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XIV ANNUAL CONFERENCE OF ESS Turin, 25-27 November 2010
SSI Incisional and Organ/Space
Prof. Andrea ImperatoriUniversity of Insubria
Center for Thoracic Surgery
Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:
identical significance and same clinical relevance?identical significance and same clinical relevance?
•• Postoperative peritonitis vs. wound SSI ? Postoperative peritonitis vs. wound SSI ?
•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)
•• Different risk factors ? Different risk factors ?
•• Different cost ?Different cost ?
•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?
Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:
identical significance and same clinical relevance?identical significance and same clinical relevance?
•• Postoperative peritonitis vs. wound SSI ? Postoperative peritonitis vs. wound SSI ?
•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)
•• Different risk factors ? Different risk factors ?
•• Different cost ?Different cost ?
•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?
•• Postoperative peritonitis vs. wound SSI ?Postoperative peritonitis vs. wound SSI ?
•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)
•• Different risk factors ? Different risk factors ?
•• Different cost ?Different cost ?
•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?
Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:
identical significance and same clinical relevance?identical significance and same clinical relevance?
•• Postoperative peritonitis vs. wound SSI ?Postoperative peritonitis vs. wound SSI ?
•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)
•• Different risk factors ? Different risk factors ?
•• Different cost ?Different cost ?
•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?
Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:
identical significance and same clinical relevance?identical significance and same clinical relevance?
Risk factors for the development of postoperative infections
1. Age and (*) associate derangements of physiologic functions
2. Type of surgical procedure (surgical trauma severity)
3. (*) Quality of surgical technique4. Operative field contamination5. Emergency surgical procedure6. (*) Inadequate antibiotic prophylaxis7. (*) Blood loss and transfusions8. (*) Malnutrition/obesity9. (*) Preexisting infection10. (*) Current disease:
a) Diabetesb) Renal failurec) Cirrhosisd) Cardiac diseasee) Chronic pulmonary diseasef) shock
11. (*) Length of preop. hospital stay
12. Immunosuppressive therapy
13. (*) Prolonged corticosteroid therapy
14. Inoperable malignancy15. (*) Invasive devices16. (*) Quality of pre- and
post-operative care
* Modifiable factors
•• Postoperative peritonitis vs. wound SSI ? Postoperative peritonitis vs. wound SSI ?
•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)
•• Different risk factors ? Different risk factors ?
•• Different cost ?Different cost ?
•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?
Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:
identical significance and same clinical relevance?identical significance and same clinical relevance?
Surgical Site Infection (SSI) Surgical Site Infection (SSI) -- CostCost
SSIs result in:
• Increased morbidity
• Prolonged hospitalization
• Socio-economic cost
Duration of SSIDuration of SSI•• From day of clinical diagnosis until day of From day of clinical diagnosis until day of
clinical resolutionclinical resolution
•• Superficial incisionalSuperficial incisional: 7 days: 7 days
•• Deep incisionalDeep incisional: 10 days: 10 days
•• Organ / SpaceOrgan / Space: 14 days (or > if re: 14 days (or > if re--operation)operation)
Mean duration of SSIMean duration of SSI
Di Leo A. et al
SSI – Classification CDC(Horan TC: Infect Control Hosp Epidemiol, 1992)
• Superficial Incisional SSIs local wound care low
CostTreatment
Cost analysis of superficial SSI in Varese
Excess in-hospital lenght of stay: 2 days
Added hospital costs: 1,000 Euro (500 Euro/day)
About 5 additional wound care procedures
Cost of extra wound care: 50 Euro (10 Euro/each)
Antibiotic therapy (7 days): 10 Euro
Total added costs: 1,060 Euro
SSI – Classification CDC(Horan TC: Infect Control Hosp Epidemiol, 1992)
Deep Incisional SSIs Deep Incisional SSIs prol. hospital stay moderateadditional procedures highantibiotic
CostTreatment
Cost analysis of deep SSICost of re-do surgery: about 3,000 Euro
Excess in-hospital lenght of stay: 5 days
Added hospital costs: 2,500 Euro (500 Euro/day)
About 15 additional wound care procedures
Cost of extra wound care : 150 Euro (10 Euro/each)
Antibiotic therapy (10 days): 400 Euro
Total added cost: 6,050 Euro
Organ or Space infections systemic, local high
ICU – hosp. stay (mortality)
CostTreatment
SSI – Classification CDC(Horan TC: Infect Control Hosp Epidemiol, 1992)
Cost analysis of “chronic” organ/space SSI
Cost of re-do surgery: about 3,000 Euro
Extra in-hospital lenght of stay: 10 days
Added hospital costs: 5,000 Euro (500 Euro/day)
About 50 additional wound care procedures
Cost of extra wound care : 500 Euro (10 Euro/each)
Antibiotic therapy (15 days): 820 Euro
Total added cost: 9,320 Euro
Surgical Site Infection (SSI) Surgical Site Infection (SSI) --EpidemiologyEpidemiology
• SSI rate differs from one country to another
according to the system employed for control of
hospital infections
• SSI rate ranges between 3% and 20%
depending on hospital, patient clinical conditions
and type of procedure
Surgical Site Infection (SSI) in ItalySurgical Site Infection (SSI) in Italy
• About 3,000,000 (in-patients) surgical
procedures per year in Italy
• About 5% of all surgeries (150,000/year)
generate SSI in Italy
KIR-NOS Study GroupKIR-NOS Study Group
Incidence Study1 April - 30 June 2002
Follow-up 30 days(visit or phone call and questionnaire at discharge)
3066 surgeries
Torino MolinetteMauriziano
BiellaOspedale Degli Infermi
Borgomanero (NO)Ospedale SS Trinità
Alto Garda Study (2009): 1281 ptsAlto Garda Study (2009): 1281 pts
Site of infection
Deep
Superficial
Organ-space
76/12815.9 %
44%
42% 14%
7.9%
[IC95%:7.0-8.9]
Localizzazione dell'infezione
Superficiale62%
Organo-spazio23%
Profonda15%
Site of infection
Deep
Superficial
Organ-space
KIR-NOS Study (2002): 3066 ptsKIR-NOS Study (2002): 3066 pts
158/30665.2%
Overall SSI Rate
Overall SSI Rate
UnderdiagnosisUnderdiagnosis of SSIof SSI
SSI:SSI:
•• Not diagnosed (not recognized; late signs)Not diagnosed (not recognized; late signs)
•• Not reported Not reported
•• MisclassifiedMisclassified
SSI (%)SSI (%)
0.72 %0.72 %2.3 %2.3 %4.0 %4.0 %7.2 %7.2 %
SSI (%)SSI (%)
0.72 %0.72 %2.3 %2.3 %4.0 %4.0 %7.2 %7.2 %
SSI (%)SSI (%)
0.72 %0.72 %2.3 %2.3 %4.0 %4.0 %7.2 %7.2 %
Authors Year n° pts % wound infection
Vilar-Compte 2009 2338 18.7
Throckmorton 2009 436 7.8
El-Tamer 2007 30474.3 (Mastectomy) 2.0 (Lumpectomy)
Gravatt Wilke 2006 4975 1.0 (axillary surgery)
Leaper 2005 168 10 (axillary surgery)
Leaper 2001 175 10
SSI rate in breast surgery
Infection surveillanceInfection surveillance
• Information concerning factors and procedures associated with increased risk of SSI
• Stratification of SSI rates according to risk factors
• Comparison of SSI rates intra- and inter-Institutions
SSI / NNIS IndexSSI / NNIS Index
• Appropriately stratifies groups of risk when applied to global analysis of surgical procedures
SSI / NNIS Index SSI / NNIS Index -- LIMITATIONSLIMITATIONS
• Incisional and Organ/Space SSIs are not separated
• Overall SSI rate (Incisional and Organ/Space) can be misleading in terms of clinical relevance