Surgical Site Infections a 21 st century challenge

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1 Surgical Site Infections a 21 st century challenge SSI the least noticed but most preventable HCAI Professor David Leaper Cardiff University and Imperial College, London 22 November 2010

2 and by exposing his microbes to non-lethal quantities of the drug make them resistant...the time may come when penicillin may be bought by anyone in the shops. Then there is a danger that the ignorant man may easily underdose himself Alexander Fleming

3 Healthcare Associated Infection (HCAIs) and resistant organisms urinary catheters ESBLs NDMs respiratory HAP VAP and ITU GRE vascular catheters and prosthetics MRCNS bacteraemias SSIs and csstis MRSA clostridium difficile (CDI) antibiotic overuse

5 definition of acute infection Aulus Aurelius Cornelius CELSUS (25BC-50AD) CALOR RUBOR DOLOR TUMOR (functio laesa) Systemic Inflammatory Response Syndrome Leaper Wounds: Biology and Management 1998 OUP, Oxford

6 HDU ITU Gloucester flesheating virus organ debridement support

7 when should antibiotics be given for SSIs and wound infection? cellulitis lymphangitis bacteraemia SIRS and MODS, MOF and DEATH definite pathogens (β-haemolytic streptococcus) large numbers (critical colonisation-infection) host defences (immunosuppression, i diabetes)

8 SIRS and MODS FACULTY for ACRONYM RESEARCH and TECHNOLOGY

9 Systemic Inflammatory Response Syndrome (SIRS) pyrexia >38 o C (or <36 o C) tachycardia >90 beats/min tachypnoea >20 breaths/min (or PaCO 2 <4.2kPa) WBC >12x10 9 /l (or <4x10 9 /l)

11 SIRS MODS MOF ( IIII; iiii ; CARS and MARS) Injury multiple trauma burns Infection abdominal abscess Ischaemia shock (of any cause) Inflammation pancreatitis (iatrogenic intoxication immune idiopathic)

12 categories of surgical wounds (prosthetic surgery?) clean clean contaminated contaminated dirty Culver et al Am J Med 1991; 91:152S-157S

13 classification of surgical site infection superficial deep organ space Culver et al Am J Med 1991; 91: 152S-157S

14 CDC 30 days purulent discharge or abscess isolated organisms 1+ Celsian signs categorical data wound separation or need for drainage

15 Additional treatment ASEPSIS Serous discharge Erythema interval ldata Purulent exudate Separation of deep tissues Isolation of bacteria Stay in hospital >14 days

16 clean surgical wound NRC Ann Surg 1964; 160: (suppl 2)33-75 no other inflammation encountered respiratory alimentary genitourinary tracts not opened no breach in aseptic technique

17 controversy in clean surgical wounds: superficial surgical site infection rates Melling et al Lancet 2001; 358: rates vary between 1.4% to over 15% how hard do you look? (telephone or surveillance) where do you look? (inpatient or primary care) prophylactic antibiotics are controversial audit techniques are flawed cost transferred to primary health care

18 definition of surgical site infection accurate audit surveillance MUST go to 30 days+ unbiased blinded trained observer scoring systems -if we are to have mandatory reporting who will y p g undertake it and who will pay?

19 consequences of surgical site infection for the healthcare setting extended ddhospitalisation i of fh the patient readmission rates to hospital increased increased care costs (for items such as prescriptions) delayed ongoing treatments decreased confidence in healthcare setting from local g population - audit results in the public domain

20 extended length of stay and cost for surgical site infection 9.8 days (7-14) 2000 ( ) 30 million procedures in Europe SSIs = b Leaper et al 2004

21 Surgical Site Infection Implementing NICE guidelines NICE clinical guideline 74 October 2008

20% of all HCAIs at least 5% of patients

22 scope surgical site infection (SSI) adults and children SSIs comprise up to 20% of all HCAIs at least 5% of patients undergoing surgery develop an SSI SSIs have a significant effect on quality of life for patients SSIs result in a considerable financial burden to healthcare providers the majority of SSIs are preventable

23 hair removal traditional improve view and access perceived reduction infection rate razors damage skin abrasion, sweat glands potentially increasing SSI rate!

clippers with a single-use head on the day of surgery.

24 hirrmo hair removal do not use hair removal routinely to reduce the risk of SSI if hair has to be removed, use electric clippers with a single-use head on the day of surgery. Do not use razors for hair removal because they increase risk of SSI

25 every operation is an experiment in bacteriology Moynihan Br J Surgery 1920; 8 : 27-35

26 the decisive period Miles and Burke Brit J Exp Pathol 1957; (adrenaline and antibiotics) Polk and Lopez-Major Surgery 1969 ;66: (first antibiotic i prophylaxis)

27 antibiotic prophylaxis give antibiotic prophylaxis to patients before: clean surgery involving the placement of a prosthesis or implant clean-contaminated surgery contaminated surgery

28 antibiotic prophylaxis empirical choice depending on surgery -decisive i period IV at induction of anaesthesia repeat ONLY with excess blood loss, long operation or prosthetic ti surgery any longer is therapy

29 antibiotic prophylaxis do not use antibiotic prophylaxis routinely for clean non-prosthetic uncomplicated surgery use the local antibiotic formulary and always consider potential adverse effects when choosing specific antibiotics for prophylaxis consider giving a single dose of antibiotic prophylaxis p intravenously on starting anaesthesia. However, give prophylaxis earlier for operations in which a tourniquet is used

30 timing at start of anaesthesia earlier if a tourniquet is used prepare p for drugs with long infusion times inform patients responsibility

intraoperative phase prepare the skin at the

suitable cover surgical incisions with an

31 intraoperative phase prepare the skin at the surgical site immediately before incision using an (aqueous or alcohol-based) antiseptic preparation: povidone-iodine or chlorhexidine are suitable cover surgical incisions with an appropriate interactive dressing at the end of the operation

32 chlorhexidine-alcohol versus povidone- iodine for surgical site antisepsis i a new paper: pp Darouiche et al. NEJM multicentre (6 hospitals); 4 years 849: power and randomisation definition and surveillance of SSI 2% chlorhexidine 10% povidone iodine paint versus scrub and paint clean-contaminated category only 95% 9.5% -16.1% 1% overall; superficial i and deep SSIs not sepsis or organ space

dressings for the management of surgical

33 postoperative phase refer to a tissue viability nurse (or another healthcare professional with tissue viability expertise) for advice on appropriate dressings for the management of surgical wounds that are healing by secondary intention after an infection

34 poor evidence preoperative showering specific patient and staff theatre wear minimizing i i i movement in the operating theatre banning of hand jewellery and nail polish nasal decontamination of all Staphylococcus aureus, not just MRSA, to reduce the risk of SSI is effective (Bode et al 2010) mechanical bowel preparation (Cochrane Collaboration) operative rituals: hand decontamination, gloves, drapes and gowns, diathermy, antiseptic lavage and wound dressings supplemental oxygen in recovery

36 extract from guideline Implementation of the Guideline will not necessarily involve major changes in current practice but it does recommend the pooling of best practice into care bundles which should reduce the risk of SSI. The introduction of the Guideline into patient care needs to be across the whole spectrum of care from the decision to operate to recovery and return to normal life style.

37 SSI care bundle

38 if the surgery is clean...why are there infections?

39 clean wound infections is the infection rate higher than we think? is antibiotic prophylaxis appropriate? what else is available.. warming perhaps?

40 forced air local warming warming

41 effect of warming on wound infection 20 Standard Local Warming 15 Systemic Warming infection rates 10 standard 13.7% 5 0 Infection local warming 3.6% (p= 0.003) systemic warming 5.8% (p=0.028)

42 the significance of local warming all warmed patients non-warmed patients P value infection 4.7% 13.7% haematoma 2.2% 3.6% 0.29 seroma 4% 5.8% 0.28 aspirated 4% 6.5% 0.19 post-op ABs 6.5% 15.9% 0.002

43 benefits of peri-operative warming: existing clinical evidence wound infection blood transfusion cardiac events morbidity and mortality intensive care and overall hospital stay cost effective Odom and Mahoney AANA J 1999; 67:

44 conductive polymers Hot Dog!

45 biofilms!

46 dental plaque is a biofilm

47 biofilms are ubiquitous it

48 biofilms (Koch s postulates upside down) complex microenvironment - bacteria and glycocalyx intercellular l communication i (quorum sensing) resist host-defences & antibiotics exist in acute and chronic wounds?

become resistant phagocytes still attracted and release proteinases, ROS and

49 immunological response, biofilms and tissue dm damage bacteria cleared by antibodies, phagocytosis and antibiotics adherent bacteria form biofilms and become resistant phagocytes still attracted and release proteinases, ROS and NO tissue damage occurs around the biofilm, releasing bacteria and lead to infection

50 infection or failure to heal? biofilm?

51 research opportunities (how can we do without antiseptics: which could reduce antibiotic use) cost effectiveness of new antiseptic incise drapes benefits of improved blood glucose control effectiveness of intra-cavity and wound lavage with modern antiseptics antimicrobial (antiseptic) sutures role of supplemental oxygen in the recovery room adaptation of chronic wound management for SSIs - in prevention (antiseptic dressings) - postoperatively after wound separation (dehiscence) (use of antiseptic dressings and topical antiseptics) effectiveness of modern debridement techniques

52 back to antiseptics!

ANTISEPTICS ( antimicrobial : antiseptic,

and alcoholic biguanides polyhexanide povidone

suture coating hexachlorophane aqueous phenolic

53 ANTISEPTICS ( antimicrobial : antiseptic, antibiotic) chlorhexidine polyhexamethylene aqueous and alcoholic biguanides polyhexanide povidone iodine aqueous and alcoholic triclosan aqueous and suture coating hexachlorophane aqueous phenolic cetrimide aqueous cationic benzalkonium surfactant HOW CAN WE DO WITHOUT THEM?

54 SEMMELWEIS: mortality and puerperal p sepsis handwashing before delivery: % % brick significance?

55 potential for antiseptic sutures (triclosan) wide spectrum antimicrobial in deep tissues good for prosthetic surgery? -orthopaedics, vascular colorectal surgery potential in resistance? MRSA MRCNS avoids antibiotic use? action on biofilms (breast surgery)? does it risk selection of antibiotic resistant organisms or transmissible resistance in human pathogens?

56 zone of inhibition- Vicryl plus suture and knots

57 Vicryl plus; Monocryl plus PDS and Vicryl plus in abdominal wall Justinger et al Surgery % to 4.9% Vicryl plus gentamicin/collagen sponge appendicectomy in children 10.3% to 5.9% (6.9% vicryl 4.6% collagen) Beltra-Pico et al Cirigia Pediatrica 2008;21:

58 Vicryl plus; Monocryl plus Vicryl plus in CSF shunts 2/46 to 8/38 p=0.038 Leonardo and Rozelle 2008 Vicryl plus in sternal closure 24/376 to 0/103! Fleck et al Annals of Thoracic Surgery 2008

59 the days of chromic catgut and silk..are gone

60 John Hunter to Edward Jenner but why think? why not try the experiment?

61 he had never learned how to repair wounds this seemed a serious flaw in his magical education Harry Potter and the Deathly Hollows Jo Rowling 2007

Treatment of Surgical Site Infection Meeting Quality Statement 6. Prof Peter Wilson University College London Hospitals

Treatment of Surgical Site Infection Meeting Quality Statement 6 Prof Peter Wilson University College London Hospitals TEG Quality Standard 6 Treatment and effective antibiotic prescribing: People with