SSI (ICAN-ISC workshop)

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











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



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)


Significant ns ns ns ns ns


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



¤ S. aureus coloniza#on


¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels



Nasal decoloniza/on


¤ An#microbial prophylaxis

¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels



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



¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels





¤ 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



¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels



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



SSI-‐rate Local Systemic

5 (4%) 8 (6%)

Control

19 (14%)

Melling. Lancet. 2001; 358:876.

* p < 0.01



¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels



JAMA 2004; 291:79-87

JAMA 2005; 294:2035-42

•  High FiO2 (0.80) during and aqer surgery •  Colorectal ! •  General surgery?



¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels



¤ Postopera/ve hyperglycemia is an important independent risk factor for SSI in general surgery pa/ents.

Archives of Surgery 2010;145:858-864]



¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels





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



¤ Surveillance

¤ Normothermia

¤ Hyperoxia

¤ Glucose levels


¤ Skin disinfec#on



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)


¤ 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 !


Reasons why implementa/on of effec/ve IC measures in the OR is complicated

J Am Coll Surg 2008; 207:810-‐20



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

SSI (ICAN-ISC workshop)

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