Download Infection Control for Obstetrics and Gynecology: Ware

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
• 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
“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."
Hospital-acquired infections reported by
Pennsylvania hospitals in 2004:
Infection
Number
Urinary tract
6,139
Bloodstream
1,932
Pneumonia
1,335
Surgical site
1,317
Multiple infections
945
Total
11,668
Source: Pennsylvania Health Care Cost Containment
Council
U.S. News and World Report, July 18, 2005.
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
• 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 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
Cost per Infection
Wound infections
Sternal wound infection
Catheter-associated
BSI
Pneumonia
Urinary tract infection
$3,000 - $27,000
$20,000 - $80,000
$5,000 - $34,000
$10,000 - $29,000
$700
Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections,
4th ed. 2003:36.
Major Sites of Nosocomial
Infections
•
•
•
•
Urinary tract infection
Bloodstream infection
Pneumonia (ventilator-associated)
Surgical site infection
Surgical Site Infections in
Obstetrics and Gynecology
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
National Nosocomial Infections
Surveillance System (NNIS)
Classification
Clean
Clean-contaminated:
GI/GU tracts entered in a
controlled manner
Wound Class
0
SSI Risk
Lower
1
Contaminated:
open, fresh, traumatic wounds
infected urine, bile
gross spillage from GI tract
Dirty-infected:
2
3
Higher
NNIS- SSI Surveillance 1992-2004
Abdominal Hysterectomy
Risk Index
Number of
hospitals
Pooled
mean rate
Median- 50%
percentile
Per 100 operations
0
107
1.36
0.91
1
100
2.32
1.96
2,3
53
5.17
4.21
Am J Infect Control 2004;32:470-85
NNIS- SSI Surveillance 1992-2004
Vaginal Hysterectomy
Risk Index Number of
hospitals
Pooled
mean rate
Per 100 operations
0,1,2,3
71
1.31
Am J Infect Control 2004;32:470-85
Median50%
percentile
0.91
NNIS- SSI Surveillance 1992-2004
Cesarean Section
Risk Index Number of Pooled
hospitals mean rate
Per 100 operations
Median50%
percentile
0
130
2.71
2.17
1
117
4.14
3.19
2,3
51
7.53
5.38
Am J Infect Control 2004;32:470-85
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
Hospital Morbidity Due to Post-operative
Infections in Obstetrics and Gynecology
Type of
operation
(%)
No. of
Operations
(%)
Wound
Infection
alone (%)
Fever alone
(%)
Both wound
Infection and
Fever (%)
Cesarean
section
2193
35 (2)
30 (1)
7 (0.3)
Major
Gynecologic
Surgery
1839
9 (0.4)
5 (0.3)
4 (0.2)
Total
4032
35 (0.9)
35 (0.9)
11(0.3)
Saudi Medical Journal 2000: Vol 21 (3) 270-273
Hospital Morbidity Due to Post-operative
Infections in Obstetrics and Gynecology
Organism
Number of Isolates
Gram Positive
•S.aureus
•S.epidermidis
•Streptococci
•Enterococci
3 (3)
13 (14)
6(6)
19 (20)
Gram Negative
•Enterbacter
•Klebsiella
•E.coli
•Proteus
•P.aeruginosa
•Acinetobacter
•Gram negative bacilli
4(4)
14(15)
11(12)
9(10)
8(8.5)
1(1)
1(1)
Candida
5(5)
Total
94
Saudi Medical Journal 2000: Vol 21 (3) 270-273
Genitourinary
flora is a
significant
source of
contamination
during surgery
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
Risk Factors for Surgical Site Infections
Following Cesarean Section
Multiple logistic-regression analysis
Risk Factor
Odds Ratio/ 95% CI/ P value
Absence of antibiotic
prophylaxis
2.63; 1.50-4.6; P=.008
Length surgery
1.01; 1.00-1.02; P=.04
<7 prenatal visits
3.99; 1.74-9.15; P=.001
Duration of ruptured
membranes
1.02; 1.01-1.03; P=.04
Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7
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
Focus on modifiable risk factors
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
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
• 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
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
•
•
•
•
•
•
•
•
•
•
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
SCIP Performance Measures
Surgical
infection
prevention
• SSI rates
• Appropriate prophylactic antibiotic chosen
• Antibiotic given within 1 hour before incision
• Discontinuation of antibiotic within 24 hours of
surgery
• Glucose control
• Proper hair removal
• Normothermia in colorectal surgery patients
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
Infection Rate
Downloaded from: Principles and Practice of Infectious Diseases
Process Indicators:
Appropriate Antibiotic Prophylaxis
Procedure
Approved Antibiotics
•Cefazolin
Hysterectomy
•Cefoxitin
Approved for β-lactam allergy
•Clindamycin +
gentamicin
•Clindamycin +
levofloxacin
•Metronidazole +
gentamicin
•Metronidazole +
levofloxacin
•Clindamycin
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
Infusion should begin within 60 minutes of
the incision
Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.
Nosocomial Bloodstream Infections
Nosocomial Bloodstream Infections,
1995-2002
Rank
N= 24,847
52 BSI/10,000 admissions
Pathogen
Percent
1
Coagulase-negative Staph
31.3%
2
S. aureus
20.2%
3
Enterococci
9.4%
4
Candida spp
9.0%
5
E. coli
5.6%
6
Klebsiella spp
4.8%
7
Pseudomonas aeruginosa
4.3%
8
Enterobacter spp
3.9%
9
Serratia spp
1.7%
10
Acinetobacter spp
1.3%
Edmond M. SCOPE Project.
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)
N= 24,847
52 BSI/10,000 admissions
In obstetrics, BSIs are uncommon.
However, the principal pathogen is
E.coli and not coagulase negative
staphylococci.
The source is typically genitourinary
Edmond M. SCOPE Project.
Nosocomial Bloodstream Infections
• 12-25% attributable mortality
• Risk for bloodstream infection:
BSI per 1,000
catheter/days
Subclavian or internal jugular CVC
5-7
Hickman/Broviac (cuffed, tunneled)
1
PICC
0.2 - 2.2
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
• 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 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
30%-40% of all Nosocomial
Infections are Attributed to
Cross TransmissionImplication For The Spread
Drug Resistant Pathogens
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
• 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
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
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.
Community-associated methicillinresistant 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.
Table 1. Clinical information for patients with methicillin-resistant Staphylococcus aureus infection during the outbreak period
Age at
onset
Sex
Strain
Infection type
Initial therapy
Definitive therapy
P1,
newborn
8d
F
USA 400
Preseptal cellulitis
Nafcillin, cefotaxime
Topical gentamicin
P2,
newborn
13 d
F
USA 400
Omphalitis, otitis
externa
Ampicillin,
cefotaxime
Topical mupirocin
P3, mother
33 y
F
USA 400
Breast abscess
Cefazolin
Surgical drainage, vancomycin, topical
mupirocin
P4,
newborn
2d
M
USA 400
Omphalitis, pustulosis
Nafcillin Gentamicin
Gentamicin, topical mupirocin
P5,
newborn
4d
M
USA 400
Pustulosis
Cephalexin
Topical bacitracin
P6,
newborn
2d
M
USA 400
Pustulosis
None
Local wound care
P7,
newborn
1d
F
USA 400
Pustulosis, mastitis
Topical mupirocin
Vancomycin
P8, mother
24 y
F
Unique
Peripheral IV catheter
site
Cefazolin
Trimethoprim-sulfamethoxazole, catheter
removal
Patient
Emerg Infect Dis. 2005 Jun;11(6):808-13.
Epidemic of Staphylococcus aureus
nosocomial infections resistant to
methicillin in a maternity ward
• Seventeen cases were recorded over a nineweek 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 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 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 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
Easy to use
Quick
solutions
Very effective antisepsis due to bactericidal properties of alcohol
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
Contact
Precautions
for drug
resistant
pathogens.
Gowns and gloves
must be worn upon
entry into the
patient’s room
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