SSI (ICAN-ISC workshop)
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Surgical site infections (SSIs) account for 20% of nosocomial infections. Approximately 3-5% of surgeries result in an SSI. There are many pre-operative and perioperative factors that influence the risk of developing an SSI, including patient characteristics (age, health status), procedure-related factors, and hospital structure and protocols. Hospitals can influence several modifiable risk factors like surveillance, antimicrobial prophylaxis, normothermia, glucose control, and skin preparation to help reduce SSIs.
![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](https://image.slidesharecdn.com/ssiican-iscworkshop-121119161056-phpapp01/85/SSI-ICAN-ISC-workshop-6-320.jpg)
SSI (ICAN-ISC workshop)
- 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