Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 1
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
¤ AQributable cost of SSI vary -‐ $3,000-‐$29,000
Your are entering the operating theatre
There are many pre-and perioperative factors that determine whether or not
a patient will develop a SSI
¤ Pa/ent-‐related
¤ Procedure-‐related
¤ Structure-‐related
¤ Pa#ent-‐related
¤ Procedure-‐related
¤ Structure-‐related
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 2
¤ Pa/ent-‐related
¤ Procedure-‐related
¤ Structure-‐related
¤ Pa/ent-‐related
¤ Procedure-‐related
¤ Structure-‐related
No influence possible
¤ Age
¤ Underlying disease
¤ Malignancy
¤ Wound classifica/on
¤ Prosthe/c material
Influence by hospital • Laminar air-‐flow • Steriliza/on • Pre-op hospitalization
Influenced by patient
• BMI >30
• Nicotine use
• Malnutrition
• Infection at remote site
Can & should be influenced
• Surveillance
• S. aureus colonization
• Normothermia/hyperoxia
• Glucose levels
• Hair-removal
• Antimicrobial prophylaxis
• Skin disinfection
¤ Avoid shaving opera/ve site
¤ Maintain Post-‐op Glucose Control for Major Cardiac Surgery
¤ Maintain Post-‐op Normothermia for Colorectal Surgery
¤ Use Prophylac/c An/bio/cs appropriately
¤ Use Basic Preven/ve Strategies from CDC
² exclude pa/ents w/infec/on, stop tobacco use, keep OR doors closed, wear masks, prepare skin w/appropriate agent.
hQp://www.ihi.org/IHI/Topics/Pa/entSafety/SurgicalSiteInfec/ons/Changes/
… or not
Disinfec/on and steriliza/on
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 3
Brandt et al, Ann Surg 2008; 248:695-700.
¤ 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
Brandt et al, Ann Surg 2008; 248:695-700.
Follow-‐up study taking in account the size of the LAF plenum shows no difference in outcome
CAN & SHOULD
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 4
¤ S. aureus coloniza#on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
Nasal decoloniza/on
¤ S. aureus coloniza/on
¤ An#microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
Classen. NEJM 1992;328:281.
Infec
tions
(%)
Hours From Incision
14/369
5/699 5/1009
2/180 1/81
1/41 1/47
15/441
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 5
¤ Reduc/on of Nosocomial Infec/ons
Li>le things can have great impact
(on hygiene)
year
No significant risk reduc#on was
observed for pa#ents operated on during the second and third surveillance years
% SSI
Geubels et al Intern J Qual Health Care 2006;18:127-133
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
Kurz et al. NEJM 1996; 334:1209-‐15
Pa/ents with colorectal opera/ons
sample
SSI rate (%)
6 %
19 %
Normothermia
Hypothermia
p=0.009
200 Pa#ents
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 6
SSI-‐rate Local Systemic
5 (4%) 8 (6%)
Control
19 (14%)
Melling. Lancet. 2001; 358:876.
* p < 0.01
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
JAMA 2004; 291:79-87
JAMA 2005; 294:2035-42
• High FiO2 (0.80) during and aqer surgery • Colorectal ! • General surgery?
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
¤ Postopera/ve hyperglycemia is an important independent risk factor for SSI in general surgery pa/ents.
Archives of Surgery 2010;145:858-864]
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec/on
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 7
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.
Rasors vs. „Clipping“
OR = 2.02 (CI95 1.21-3.36)
Rasors vs. Depilatory cream
OR = 1.54 (CI95 1.05-2.24)
Tanner et al. Cochrane Database Syst Rev 2006 Jul 19
¤ Inappropriate: ² Shaving
¤ Appropriate: ² No hair removal at all ² Clipping ² Depilatory use
¤ S. aureus coloniza/on
¤ An/microbial prophylaxis
¤ Surveillance
¤ Normothermia
¤ Hyperoxia
¤ Glucose levels
¤ Hair-‐removal
¤ Skin disinfec#on
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 8
New results !
NEJM
Darouiche et al NEJM 2010;362:18-‐26
¤ The overall rate SSI was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group (9.5% vs. 16.1%; P=0.004)
¤ Chlorhexidine–alcohol was significantly more protec/ve against
² superficial incisional infec/ons (4.2% vs. 8.6%, P=0.008)
² deep incisional infec/ons (1% vs. 3%, P=0.05)
Darouiche et al NEJM 2010;362:18-‐26
¤ Alcoholic solu/ons standard of care in NL en other EU ² I miss the comparison with povidone–iodine-‐alcohol!
¤ What part of chlorhexidine–alcohol works?
¤ How important is the CHG concentra/on ¤ Landmark study that shows that the choice of skin-‐prep counts !
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
Surgical Site Infec/ons November 2012
Andreas Voss, MD, PhD 9
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