Transcript PREVENTING SURGICAL SITE INFECTIONS

SURGICAL SITE INFECTIONS:
EPIDEMIOLOGY, PATHOGENESIS & PREVENTION, 2014
David Jay Weber, M.D., M.P.H.
Professor of Medicine, Pediatrics, & Epidemiology
Associate Chief Medical Officer
Medical Director, Hospital Epidemiology
University Of North Carolina at Chapel Hill
TOPICS: SSI

Epidemiology




Pathogenesis





Impact of healthcare-associated SSI
Definitions
NHSN surveillance definitions
Risk factors
Microbiology
Diagnosis
Treatment
Prevention
SSIs: IMPACT


An estimated 16 million operations were performed in acute care
hospitals in 20101
Prevalence




Impact




1-
2-5% of surgical patients develop an SSI2
~160,000-300,000 SSIs per year in US 2
SSI is now the most common and costly HAI2
Each SSI results in 7-11 additional hospital days2
Patients with SSI have a 2-11 times higher risk of death2
77% of deaths among patients with SSI are directly due to SSI2
Cost (2007 dollars): $3.5 to $10 billion annualy2
www.cdc.gov/nhsn/pdfs, 2Anderson D, et al ICHE 2014 (in press)
Magill SS, et al. New Engl J Med 2014;370:1198
CMS, VALUE BASES PURCHUSING, FY
2013 MEASURES
Dupress JM, et al. J Am Coll Surg 2014;218:1-7
SELECTING AN NHSN
OPERATIVE PROCEDURE


Select at least one NHSN operative procedure category. A
procedure must meet the NHSN definition of an operative
procedure in order to be included in the surveillance
Example 1
Legacy code = APPY
Operative procedure = Appendix surgery
Description = Operation of appendix (not incidental to another procedure)
 ICD-9-CM Codes/CPT Codes: 47.01, 47.09, 47.2, 47.91, 47.92, 47.99




Example 2
Legacy code = CHOL
Operative procedure = Gallbladder surgery
Description = Cholecystectomy and cholecystotomy
 ICD-9-CM Codes/CPT Codes: 51.03, 51.04, 51.13, 51.21-51.24 / 47480, 47562,
47563, 47564, 47600, 57605, 47610, 47612, 47620



ICD-9 codes take precedence over CPT codes
SURGICAL SITE INFECTONS (SSI):
REQUIREMENTS


Both post-discharge and ante-discharge surveillance methods
should be used to detect SSIs followinog in- and outpatient
operative procedures.
These methods include (any combination of methods is
acceptable):




Direct examination of patients’ wounds during the follow-up visits to
either surgery clinics or physician’s offices
Review of medical records or surgery clinic patient records
Surgeon surveys by mail or telephone
Patient surveys by mail or telephone
http://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html
NHSN DEFINITIONS

An NHSN operative procedures is a procedure:



That is included in the NHSN list of surgeries AND
Takes place during an operation (defined as a single trip to the operating
room (OR) where a surgeon makes at least one incision through the skin
or mucous membrane, including laparoscopic approach AND
That takes place in an operating room (defined by AIA)AND
CDC, January 2014
NHSN DEFINITIONS: DENOMINATOR I

ASA physical status (patient is assigned one of the following)







A normally healthy patient (1)
A patient with mild systemic disease (2)
A patient with severe systemic disease (3)
A patient with severe systemic disease that is a constant threat to life (4)
A moribund patient who is not expected to survive without operation (5)
Do NOT report procedures with an ASA score of 6 (brain dead patient
whose organs are being removed for transplant)
Date of event: For an SSI the date of event is the date when the last
element used to meet the SSI infection cirterion occurred
CDC, January 2014
NHSN DEFINITIONS: DEMONINATOR II







Diabetes: Insulin or non-insulin diabetes
Duration of operative procedure: The interval in hours and minutes
between the procedure start and finish time
Emergency: A non-elective, unscheduled operative procedure
General anesthesia: Administration of drugs or gases that enter the
general circulation and effect the CNS to render the patient pain free,
amnesic, unconscious, and often paralized
Height: Record in feet and inches or meters
NHSN inpatient: Different dates of admission and discharge
HNSN outpatient: Same date of admission and discharge
CDC, January 2012
NHSN DEFINITIONS: DENOMINATOR III





Non-primary closure: Defined as closure that is other than primary and
includes surgical in which the superficial layers are left completely
open
Primary closure: Defined as closure of all tissue levels during the
original surgery regardless of the presence of wires, wicks, drains, etc.
Scope: An instrument used to visualize the interior of a body cavity
Weight: Most recent weight in pounds or kilograms
Wound Class:

Clean, Clean-contaminated, Contaminated, Dirty or infected
CDC, January 2014
SSI RISK AS A FUNCTION
OF WOUND CLASSIFICATION
Wound Classification
Risk of Infection
Clean
1.3-2.9%
Clean-contaminated
2.4-7.7%
Contaminated
6.4-15.2%
Dirty and infected
7.1-40.0%
NHSN DEFINITIONS: DENOMINATOR IV

ASA physical status (patient is assigned one of the following)







A normally healthy patient (1)
A patient with mild systemic disease (2)
A patient with severe systemic disease (3)
A patient with severe systemic disease that is a constant threat to life (4)
A moribund patient who is not expected to survive without operation (5)
Do NOT report procedures with an ASA score of 6 (brain dead patient
whose organs are being removed for transplant)
Date of event: For an SSI the date of event is the date when the
last element used to meet the SSI infection cirterion occurred
CDC, January 2014
SURVEILLANCE OF SSIs

NHSN definitions



Superficial incisional SSI
Deep incisional SSI
Organ/space SSI
www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf
NHSN DEFINITIONS:
SUPERFICIAL INCISIONAL SSI



Infection occurs within 30 days after NHSN operative procedure AND
Involves only skin and subcutaneous tissues of the incision AND
Patient has at least one of the following




Purulent drainage from the superficial incision
Organism isolated from an aseptically obtained culture of fluid or tissue
from the superficial incision
Superficial incision is deliberated opened by surgeon and is culturepositive or not cultures AND at least one of the following: pain or
tenderness; localized swelling, redness or heat. A culture-negative
finding does not meet this definition
Diagnosis of superficial incisional SSI by surgeon or attending MD
NHSN DEFINITIONS:
SUPERFICIAL INCISIONAL SSI

Comments: There are 2 specific types of superficial incisional
SSIs


Superficial Incisional Primary (SIP): A superficial incisional SSI that
is identified in the primary incision in a patient that has had an
operation with one or more incisions (e.g., C-section incision or chest
incision for CBBG)
Superficial Incisional Secondary (SIS): A superficial incisional SSI
that is identified in the secondary incision in a patient that has had an
operation with one or more incisions (e.g., donor site [leg] incision for
CBGB)
NHSN DEFINITIONS:
SUPERFICIAL INCISIONAL SSI







Do not report stitch abscess (minimal inflammation and discharge
confined to the points of suture penetration) as an infection
Do not report a localized stab wound infection as SSI, instead report at
skin (SKIN), or soft tissue (ST), infection, depending on its depth
“Cellulitis”, by itself does not meet the criteria for a superficial SSI
If the incisional site infection involves or extends into the fascial and
muscle layers, report as a deep incisional SSI
Classify infection that involves both superficial and deep incision sites as
deep incisional SSI
Report infection of the circumcision site in newborns as CIRC.
Circumcision is not an NHSN operative procedure
An infected burn wound in classified as BURN
NHSN DEFINITIONS:
DEEP INCISIONAL SSI



Infection occurs within 30 or 90 days after the NHSN operative
procedure (see following slides 30&90 days) AND
Involves deep soft tissue (e.g., fascial layers) AND
Patient has at least one of the following



Purulent drainage from the deep incision
A deep incision spontaneously dehisces or is deliberately opened by a surgeon
and is culture positive or not cultured AND the patient has at least one of the
following: fever (>38 oC) or localized pain or tenderness. A culture-negative
finding does not meet this definition
An abscess or other evidence of infection involving the deep incision is found on
direct examination, during invasive procedure, or by histopathologic or radiologic
examination
NHSN DEFINITIONS:
DEEP INCISIONAL SSI

Comments: There are 2 specific types of deep incisional SSIs



Deep Incisional Primary (DIP): A deep incisional SSI that is identified
in a primary incision in a patient that has had an operation with one
or more incisions (e.g., C-section or chest incision for CBGB)
Deep Incisional Secondary (DIS): A deep incisional SSI that is
identified in a secondary incision in a patient that has had an
operation with one or more incisions (e.g., donor site [leg] incision for
CBGB)
Reporting instructions

Classify infection that involves both superficial and deep incisional
sites as deep incisional SSI
NHSN DEFINITIONS:
DEEP INCISIONAL SSI

Comments: There are 2 specific types of deep incisional SSIs


Deep Incisional Primary (DIP): A deepincisional SSI that is identified
in the primary incision in a patient that has had an operation with one
or more incisions (e.g., C-section incision or chest incision for CBBG)
Deep Incisional Secondary (DIS): A deep incisional SSI that is
identified in the secondary incision in a patient that has had an
operation with one or more incisions (e.g., donor site [leg] incision for
CBGB)
SURVEILLANCE PERIOD FOR DEEP INCISIONAL OR ORGAN?
SPACE SSI FOLLOWING SELECTED NHSN PROCEDURES
SURVEILLANCE PERIOD FOR DEEP INCISIONAL OR ORGAN?
SPACE SSI FOLLOWING SELECTED NHSN PROCEDURES
NHSN DEFINITIONS:
ORGAN/SPACE SSI



Infection occurs within 30 or 90 days after HNSN operative procedure
(see preceeding slides 30&90 days) AND
Infection involves any part of the body (excluding the skin incision, fascia
or muscle layers) that is opened and manipulated during the operative
procedure AND
Patient has at least one of the following:





Purulent drainage from a drain that is placed into the organ/space
Organism isolated from an aseptically obtained culture of fluid or tissue in
the organ/space
An abscess or other evidence of infection involving the organ/space that is
found on direct examination, during invasive procedure, or by
histopathologic or radiology examination
Diagnosis of organ/space SSI by surgeon or attending MD AND
Meets at least one of the criterion for a specific organ/space infection
SPECIFIC SITES OF AN
ORGAN/SPACE SSI
NHSN DEFINITIONS: NUMERATOR I




General: All patients having any of the procedures in the selected NHSN
operative procedure cathegory(s) are monitored for signs of SSI
Multiple tissue levels are involved in the infection: The type of SSI
(superficial incisional, deep incisional, or organ/space) report should reflect
the deepest tissue layer involved in the infection
Attributing SSI to NHSN procedures when several are performed on different
dates: If a patient has several NHSN operative procedures prior to an
infection, report the operative procedure code of the operation that was
performed most closely in time prior to the infection date, unless there is
evidence that the infection is associated with a different operation
Attributing SSI to NHSN procedures that involve multiple primary incision
sites: If multiple primary incision sites of the same NHSN operative
procedure become infected, only report as a single SSI
CDC, January 2014
NHSN DEFINITIONS: NUMERATOR II


SSI attribution after surgery multiple types of NHSN procedures are
performed during a single trip to the OR: If more than one NHSN operative
procedure category was performed through a single incision during a single
trip to the OR, attribute the SSI to the procedure that is thought to be
associated with the infection
SSI following invasive manipulation/accession of the operative site: If during
the post-operative period the surgical site has an invasive
manipulation/accession for diagnostic or therapeutic purposes, and following
this manipulation an SSI develops, the infection is NOT atributed to the
operation.
CDC, January 2014
NHSN: DATA ANALYSIS

The standard infection ratio (SIR) is calculated by dividing the
number of observed infections by the number of predicted
infections. The number of predicted infections is calculated using
SSI probabilities estimated from multivariate logistic regression
models constructed from NHSN data during a baseline period,
which represents a standard population’s SSI experience
SSI SIR MODELS
“NEW” NHSN SSI RISK STRATIFICATION


Study goal: Improve NHSN SSI risk stratification
Methods: NHSN data from 2006-2008 analyzed


Procedure specific risk models developed
Results


Data from 849 hospitals and 849,659 procedures analyzed
“New” model superior to “old” model (c-index, 0.67 vs 0.60)
Mu Y, et al. ICHE 2011;32:970-986
“NEW” NHSN SSI RISK STRATIFICATION
MULTIVARIATE MODELS PREDICTING SSI
LIMITATIONS OF “NEW” NHSN
SSI RISK MODEL

Model generated from predictor variables of convenience that
exist in NHSN database rather than all known risk factors


Predictor variables chosen for inclusion in the model on the basis
of statistical parameters alone



Patient level variables = Age, gender, wound class, ASA score, and 23 other variables
Unknown relevance of bed size and medical school affiliation
Study sample over emphasized large hospitals
Overall change in c-index is modest

Only 16 (41%) of procedure-specific models have c-index >0.7
Moehring RW, Anderson DJ. ICHE 2011;32:987
SSIs: NNIS, 1992-1998
Gaynes RP, et al. CID 2001;33(suppl 2):S69
SSI: SOURCES OF PATHOGENS

Endogenous


Patient’s own skin flora at or contiguous to site of operation(s)
or at distant site
Exogenous


Personnel: Hands or fallout from hair, scalp, nares or
oropharynx of operative team
Environment: Surfaces rarely incriminated; Air not thought to
significantly contribute
MICROBIOLOGY OF SSIs




Skin: Gram (+): Staphylococci and streptococci primarily
Gastrointestinal system: Mixed flora including enteric, Gram (-)
bacilli; anaerobes; and Gram (+) organisms (enterococci) and yeast
Genitourinary tract: Gram (-) organisms primarily (E. coli, Klebsiella
spp., and Pseudomonas) but also some Gram (+) organisms
(enterococci)
Female genital tract: Enteric, Gram-negative bacilli; Gram (+) cocci
such as enterococci, group B streptococci, straphylococci, and
streptococci; and anaerobes
TOP 9 PATHOGENS ASSOCIATED WITH
SSIs: NHSN, 2009-2010
S. aureus
CoNS
E. coli
E. faecalis
P. aeruginosa
Enterobacter spp.
K. pneumoniae/oxytoca
Enterococcus spp.
Sievert DM, et al. ICHE 2013;34;1-14
Proteus spp.
Other
0%
5%
10%
15%
20%
25%
30%
35%
COMMUNITY VERSUS POSTOPERATIVE
PATHOGENS IN PERITONITIS
Roehrborn A, et al. CID 2001;33:1513
BACTERIOLOGIC FINDINGS IN SURVIVORS VERSUS
NONSURVIVORS IN POSTOPERATIVE PERITONITIS
SSI: TRENDS IN MICROBIOLOGY

Pathogens with increasing incidence



MRSA, VRE, antibiotic resistant Gram-negative bacilli
Candida spp.
Possible reasons for changes in pathogens



Increased severity of illness of surgical patients
An increased number of immunocompromised surgical
patients
More widespread use of prophylactic and therapeutic
antimicrobial agents
SSI: PATHOGENESIS
Risk of surgical site infections =
Microbial load x Virulence x Tissue injury x Foreign material x Antibiotic resistance
____________________________________________________________
Host resistance x Perioperative antibiotics
SSI: INTRINSIC RISK FACTORS
(patient related – perioperative)

Unmodifiable



Age
History of radiation
History of skin and softtissue infections

Modifiable





Glucose control
Obesity
Smoking cessation
Immunosuppressive
medications
Hypoalbuminemia
Anderson D, et al. ICHE (in press)
SSI: EXTRINSIC RISK FACTORS
(procedure related – perioperative)

Preparation of patient



Hair removal: Avoid
Pre-operative infections: Identify and treat
Operating room characteristics




Ventilation: Follow AIA recommendations for air handling in the OR
Traffic: Minimize OR traffic
Environmental surfaces: Disinfect with an EPIA approved product
Sterilization of surgical equipment: Follow published guidelines
(minimize use of immediate use steam sterilization)
Anderson D, et al. ICHE (in press)
SSI: EXTRINSIC RISK FACTORS
(procedure related – perioperative)

Operative characteristics








Surgical scrub: use appropriate antiseptic
Skin preparation: apply around skin incision (use an alcohol containing
product)
Use appropriate antimicrobial prophylaxis (correct antibiotic choice,
administration timing, and duration)
Blood transfusions: Avoid if possible
Surgeon skill/technique: Handle tissue carefully and eradicate dead space
Appropriate gloving
Adhere to aseptic techniques
Minimize operative time
SSI: MICROBE-RELATED RISK FACTORS

Load of bacteria introduced into wound





Contamination with >105 microorganisms/gm of tissue
markedly increases the risk of SSI while less contamination
generally does not produce inflammation
Virulence of the bacteria contaminating the wound
Elaboration of endotoxins
Ability to resist host defenses
Ability to adhere to wound surfaces/prosthetic devices
SPECTRUM OF POST-OPERATIVE
INFECTIONS

Skin and soft tissue



Gangrenous infections: Onset of clinical findings is 2448 hr after operation


Staphylococci, streptococci
Abdominal surgery: Gram (+) plus Gram (-) and anaerobes
Group A -hemolytic streptococci, Clostridia
Necrotizing infections: Onset of clinical findings is >4
days (subacute) after operation

Polymicrobial; aerobic and anaerobic bacteria
STREPTOCOCCAL CELLULITIS
STREPTOCOCCAL GRANGRENOUS
INFECTION FOLLOWING MINOR TRAUMA
Nichols RL, Florman S. CID 2001;33(suppl 2):S84
STREPTOCOCCAL GRANGRENOUS INFECTION
FOLLOWING AN OPERATIVE PROCEDURE
Nichols RL, Florman S. CID 2001;33(suppl 2):S84
CLOSTRIDIAL MYONECROSIS
NECROTIZING FASCIITIS
NECROTIZING FASCIITIS
RECOGNITION AND TREATMENT OF SSIs:
SUPERFICIAL WOUND INFECTIONS

Signs: Cellulitis/erythema at wound margin and no pus
expressible




If physical exam reveals signs of a fluid collection consider
aspiration of the fluid for Gram stain and culture
Usually caused by staphylococci and streptococci and
treated with an appropriate antibiotic
Oral therapy often effective
Consider possibility of deep/organ space infection
RECOGNITION AND TREATMENT OF SSIs:
SUPERFICIAL WOUNDS

Without sepsis (generally only oral therapy required)




Primary: 1o cephalosporin, semisynthetic penicillin; consider need
for MRSA coverage
Alternatives: Amp/sul, quinolone, linezolid, tigecycline, ceftaroline
Necrotizing cellulitis (e.g., streptococcal) may required different
therapy
With sepsis (IV therapy required)


Primary: Pip/tazo, amp/sul, imipenem, meropenem, doripenem;
consider need for MRSA coverage
Alternatives: 3o/4o cephalosporin (combination therapy should be
highly considered)
RECOGNITION AND TREATMENT OF SSIs:
DEEP WOUNDS


Signs: Fever, elevated WBC, superficial wound
infection, pus drains between fascial sutures, failure to
heal, spontaneous dehiscence
Non-antimicrobial therapy
Wound should be reopened
 Consider surgical reexploration or percutaneous drainage
 Debridement of necrotic tissue indicated
 Irrigation of wound using physiologic solutions and packing
with fine mesh sterile gauze

RECOGNITION AND TREATMENT OF SSIs:
DEEP AND ORGAN SPACE SSIs



Antibiotic therapy is directed by Gram stain and culture
of purulent material and/or empirical selection based on
likely pathogens
Blood cultures should be obtained when deep or organ
space SSIs are considered
Obtain cultures of deep sites or organ spaces via
aspiration (CT guided) or during re-exploration
RECOGNITION AND TREATMENT OF SSIs:
DEEP WOUNDS



Without sepsis (IV therapy generally indicated)
 Primary: 1o/2o cephalosporin; consider need for MRSA coverage
 Alternatives: Amox/clavulanate, semisynthetic penicillin,
quinolone, linezolid, tigecycline, ceftaroline
 Necrotizing fasciitis (e.g., usual mixed flora) may required different
therapy (vanc, clindamycin, carbapenem)
With sepsis (IV therapy required)
 Primary: Pip/tazo, amp/sul, imipenem, meropenem, doripenem;
consider need for MRSA coverage
 Alternatives: 3o/4o cephalosporin (combination therapy should be
highly considered)
For surgery involving GI or GU tracts consider need for anaerobic and
enterococcal coverage
RECOGNITION AND TREATMENT OF SSIs:
ORGAN SPACE INFECTIONS


Signs: Fever, elevated WBC, superficial/deep wound
infection, pus drains between fascial sutures, failure to
heal, spontaneous dehiscence, organ dysfunction, sepsis
Non-antimicrobial treatment




Noninvasive or invasive drainage of abcess
May require open exploration with remove fascial sutures,
debridement if fascial necrosis present
If fascial tension present and concern exists regarding intestinal
herniation, the fascial defect may be allowed to persist and
repaired after infection resolved
May require placement of drains
IDSA GUIDELINE FOR THERAPY OF INTRAABDOMINAL INFECTIONS











Most patients with IAI can be identified with routine history, physical and labs (A-II)
Further diagnostic imaging is unnecessary in patients with obvious signs of
peritonitis (B-III)
In adults not undergoing immediate laparotomy, CT is imaging modality of choice to
demonstrate an IAI (A-II)
Provide fluid resuscitation (A-II)
Initiate antibiotics once a patient diagnosed with an IAI (A-III)
Appropriate source control to drain infected foci is recommended (B-II)
Where feasible, percutaneous drainage of abscesses is preferred (B-II)
Obtain blood cultures only if patient toxic or immunocompromised (B-III)
Obtain cultures from site of infection for patients with prior antibiotic exposure (A-II)
Empiric antibiotics should be active against enteric Gram (-) aerobes and facultative
bacilli and enteric Gram (+) streptococci (A-I)
Cover anaerobes for distal small bowel and colon-derived infections (also
perforations in the presence of obstruction or paralytic ileus (A-I)
Solomkin JS, et al. CID 2010;50:133
STRENGTH OF RECOMMENDATIONS
AND QUALITY OF EVIDENCE
CLINICAL FACTORS PREDICTING FAILURE OF
SOURCE CONTROL IN INTRA-ABDOMINAL INFECTIONS
REGIMENTS FOR INITIAL EMPIRIC THERAPY
OF EXTRA-BILIARY COMPLICATED IAI
REGIMENTS FOR INITIAL EMPIRIC THERAPY
HEALTHCARE-ASSOCIATED IAI
STRATEGIES TO DETECT SSI


Direct method (daily observation) is most accurate
Indirect reliable (sens, 84%-89%) and specific (spec, 99.8%)








Review of microbiology reports and patient medical records
Surgeon and/or patient surveys
Screening for readmission of surgical patients
Other: Coded diagnoses or operative reports
Indirect method is less time consuming and readily performed
Indirect methods are not reliable for surveillance of superfiical SSIs
Automated methods can be used to broaden SSI surveillance
No standardized method for post-discharge surveillance
Anderson D, et al. ICHE 2014 (in press)
STRATEGIES TO PREVENT SSIs

CMS – Surgical Infection Prevention (SIP) Project (2002)




Deliver antibiotic prophylaxis within 1 hour (2 hours for
vancomycin/quinolones) before incision
Use an antibiotic with known effectiveness (consistent with guidelines)
Discontinue antibiotics within 24 hours (48 hours for cardiac surgery)
CMS - Surgical Care Improvement Project (SCIP, 2003)



Proper hair removal (clip immediately before surgery)
Control blood glucose post-op days 1 and 2 (<200 mg/dL no w<180 mg/dL)
for cardiac surgery patients within 18-24 hours after anesthesia
Maintain perioperative normothermia for patients who have anesthesia
duration of at least 60 minutes
Anderson D, et al. ICHE 2014 (in press)
STRATEGIES TO PREVENT SSIs

SIP and SCIP surgeries
Coronary artery bypass grafting
 Vascular surgery: Aneurysm repair, thromboendarterectomy,
vein bypass
 General abdominal colorectal surgery
 Hip and knee arthroplasty (excludes revisions)
 Abdominal and vaginal hysterectomy

Anderson D, et al. ICHE 2008;29(suppl 1):S51-S61
FEDERAL REQUIREMENTS: CMS

CMS requires hospitals to submit data on 7 SCIP measures
including





Antimicrobial prophylaxis within 1 houirs of incision
Antimicrobial selection
Cardiac surgery perioperative glucose control
CMS requires hospitals to report SSI rates for patients undergoing abdominal hysterectomy and colorectal surgery via NHSN
Actual rates of payment under SCIP measures now impacts
hospital payment under Value-Based Purchasing (VBP) program
RECOMMENDED PREVENTION STRATIGIES:
BASIC PRACTICES (all acute care hospitals)

Administer antimicrobial prophylaxis according to evidence based
standards and guidelines





Begin within 1 hour before incision (2 hours allowed for vancomycin
and fluoroquinolones)
Infuse all antibiotics prior to inflation of tourniquets in procedures
using “bloodless” techniques (e.g., carpal tunnel surgery)
Select appropriate agents based on the surgical procedure and most
common pathogens
Stop antibiotics within 24 hours of surgery (no evidence that agents
given after closure contribute to efficacy)
Adjust dosing based on patient weight
RECOMMENDED PREVENTION STRATIGIES:
BASIC PRACTICES (all acute care hospitals)

Administer antimicrobial prophylaxis according to evidence based
standards and guidelines




Re-dose antibiotics at intervals of 2 half-lives (for prolonged
procedures or excessive blood loss)
Using a combination of parenteral antibiotics and oral antibiotics for
colorectal procedures
Do NOT remove hair at operative site unless the presence of hair
will interfere with the operation. Do NOT use razors
Control blood glucose during the immediate post-operative period
for cardiac patients and non-cardiac surgery patients (maintain
blood glucose <180 mg/dL)
HAIR REMOVAL


Seropian and Reynolds (Am J Surg 1971;121:251)
 SSI rate, razor-shave = 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%
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%
RECOMMENDED PREVENTION STRATIGIES:
BASIC PRACTICES (all acute care hospitals)


Maintain normothermia (temperature >35.5 oC) during the
perioperative period
Optomize tissue oxygenation by administering supplemental
oxygen during and immediately following surgical procedures
involving mechanical ventilation


Aim for 80% FiO2 instead of 30-35%
Use alcohol-containing pre-operative skin preparatory agents if
not contraindication exists (the most effective antiseptic to
combine with alcohol is unclear)

In the absence of alcohol, chlorhexidine may have advantages over
povidone iodine
Kao LS, et al. Ann Surg 2012;256:894-901
RECOMMENDED PREVENTION STRATIGIES:
BASIC PRACTICES (all acute care hospitals)



Use impervious plastic wound protectors for gastrointestinal and
biliary tract surgery
Use a checklist based on the WHO checklist to ensure
compliance with best practices to improve surgical patient safety
Perform surveillance for SSI





Identify,high-risk, high-volume operative procedures
Identify, collect, store, and analyze data for the surveillance program
Prepare periodic SSI reports
Collect denominator data for targeted procedures
Use update NHSN definitions for SSI
RECOMMENDED PREVENTION STRATIGIES:
BASIC PRACTICES (all acute care hospitals)





Increase the efficiency of surveillance through utilization of
automated methods
Provide ongoing feedback of SSI rates to surgical and
perioperatiave personnel and leadership
Measure and provide feedback to providers regarding rates of
compliance with process measures
Educate surgeons and perioperative personnel about SSI
prevention
Educate patients and their families about SSI prevention as
appropriate
RECOMMENDED PREVENTION STRATIGIES:
BASIC PRACTICES (all acute care hospitals)

Implement policies and practices aimed at reducing the risk of
SSI that align with evidence-based standards




Optimal preparation and disinfection of the operative site and hands of
surgical team members
Adherence to hand hygiene
Reduce unnecessary traffic in OR
Appropriate care and maintenance of Ors,including appropriate air
handling and optimal cleaning and disinfection of equipment and
environment
SPECIAL APPROACHES FOR PREVENTING
SSI (use if unacceptably high SSI rate)


Screen for SA and decolonize patients with anti-staphylococcal
agents in the peri-operative setting for high risk procedures (e.g.,
selected orthopedic and cardiothoracic)
Perform antiseptic wound lavage




Dilute povidone-iodine
Perform an SSI risk assessment
Observe and review operating room personnel and environment
of care in the OR
Observe and review practices in the post-anesthesia care unit,
SICU, and surgical unit
APPROACHES THAT SHOULD NOT BE CONSIDERED
A ROUTINE PART OF SSI PREVENTION




Do NOT routinely use vancomycin for antimicrobial prophylaxis
Do NOT routinely delay surgery to provide parenteral nutrition
Do NOT routinely use antiseptic-impregnated sutures as a
strategy to prevent SSI
Do NOT routinely use antiseptic drapes as a strategy to prevent
SSI
UNRESOLVED ISSUES




Pre-operative bathing with chlorhexidine-containing products
Pre-operative intranasal and pharyngeal chlorhexidine treatment
for patients undergoing cardiothoracic procedures
Use of gentamicin-collagen sponges
Use of “bundles” to ensure compliance with best practices
EXAMPLES OF IMPLEMENTATION
STRATEGIES

Engage






Obtain support for SSI reduction from senior leadership
Obtain a highly engaged physician as a champion
Use multidisciplinary teams
Adopt evidence based practices and guidelines
Focus on a culture of safety
Education: Staff, patients, families
EXAMPLES OF IMPLEMENTATION
STRATEGIES

Execute






Use a quality improvement methodology
Differentiate between pediatric and adult populations
Use information technologies
Participate in a collaborative
Use preoperative/postoperative order sets
Evaluate



Use performance improvement tools
Direct observation of evidenc based practices
Longitudinal evaluation of SSI rates and compliance rates
IDSA GUIDELINE





Infusion of the first dose within 60 min of surgical incision
Prophylactic therapy should be discontinued within 24 hrs
Provide additional intraoperative doses if surgery extends
beyond 2 half-lives of the initial dose
Provide therapy based on weight (>30% above ideal
body weight) or body mass index
Additional measures

Supplemental oxygen administration, perioperative glucose
control, aggressive fluid resuscitation, proper intraoperative
temperature control
Bratzler DW, et al. Am J Health-Syst Pharm 2013;70:195-283
ANTIMICROBIAL SURGICAL PROPHYLAXIS
ANTIMICROBIAL SURGICAL PROPHYLAXIS
ANTIMICROBIAL PROPHYLAXIS

Classen et al. NEJM 1992;326:281
SSI rate, appropriate AP (<2 hrs prior to incision) = 0.6%
 SSI rate, perioperative administration AP (during 3 hours after
incision) = 1.4%
 SSI rate, early AP (2-24 hours prior to incision) = 3.8%
 SSI rate, postoperative AP (3-24 hours after incision) = 3.3%

CONCLUSIONS



Surgical site infections result in significant patient
morbidity and mortality, and increased hospital cost
Reduction in surgical site infections can be achieved by
strict adherence to standard surgical guidelines
Proper use of surgical prophylaxis crucial to maintaining
a low rate of SSIs and now reported to CMS
THANK YOU!!