiseptics to
prevent SSI.
Surgical Site Infection
History of Preventive Strategies
Antisepsis
Asepsis
Antibiotics
Preventive Systemic
Antibiotics
Experimental Evidence


Cutaneous injection
of bacteria
Inflammation at 2448 hrs is proportional
to the logarithm of
the bacterial
inoculum.
Prevention of Surgical Site Infection
Use of Preventive Antibiotics: GI Surgery
Cephaloridine
Patients
Infections
Placebo
101
98
6
29
(Polk and Lopez-Mayor, Surgery 1969; 66:97)
Preventive Systemic Antibiotics:
Importance of Timing(Cefazolin)
8-12Hrs Preop 1Hr Preop 1-4Hrs Postop None
Gastric
5%
4%
17%
22%
Biliary
3%
0%
9%
11%
Colon
Total
6%
4%
6%
3%
15%
14%
16%
15%
( Stone, Ann Surg 1976; 184:443)
Preventive Systemic Antibiotics
Postoperative Administration(Cefamandole)
Preop Drug
Gastric
Biliary
Colon
Total
+ 5 Days of Drug
0%
0%
11%
5%
(Stone, Ann Surg 1979; 189:691)
Preop Drug
+ 5 Days of Placebo
0%
6%
9%
6%
Systemic Preventive
Antibiotics
Penetrating Abdominal Trauma
Timing
Preoperative
Intraoperative
Postoperative
# of Patients
116
98
81
( Fullen et al: J Trauma 1972; 12:282)
Infection Rate
7%
33%
30%
Systemic Preventive
Antibiotics
Aortobifemoral Bypass
Cefazolin
Placebo
SSIs/Patients
2/225
16/237
( Kaiser et al: Ann Surg 1978; 188:283)
Infection Rate
0.9%
6.8%
Systemic Preventive Antibiotics
Hip Fracture Surgery
Nafcillin
Placebo
SSIs/Patients
1/135
7/145
(Boyd et al: JBJS 1973; 55:1251)
Infection Rate
1%
5%(P<.04)
Systemic Preventive Antibiotics
Open Fractures
Cefonicid(One Day)
Cefonicid(Five Day)
Cefamandole(5 Day)
#Patients
#Infections
79
85
84
10(13%)
10(12%)
11(13%)
(Dellinger et al:Arch Surg 1988; 123:333)
Antibiotic Prophylaxis
Demonstrated Benefit

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G.I. Procedures (including appendicitis)
Oropharyngeal procedures
Vascular (abd & leg) procedures
Open heart procedures
Obstetrical and Gynecological procedures
Orthopaedic hardware placement
Craniotomy
Some “clean” procedures
Systemic Preventive
Antibiotics
Contraindications
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Ventilator Patients to Prevent Pneumonia
Foley Catheters to Prevent UTI
IV Lines to Prevent Catheter Sepsis
Chest Tubes to Prevent Empyema
Open Wounds(Including Fractures)
Song and Glenny: Brit J Surg 1998; 85:1232
100
10
Favors single dose
1
0.1
All studies, fixed
All studies, random
Multi > 24h
Multi < 24h
Favors multiple dose
Single vs Multiple Dose Surgical
Prophylaxis: Systematic Review
0.01
McDonald M: Aust NZ J Surg 1998;68:388
Systemic Preventive Antibiotics
Why Postoperative Administration Fails


Systemically Administered Antibiotic does
not penetrate the Established Fibrin Matrix
in the Wound.1
The Closed Surgical Wound has continued
Inflammation and Edema, which creates a
“Halo” of Ischemia.2
Dunn D, Simmons DL: Surgery 1982; 92:513-9.
Lee JT: Surgical Infections, Fry DE(Ed), Little-Brown, Boston. Pp. 145-59, 1995.
Systemic Preventive Antibiotics
Consequences of Prolonged Postoperative
Use
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Excessive Antibiotic and Drug
Delivery Costs.
Increased Patterns of Antibiotic
Resistance.
Increased Antibiotic-Associated
Complications.
Bratzler et al Arch Surg 2005, 140:174-82.
Preventive Systemic Antibiotics
Antibiotic-Associated Complications
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Hypersensitivity
Nephrotoxicity
Hepatic Toxicity
Coagulation/Platelet Aggregation
Complications
Fungal Super-infections
Clostridium difficile Enterocolitis
Cunha BA: Med Clin N Am 2001; 85:149-85.
Systemic Preventive Antibiotics
Elimination Half-life Counts


Cephalothin is gone
from the wound in 90
min from time of
administration.
Cefazolin in
therapeutic
concentrations
beyond 2½ hours.
Fry and Pitcher: Arch Surg 1990; 125:1490
Prevention of SSIs
Surgical Infection Prevention Project
 Administration of antibiotic within 60 min of
skin incision.
 Antibiotic consistent with recommended
choices.
 Antibiotic should not be continued beyond
24 hours after completion of the
procedure.
Bratzler et al Arch Surg 2005, 140:174-82.
Surgical Infection Prevention
Performance Stratified by Surgery
Antibiotic within
1 hour
%
Correct
Antibiotic
%
Antibiotic
Stopped within
24 hours
%
Cardiac (7,861)
45.3
95.8
34.3
Vascular (3,207)
40.0
91.9
44.8
Hip/knee (15,030)
52.0
97.4
36.3
Colon (5,279)
40.6
75.9
41.0
Hysterectomy (2,756)
52.4
90.8
79.1
All Surgeries (34,133)
47.6
92.9
40.7
Surgery (N)
Discontinuation of Antibiotics
100
88
85.8
100
90.7
79.5
80
73.3
60
60
50.7
40.7
40
40
26.2
22.6
14.5
20
20
10
9.3
6.3
6.2
2.7
2.2
Hours After Surgery End Time
Patients were excluded from the denominator of this performance measure if there was any
documentation of an infection during surgery or in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.
96
>
-9
6
>8
4
-8
4
>7
2
-7
2
>6
0
-6
0
>4
8
-4
8
>3
6
-3
6
>2
4
>1
2
le
12
or
-2
4
0
ss
0
Cumulative Percent
Percent
80
Public Law 109-171
Deficit Reduction Act of 2005

Procedures of reporting
 Each hospital must:
 For the FY 2007 update, hospitals are
required to complete and return a written
form on which they pledge to submit data
21 clinical quality measures beginning with
discharges that occur in July 2006
 Failure to report results in loss of
2% of the hospital’s annual
payment update
Final Inpatient Prospective Payment System Rule
published August 18, 2006 in Federal Register
Public Law 109-171
Deficit Reduction Act of 2005

Surgical Infection Prevention/SCIP
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Antibiotic within 60 minutes incision
Antibiotic choice consistent with SIP/SCIP
Recommendations
Antibiotic DCed within 24 hours surgery end
time (48 hours cardiac surgery)
Prevention of SSIs
Something New
Potential Strategies to Augment the
Host!
 Oxygen Supplementation
 Intraoperative Temperature Control
 Glucose Control
Prevention of SSIs
Enhanced Oxygenation
No. Patients
SSIs
Infection Rate
0.30 FiO2
250
28
11%
(Grief et al: NEJM 2000; 342:161)
0.80 FiO2
250
13
5%
Prevention of SSIs
Temperature Control
No. Patients
Transfused Pts.
SSIs
Infection Rate
To>36.5
104
23(22%)
6
5.8%
( Kurz et al: NEJM 1996; 334:1209)
To>34.5
96
34(35%)[P<.054]
18
18.8%(P< .009)
Prevention of SSIs
Glucose Control
Intermittent
Insulin
No. Patients
968
Deep Sternal SSI
19
Infection Rate
2.0%
Continuous
Infusion
1499
12(P<0.01)
0.8%
(Furnary et al: Ann Thorac Surg 1999; 67:352)
Surgical Care Improvement
Project: Why?
Medicare could prevent* up to:
13,027 perioperative deaths
271,055 surgical complications
* Major surgical cases
Surgical Care Improvement
Project
National Goal
To reduce preventable surgical
morbidity and mortality by
25% by 2010
Surgical Care Improvement Project
(SCIP)
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Preventable Complication Modules
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Surgical infection prevention
Cardiovascular complication prevention
Venous thromboembolism prevention
Respiratory complication prevention
Surgical Care Improvement Project
Performance measures - Process
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Surgical infection prevention
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Antibiotics
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Administration within one hour before incision
Use of antimicrobial recommended in guideline
Discontinuation within 24 hours of surgery end
Glucose control in cardiac surgery patients
 Proper hair removal
 Normothermia in colorectal surgery patients
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Reporting of SSI rates by Hospital is
expected to be the first surgical outcome
measure for reporting.
Preventive Antibiotics in Colorectal
Surgery
Before
After
• One year
100
demonstration project of
90
56 hospitals.
• Employed systems
changes, education, and
monitoring of process
measures.
•Marked improvement in
all procedures seen
compared to national
data.
•27% improvement in
SSI rates.
80
70
60
50
40
30
20
10
0
SIP #1
SIP #2
Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate
to decrease surgical site infections. Am J Surg. 2005;190(1):9-15.
SIP #3
Preventing Surgical Site Infection
Summary



Appropriate Preparation of the Surgical Site
 Appropriate Hair Removal
 Antiseptic Preparation of the Site
Appropriate Use of Systemic Preventive Antibiotics
 Administer within 60 min window before incision
 Appropriate drug choice
 Discontinue with 24 hours of the procedure
Optimization of the Physiology of the Host
 Supplemental Oxygenation
 Core Temperature Control
 Glucose Control