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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!!