ICAN-ISA workshop on HAI control. Talk on surgical site infections (SSI)

1. Surgical
Site
Infec/ons
November
2012
Andreas
Voss
iPrevent
UMCN
&
CWZ
Nijmegen,
The
Netherlands
OCCUR WITHIN 30 DAYS POST SURGERY
UNLESS IMPLANT UP TO 1 YEAR
¤ Surgical
site
infec/ons
account
for
20%
of
all
nosocomial
infec/ons
¤ Approximately
3-­‐5%
of
surgical
opera/ons
result
in
an
infec/on
¤ 77%
of
deaths
among
pa/ents
with
SSI
are
directly
aQributable
to
SSI
Your are entering the
There are many pre-and perioperative
factors that determine whether or not
¤ AQributable
cost
of
SSI
vary
-­‐
$3,000-­‐$29,000
operating theatre
a patient will develop a SSI
¤ Pa/ent-­‐related
¤ Pa#ent-­‐related
¤ Procedure-­‐related
¤ Procedure-­‐related
¤ Structure-­‐related
¤ Structure-­‐related
Andreas
Voss,
MD,
PhD
1

2. Surgical
Site
Infec/ons
November
2012
¤ Pa/ent-­‐related
¤ Pa/ent-­‐related
¤ Procedure-­‐related
¤ Procedure-­‐related
¤ Structure-­‐related
¤ Structure-­‐related
No
influence
possible
Influence by hospital
• Laminar
air-­‐flow
¤ Age
¤ Avoid
shaving
opera/ve
site
• Steriliza/on
¤ Underlying
disease
• Pre-op hospitalization
¤ Maintain
Post-­‐op
Glucose
Control
for
Major
Cardiac
Surgery
¤ Malignancy
¤ Wound
classifica/on
Can & should be influenced ¤ Maintain
Post-­‐op
Normothermia
for
Colorectal
Surgery
¤ Prosthe/c
material
• Surveillance
• S. aureus colonization
¤ Use
Prophylac/c
An/bio/cs
appropriately
Influenced by patient • Normothermia/hyperoxia
¤ Use
Basic
Preven/ve
Strategies
from
CDC
• BMI >30 • Glucose levels
• Hair-removal ² exclude
pa/ents
w/infec/on,
stop
tobacco
use,
keep
OR
doors
closed,
• Nicotine use
wear
masks,
prepare
skin
w/appropriate
agent.
• Antimicrobial prophylaxis
• Malnutrition
• Skin disinfection
• Infection at remote site
hQp://www.ihi.org/IHI/Topics/Pa/entSafety/SurgicalSiteInfec/ons/Changes/
Disinfec/on
and
steriliza/on
not
… or
Andreas
Voss,
MD,
PhD
2

3. Surgical
Site
Infec/ons
November
2012
¤ 63
surgical
departments
par/cipa/ng
in
KISS
¤ >99.000
opera/ons
¤ Turbulent
+
HEPA
versus
laminar
airflow
+
HEPA
¤ Mul/variate
analyis
to
comtrol
fot
other
factors
influencing
outcome
(SSI)
Brandt et al, Ann Surg 2008; 248:695-700.
Significant
ns
ns
ns
ns
ns
Follow-­‐up
study
taking
in
account
the
size
of
the
LAF
plenum
shows
no
difference
in
outcome
Brandt et al, Ann Surg 2008; 248:695-700. Brandt et al, Ann Surg 2008; 248:695-700.
¤ S.
aureus
coloniza/on
¤ An/microbial
prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose
levels
CAN & SHOULD
¤ Hair-­‐removal
¤ Skin
disinfec/on
Andreas
Voss,
MD,
PhD
3

4. Surgical
Site
Infec/ons
November
2012
Nasal
decoloniza/on
¤ S.
aureus
coloniza#on
¤ An/microbial
prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose
levels
¤ Hair-­‐removal
¤ Skin
disinfec/on
¤ S.
aureus
coloniza/on
¤ An#microbial
prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose
levels
¤ Hair-­‐removal
¤ Skin
disinfec/on
¤ S.
aureus
coloniza/on
14/369
15/441 ¤ An/microbial
prophylaxis
Infections (%)
1/41 ¤ Surveillance
1/47
1/81
¤ Normothermia
2/180
¤ Hyperoxia
5/699
5/1009
¤ Glucose
levels
¤ Hair-­‐removal
Hours From Incision
¤ Skin
disinfec/on
Classen. NEJM 1992;328:281.
Andreas
Voss,
MD,
PhD
4

5. Surgical
Site
Infec/ons
November
2012
Li>le
things
can
have
great
impact
(on
hygiene)
¤ Reduc/on
of
Nosocomial
Infec/ons
%
SSI
¤ S.
aureus
coloniza/on
¤ An/microbial
prophylaxis
No
significant
risk
reduc#on
was
¤ Surveillance
observed
for
pa#ents
operated
on
during
¤ Normothermia
the
second
and
third
year
surveillance
years
¤ Hyperoxia
¤ Glucose
levels
¤ Hair-­‐removal
Geubels et al Intern J Qual Health Care 2006;18:127-133 ¤ Skin
disinfec/on
200
Pa#ents
SSI
rate
(%)
Pa/ents
with
Normothermia
6
%
colorectal
opera/ons
sample
p=0.009
Hypothermia
19
%
Kurz
et
al.
NEJM
1996;
334:1209-­‐15
Andreas
Voss,
MD,
PhD
5

6. Surgical
Site
Infec/ons
November
2012
SSI-­‐rate
¤ S.
aureus
coloniza/on
¤ An/microbial
prophylaxis
Local
Systemic
5
(4%)
8
(6%)
¤ Surveillance
Control
¤ Normothermia
19
(14%)
*
p
<
0.01
¤ Hyperoxia
¤ Glucose
levels
¤ Hair-­‐removal
¤ Skin
disinfec/on
Melling. Lancet. 2001; 358:876.
JAMA 2004; 291:79-87
¤ S.
aureus
coloniza/on
¤ An/microbial
prophylaxis
¤ Surveillance
¤ Normothermia
JAMA 2005; 294:2035-42 ¤ Hyperoxia
•
High
FiO2
(0.80)
during
and
aqer
¤ Glucose
levels
surgery
•
Colorectal
!
•
General
surgery?
¤ Hair-­‐removal
¤ Skin
disinfec/on
¤ Postopera/ve
hyperglycemia
is
an
important
¤ S.
aureus
coloniza/on
independent
risk
factor
for
SSI
in
general
¤ An/microbial
prophylaxis
surgery
pa/ents.
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose
levels
¤ Hair-­‐removal
¤ Skin
disinfec/on
Archives of Surgery 2010;145:858-864]
Andreas
Voss,
MD,
PhD
6

7. Surgical
Site
Infec/ons
November
2012
No
Hair
Group
Removal
Depilatory
Shaved
¤ Number
155
153
246
¤ Infec/on
rate
0.6%
0.6%
5.6%
Seropian.
Am
J
Surg.
1971;
121:
251.
¤ Inappropriate:
² Shaving
Rasors vs. OR = 2.02
„Clipping“ (CI95 1.21-3.36) ¤ Appropriate:
Rasors vs. OR = 1.54 ² No
hair
removal
at
all
Depilatory cream (CI95 1.05-2.24)
² Clipping
² Depilatory
use
Tanner
et
al.
Cochrane
Database
Syst
Rev
2006
Jul
19
¤ S.
aureus
coloniza/on
¤ An/microbial
prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose
levels
¤ Hair-­‐removal
¤ Skin
disinfec#on
Andreas
Voss,
MD,
PhD
7

8. Surgical
Site
Infec/ons
November
2012
lt s !
resu
New
NEJM
Darouiche
et
al
NEJM
2010;362:18-­‐26
¤ The
overall
rate
SSI
was
significantly
lower
in
¤ Alcoholic
solu/ons
standard
of
care
in
NL
en
the
chlorhexidine–alcohol
group
than
in
the
other
EU
povidone–iodine
group
(9.5%
vs.
16.1%;
P=0.004)
² I
miss
the
comparison
with
povidone–iodine-­‐
alcohol!
¤ Chlorhexidine–alcohol
was
significantly
more
protec/ve
against
¤ What
part
of
chlorhexidine–alcohol
works?
¤ How
important
is
the
CHG
concentra/on
² superficial
incisional
infec/ons
(4.2%
vs.
8.6%,
P=0.008)
¤ Landmark
study
that
shows
that
the
choice
of
² deep
incisional
infec/ons
(1%
vs.
3%,
P=0.05)
skin-­‐prep
counts
!
Darouiche
et
al
NEJM
2010;362:18-­‐26
Darouiche
et
al
NEJM
2010;362:18-­‐26
Reasons
why
implementa/on
of
effec/ve
IC
measures
in
the
OR
is
complicated
J
Am
Coll
Surg
2008;
207:810-­‐20
Andreas
Voss,
MD,
PhD
8

9. Surgical
Site
Infec/ons
November
2012
What
do
we
need
to
effec/vly
implement
IC
measures
in
the
OR
¤ People,
/me
and
money
¤ Strong
leadership
² To
handle
the
mul/-­‐disciplinary
environment
² To
ensure
responsibili/es
are
known
to
individual
HCWs
¤ Pa/ent
safety
culture
² Survey
and
act
on
process
&
outcome
data
¤ “Conformity”
of
all
HCWs
‘opera/ng”
in
and
around
the
OR
² To
increase
compliance
with
basic
IC
measures
in
OR
Andreas
Voss,
MD,
PhD
9