Transcript ICU - TSICP Texas Society of Infection Control and Prevention

Prevention of Surgical Site Infections
William A. Rutala, Ph.D., M.P.H.
UNC Health Care System and UNC School of
Medicine, Chapel Hill, NC
Disclosure
This educational activity is brought to you, in part, by
Advanced Sterilization Products (ASP) and Ethicon.
The speaker receives an honorarium from ASP and
Ethicon and must present information in compliance
with FDA requirements applicable to ASP.
TOPICS
Epidemiology of healthcare associated infections (HAI)
 Review the morbidity, mortality, and economic
consequences of HAIs
 Discuss the risk factors and etiology of SSIs
 Provide strategies to prevent SSIs
 National initiatives to prevent SSIs

Healthcare-Associated Infections (HAIs)
HAIs are those that develop in the hospital that were
neither incubating nor present at the time of admission
 40 million persons hospitalized annually in US; 5% or
2M will develop a HAI

Morbidity and mortality (90,000 deaths); 6th leading cause
of death in the US
 Variable prolongation of hospital stay
 $5-10 billion/year

Impact of Healthcare-Associated Infections
Infection Type Deaths Directly
Due To Infection
%
U.S. Total
Pneumonia
3.1
7,087
BSI
4.4
4,496
SSI
0.6
3,251
UTI
0.1
947
Total
0.9
19,027
Deaths, Infections
Contributed
%
U.S. Total
10.1
22,983
8.6
8,844
1.9
9,726
0.7
6,503
2.7
58,092
Source: Emori TG, Gaynes R. Clin Microbio Rev 1993;6:429
Cost Estimates for Specific
Healthcare-Associated Infections
HAI type
VAP
BSI
SSI
CA-UTI
Weight-Adjusted Cost per HAI
Mean + SE
25,072 + 4,132
23,242 + 5,184
10,443 + 3,249
758 + 41
2005 US dollars
Anderson DJ, et al. ICHE 2007;28:767-773
Range of Published Estimates
of Cost per HAI
8,682-31,316
6,908-37,260
2,527-29,367
728-810
Most Prevalent
O ther
25%
Urinary Tract
33%
Urinary Tract
S urg ical S ite
P rimary B loods tream
O ther
P rimary
B loods tream
19%
Weinstein RA. Emerg Infect Dis. 1998;4(3):416-420.
CDC, NNIS Semiannual Report, Dec 2000.
S urg ical S ite
23%
Surgical Site Infection
Surgical Site Infection





SSIs third most common HAI, accounting for 14-16% of HAIs
Among surgical patients, SSIs were most common accounting for
~40% of healthcare-associated infections
 67% incisional infections (confined to incision)
 33% organ/space infections
Increase an average of 7 days to each hospitalization
Increase >$10,000 (2005 $) to each hospitalization
Appropriate preoperative administration of antibiotics and other
prevention measures are effective in preventing infection
Surgical Site Infections. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/.
Odom-Forren J. Nursing2006. 2006;36(6):58-63.
Surgical Site Infection

Advances in infection control practices
Improved operating room ventilation
 Sterilization methods
 Barriers
 Surgical technique
 Antimicrobial prophylaxis

Challenges in the Prevention and Management
of Surgical Site Infections

Changing population of hospital patients









Increased severity of illness
Increased numbers of surgical patients who are elderly
Increased numbers of chronic, debilitating or immunocompromising
underlying diseases
Shorter duration of hospitalization
Increased numbers of prosthetic implant and organ transplant
operations performed
Public reporting of infection rates/proportions
Growing frequency of antimicrobial-resistant pathogens
Non-reimbursement for “medical errors”-CMS
Lack of compliance with hand hygiene
SSI: Pathogenesis
Risk of surgical site infections =
Dose of bacterial contamination x virulence (toxins)
Resistance of the host
SSI: Primary Risk Factors

Endogenous microorganisms

Skin-dwelling microorganisms
Most
common source
S aureus most common isolate
Fecal flora (gnr) when incisions are near the perineum or groin

Exogenous microorganisms
Surgical personnel (members of surgical team)
 OR environment (including air)
 All tools, instruments, and materials

Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
SSI: Microbiology (NNIS, 1996)
Pathogen
Staphylococcus aureus
Coagulase-negative staphylococci
E. coli
Enterococcus sp.
Pseudomonas aeruginosa
Enterobacter sp.
Proteus mirabilis
Klebsiella pneumonae
Other Streptococcus spp.
Candida albicans
C. albicans, Grp D strep, Other Gram(+)
1986-89
17%
12%
10%
8%
8%
8%
4%
3%
3%
2%
----
1990-96
20%
14%
8%
12%
8%
7%
3%
3%
3%
3%
2% each
PATHOGENS ASSOCIATED WITH SSIs:
NHSN, 2006-2007
S. aureus
CoNS
Enterococcus
E. coli
P. aeruginosa
Enterobacter
K. pneumoniae
Candida
K. oxytoca
Hidron AI, et al. ICHE 2008;29:996-1011
A. baumannii
Other
0%
5%
10%
15%
20%
25%
30%
35%
To Reduce the Risk of Surgical Site
Infection
A simple but realistic approach must be applied with the
awareness that the risk of SSIs is influenced by characteristics of
the patient, operation, personnel and hospital
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
CDC: SSI Recommendations, 1999

Definitions
IA: Strongly recommended for all hospitals and strongly
supported by experimental or epidemiologic studies
 IB: Strongly recommended for all hospitals and viewed as
effective by experts
 II: Suggested for implementation in many hospitals;
suggestive clinical or epidemiologic studies, strong
theoretical rationale

SSI: CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
SSI: CDC Guidelines
Patient characteristics/risk factor
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
Risk and Prevention in SSIs
Risk Factor-a variable that has a significant independent
association with the development of SSI after a specific
operation
SSI: Intrinsic/Patient Risk Factors





Age-extremes
Nutritional status-poor
Diabetes-controversial;
increased glucose levels in
post-op period ↑ risk
Smoking-nicotine delays
wound healing ↑ risk
Obesity>20% ideal body
weight





Remote infections ↑ risk
Endogenous mucosal
microorganisms
Preoperative nares S.
aureus- CT patients
Immunosuppressive drugs
may ↑ risk
Preoperative stay-surrogate
for severity of illness
Prevention of SSIs

Preoperative preparation of the patient
 Minimize preoperative stay (II)
 Identify and treat remote site infections (IA)
 Adequately control glucose in diabetics (IB)
 Encourage discontinuation of tobacco for 30d (IB). Consider
delaying elective procedures in severely malnourished
patients (II)
 No recommendations to taper or discontinue steroids
(Unresolved issue)
SSI: CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
SSI: Preoperative Issues
Modifiable Risks
Glucose control-in diabetic patients
Preoperative CHG shower
Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia-hypo higher risks
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
5 Million lives. Institute for Healthcare Improvement. Available at:
http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.
Prevention of SSIs

Preoperative preparation of the patient
 Preoperative showers with antiseptic agent at least the
night before (IB)
 Do not remove hair preoperatively unless it will interfere
with the operation (IA)
 If hair removed, remove just prior to surgery with electric
clippers (IA)
 Wash and clean at and around incision site prior to
performing antiseptic skin preparation (IB)
Preoperative Showers

Garibaldi R (J Hosp Infect 1988;11(suppl B):5
 Reduction in bacterial counts: Chlorhexidine 9-fold,
povidone-iodine 1.3-fold

Cruse and Foord (Arch Surg 1973;107:206)

Clean surgery
 SSI rate, no shower = 2.3%
 SSI rate, shower with soap = 2.1%
 SSI rate, shower with hexachlorophene = 1.3%
Chlorhexidine:
Preoperative Showers

CDC recommends preoperative
showering with antiseptic1

CHG more effective than PI and
triclocarban

Lower rates of intraoperative wound
contamination
1. Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
2. Garibaldi RA. J Hosp Infect. 1988;11(suppl B):5-9.
Chlorhexidine:
Preoperative Showers
Patients who had 2 preoperative
showers with CHG 24 hours before
surgery had reduced rates of wound
infection compared to patients who
showered with soap.
Hayek LJ, et al. J Hosp Infect. 1987;10(2):165-172.
4% Chlorhexidine Gluconate (CHG) Shower Mean Skin Surface Concentration (N=60)
CHG Concentration (PPM)
150
CHG Shower
125
Group 1A
“Evening (PM)”
100
Group 2A
“Morning (AM)”
Group 3A
75
“Both (AM and PM)”
p <0.05
NS
P<0.001
50
25
0
MIC90 = 4.8 ppm
Left
Elbow
Right
Elbow
Abdominal
Left
Knee
Right
Knee
Skin Sites
Edmiston et al, J Am Coll Surg 2008;207:233-239
Preoperative Hair Removal

Seropian and Reynolds (Am J Surg 1971;121:251)
 SSI rate, razor-shave (microabrasions) = 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%
Preoperative Hair Removal

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%
SSI: Preoperative Issues
Modifiable Risks
Glucose control-in diabetic patients
Preoperative CHG shower
Appropriate hair removal
Hand hygiene
Skin antisepsis
Antimicrobial prophylaxis
Normothermia-hypo higher risks
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
5 Million lives. Institute for Healthcare Improvement. Available at:
http://ihi.org/IHI/Programs/Campaign/Campaign.htm. Accessed on February 8, 2007.
Prevention of SSIs

Preoperative preparation of the surgical team
 Keep nails short and no artificial nails (IB)
 Perform preoperative surgical scrub for 2-5 minutes with
antiseptic-alcohol, chlorhexidine, iodophors (IB); new
waterless, surgical hand antisepsis with alcohol
 Perform preoperative scrub including forearms (IB)
 Do not wear hand/arm jewelry (II)
 Prohibiting nail polish (No recommendation)
Importance of Our Skin
#1 Function:
Protective Barrier
Microorganisms


80% in first 5 cell layers of epidermis
When skin is perforated

Integrity is compromised

 infection risk
Normal Skin Micro-Flora
Numbers of bacteria that colonize different parts of the body
Numbers per square centimeter of skin surface (cfu/cm2). Counts on hands range from 3.9x104 to 4.6x106.
Surgical Hand Antisepsis
Surgical Hand Antisepsis

Surgical hand scrubs should:
Significantly reduce microorganisms on intact skin
 Contain a non-irritating antimicrobial preparation
 Have broad-spectrum activity
 Be fast-acting and persistent

Combined Agents
Tincture of
Iodine
Traditional
Iodophors
CHG/ Alcohol
Broad Spectrum
X
X
X
Rapid Activity
X
X
X
Active Agents
Residual Activity
X
Activity in Blood/Organic
X
Non-Irritating
X
Minimal Absorption
X
Surgical Hand Antisepsis
Studies suggest that neither a brush nor a sponge is
necessary to reduce bacterial counts on the hands of
surgical personnel to acceptable levels, especially
when alcohol-based products are used
 One study (AORN J 2001;73:412) found a brushless
application of a preparation of 1% CHG plus 61%
ethanol yielded lower bacterial counts on the hands of
participants than using a sponge/brush to apply 4%
CHG

Prevention of SSI

Preoperative preparation of the patient
 Use appropriate antiseptic for skin preparation (IB)
 Alcohol (70-92%)
 Chlorhexidine 4%, 2% or 0.5% in alcohol base
 Iodine/iodophors
 Apply in concentric circles moving to periphery
 Prep area to include incision and any drain sites
2% CHG/70% IPA vs. 10% PVP-I




Randomized, parallel group, open label, healthy human
volunteers
55 subjects
Microbial samples: right and left abdominal and inguinal sites
Efficacy defined as


≥2.0 log10 reduction from baseline CFUs/cm2 on abdominal sites
≥3.0 log10 mean reduction from baseline CFUs/cm2 on inguinal sites
Hibbard JS. J Infus Nursing. 2005;28(3):194-207.
2% CHG/70% IPA vs. 10% PVP-I
3.5
3
2.5
2
1.5
1
0.5
0
10 minutes
2% CHG/70% IPA
10 % PVP-1
24 hours
48 hours
Mean reduction in CFU counts
Mean reduction in CFU counts
2% CHG/70% IPA
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
10 minutes
Abdominal
P=0.0001 compared to baseline for all results
Hibbard JS. J Infus Nursing. 2005;28(3):194-207
10% PVP-1
24 hours
Inguinal
48 hours
2% CHG/70% IPA for
Foot and Ankle Surgery

Prospective, randomized trial

125 evaluable patients



Products




40 subjects/group
5 pre-prep baseline
ChloraPrep® (2% CHG/70% IPA)
DuraPrep® (0.7% Iodine/74% IPA)
Techni-Care® (3% Chloroxylenol-PCMX)
Cultures: hallux, web spaces between toes, and control site
Ostrander RV, et al. Bone Joint Surg Am. 2005;87(5):980-985.
2% CHG/70% IPA for
Foot and Ankle Surgery
Control = anterior tibia, 12 cm proximal to the ankle joint.
Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A:980-985.
2% CHG/70% IPA for
Foot and Ankle Surgery
Ostrander RV, et al. J Bone Joint Surg Am. 2005;87-A:980-985.
Prevention of SSIs

Management of infected or colonized surgical personnel
 Exclude from duty, surgical personnel who have draining
skin lesions until infection eliminated or personnel have
received adequate therapy (IB)
 Do not routinely exclude personnel colonized with S. aureus
or group A strep unless personnel linked epidemiologically
to outbreak (IB)
 Educate personnel regarding symptoms and signs of
infection-have them report to OHS (IB)
Prophylactic Antibiotics
Antibiotics given for the purpose of
preventing infection when infection is not
present but the risk of postoperative
infection is present. Cefazolin is widely
used for clean operations.
Surgical Infection Prevention
Arch Surg 2005;140:174
Antibiotic
Surgery
within 1
hour
%
(N)
Correct
Antibiotic
%
Antibiotic
stopped
within 24 hours
%
Cardiac (7,861)
45.3
95.8
34.3
Vascular
40.0
91.9
44.8
Hip/knee (15,030)
52.0
97.4
36.3
Colon
40.6
75.9
41.0
(2,756)
52.4
90.8
79.1
Surgeries (34,133)
47.6
92.9
40.7
(3,207)
(5,279)
Hysterectomy
All
Prevent Surgical Site Infections:
Institute for Healthcare Improvement

Components if implemented reliably can eliminate SSIs




Appropriate use of antibiotics: one hour before incision; appropriate
antibiotics; discontinue with 24 h after surgery (Surgical Care
Improvement Project-CMS Quality Indicator)
Appropriate hair removal
Maintenance of postoperative glucose control (<200mg/dl) for major
cardiac surgery patients
Establishment of postoperative normothermia for colorectal surgery
patients
SSI: CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
SSI: Primary Risk Factors

Endogenous microorganisms

Skin-dwelling microorganisms
Most
common source
S aureus most common isolate
Fecal flora (gnr) when incisions are near the perineum or groin

Exogenous microorganisms
Surgical personnel (members of surgical team)
 OR environment (including air)
 All tools, instruments, and materials

Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
OR Environment

Air
Largest source of airborne microbial contamination is the
OR staff
 Organisms become airborne as a result of conversation or
shedding from the hair or exposed skin
 Microbial level directly proportional to the number of people
moving about in the room
 Improved ventilation associated with decreased SSI

Prevention of SSIs

Intraoperative (Ventilation)
 Maintain 15 AC/hr (>3 fresh), positive pressure (IB)
 Filter all air through appropriate filters (IB)
 Introduce air at ceiling and exhaust near floor (IB)
 Keep OR doors closed as needed for passage of
equipment, personnel, and patients (IB)
 Limit the number of OR personnel (IB)
 Consider ultraclean air for orthopedic implants (II)
OR Environment

Ventilation
Three primary design components act to purify the OR air
High-flow ventilation - 15 air changes per hour (3 outside
air)
High-efficiency filtration 90-99.97%
Positive pressure relative to adjacent areas (prevents
contamination from less clean areas)
 Maintain the temperature (680-730F [20-230C]) and relative
humidity (30-60%)

Prevention of SSIs

Intraoperative (Cleaning/disinfection environmental surfaces)
 Clean when visibly soiled/contaminated with EPA approved
disinfectant before the next operation (IB)
 Do not perform special cleaning after contaminated or dirty
surgery (IB)
 Do not use tacky mats (IB)
 Cleaning between surgery if no visible contamination (No
recommendation)
Prevention of SSIs

Intraoperative (Sterilization of surgical instruments)
 Perform flash sterilization only for patient care items that will
be used immediately. Do not use for reasons of
convenience, as an alternative to purchasing additional
instrument sets, or to save time (IB)
 Sterilize all surgical instruments according to published
guidelines (IB)
OR Environment

Microbiologic Sampling
No standardized parameters by which to compare
microbial levels obtained from cultures of ambient air or
environmental surface
 Routine microbiologic sampling cannot be justified
 Environmental sampling should only be performed as
part of an epidemiologic investigation

Prevention of SSIs

Intraoperative (Surgical attire and drapes-minimize patient’s
exposure to skin, mm, or hair of surgical team and protect
team from exposure to blood and OPIM)
 Wear a mask to fully cover the mouth and nose, and a cap
or hood to fully cover hair on head and face (IB)
 Wear sterile gloves (IB)
 Do not wear shoe covers to prevent SSIs (IB)
Prevention of SSIs

Intraoperative
Use materials for surgical gowns and drapes that are
effective barriers when wet (IB)
 Change surgical scrubs when visibly soiled, contaminated
and/or penetrated by blood (IB)

Prevention of SSIs

Asepsis and surgical technique
Adhere to the principles of asepsis when placing
intravascular devices, spinal or epidural anesthesia
catheters, or when dispensing and administering IV drugs
(IB)
 Handle tissue gently, maintain effective hemostasis,
minimize devitalized tissue and foreign bodies, and
eradicate dead space at the surgical site (IB)

CDC Surgical Site Infection
Prevention Guidelines - 1999
Category IA and IB
No prior infections
15 air changes/hr in OR
Do not shave in advance
Keep OR doors closed
Control glucose in D.M. pts
Use sterile instruments
Stop tobacco use
Wear a mask
Shower with antiseptic soap
Cover hair
Prep skin with approp. agent
Wear sterile gloves
Surgical team nails short
Gentle tissue handling
Surgical team scrub hands
DPC for heavily contaminated
Exclude I/C surgical team
wounds
Give prophylactic antibiotics
Closed suction drains (when used)
Pos pressure ventilation in OR
Sterile dressing x 24-48 hr
SSI surveillance with feedback to surgeons
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
Observations have revealed failure to follow standard
guidelines
Strict adherence to standard guidelines crucial to reduce SSIs
TOPICS
Epidemiology of healthcare associated infections (HAI)
 Review the morbidity, mortality, and economic
consequences of HAIs
 Discuss the risk factors and etiology of SSIs
 Provide strategies to prevent SSIs
 National initiatives to prevent SSIs

Thank you