Surgical Site Infection (SSI) Prevention: The Latest, Greatest and Unanswered Questions

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1 Surgical Site Infection (SSI) Prevention: The Latest, Greatest and Unanswered Questions Keith S. Kaye, MD, MPH Corporate Vice President of Quality and Patient Safety Corporate Medical Director, Infection Prevention, Epidemiology and Antimicrobial Stewardship Detroit Medical Center and Wayne State University

2 Overview SSI Epidemiology and Outcomes Pathogenesis and categorization SSI and CMS Prevention The basics Special Approaches Not recommended/unresolved Ongoing challenges and opportunities

3 SSI Epidemiology SSIs occur in 2% 5% of patients undergoing inpatient surgery. Approximately 160, ,000 SSIs occur each year in the United States. SSI is now the most common and most costly HAI. Most occur within 30 days of surgery; those involving prostheses might occur later (up to 90 days) Anderson et al, infection control and hospital epidemiology june 2014, vol. 35, no. 6

4 Outcomes Up to 60% of SSIs estimated to be preventable Account for 20% of all HAIs in hospitalized patients. Each SSI associated with ~ 7 11 additional postoperative hospital-days. Patients with an SSI have a 2 11-times higher risk of death Seventy-seven percent of deaths in patients with SSI are directly attributable to SSI. Attributable costs of SSI vary depending on the type of operative procedure and the type of infecting pathogen. SSIs are account for $3.5 $10 billion annually in healthcare expenditures

5 Pathogenesis of SSI Most SSI are caused by a patient s endogenous flora Aerobic gram-positive cocci (eg staphylococci) most common Anaerobes, gram-negative aerobes, other gram-positives for surgery involving colon, perineum, groin Exogenous sources of SSI are rare Surgical team OR environment Tools, instruments

6 Organisms Causing SSI January 2009-October 2010, N=21,100 Staphylococcus aureus 30.4 Coagulase-negative staphylococci 11.7% Enterococcus spp. 11.6% Escherichia coli 9.4% Pseudomonas aeruginosa 5.5% Enterobacter spp 4.0% Klebsiella pneumoniae 4.0% Proteus spp. 3.2% Candida spp. 1.8% Serratia spp.1.8% Sievert et al, Infection Control and Hospital Epidemiology, January, 2013, 34(1), 1-14

7 SSI classification

8 CMS and SSI: VBP Safety Measures, FY 2018

9 Similar for FY 2018 except CY 2016 included as performance period Non-ICU CLABSI included 9

10 Several Outcome Measures Used in Both VBP and HAC Payment Programs Measure Date Reporting Began VBP Program (1 st fiscal year) HAC Reduction Program (1 st fiscal year) CLABSI 2011 Q CAUTI 2012 Q SSI 2012 Q MRSA 2013 Q C.diff 2013 Q AHRQ Composite ( PSI 90 ) (CMS calculates) Performance Periods 2015 VBP = CY VBP = CY VBP = CY VBP = CY

11 CMS Readmissions Reduction Program FY 2016 includes 30-day readmissions for AMI CHF Pneumonia COPD Elective THA, TKA

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13 Risk Factors Microbial Characteristics Surgical Characteristics Risk of SSI Patient Characteristics

14 Risk Factors Patient Related Age Diabetes Obesity Smoking Immunosuppression Organism Colonization Virulence Drug-Resistance Peri-operative Hair removal Pre-op infections Surgical scrub Skin prep Antimicrobial prophylaxis Agent Timing Surgical skill Operative time OR traffic

15 Recommended Strategies for SSI Prevention Core processes that should be routinely practiced to prevent SSI

16 Hair Removal Do not remove hair unless necessary Remove outside of OR using clippers or depilatory Possible exception for shaving urologic surgery

17 Antimicrobial Prophylaxis For indicated procedures, right agent, right time Begin administration 1 hour prior to incision (2 hours for vancomycin, fluoroquinolones) Sweet spot target minutes Stop antibiotics within 24 hours after surgery Adjust dose for patient weight Re-dose for procedures lasting 2 half-lives or longer than prophylactic antibiotic Oral and IV prophylaxis for colorectal surgery

18 Role of Vancomycin in Prophylaxis Do not routinely use vancomycin for antimicrobial prophylaxis Consider if methicillin-resistant Staphylococcus aureus (MRSA) SSI outbreak; of if high endemic MRSA SSI rates If used for a procedure where Staphylococci are common pathogens, administer in combination with B-lactam (eg cefazolin) Consider combination prophylaxis for surgeries involving prostheses

19 Glucose Control Control blood glucose during the immediate postoperative period for cardiac surgery patients (level I) Maintain postoperative blood glucose of 180 mg/dl or lower hours after anesthesia end time Avoid targeting levels of 110 mg/dl or lower Also recommended (level II) for other surgeries

20 Normothermia Maintain normothermia (temperature of 35.5 C or more) during the perioperative period Even mild degrees of hypothermia can increase SSI rates. Hypothermia may directly impair neutrophil function or impair it indirectly by triggering subcutaneous vasoconstriction and subsequent tissue hypoxia. In addition, hypothermia may increase blood loss Most data in colon/abdominal surgery

21 Supplemental Oxygen Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation 80% FI02 for 2-6 hours post-op Exclude patients with severe COPD Data strongest in colon surgery populations 25% reduction is SSI rates in some studies Qadan et al, Arch Surg Apr;144(4):359-66

22 Alcohol-containing Preoperative Skin Prep Alcohol is effective for preoperative skin antisepsis but does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining with chlorhexidine gluconate (CHG) or aniodophor (povidone-iodine). Both CHG and povidone-iodine are acceptable. Alcohol is contraindicated for certain procedures Including procedures in which the preparatory agent may pool or not dry (eg, involving hair) due to fire risk. Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.

23 Impervious Plastic Wound Protectors for GI and Biliary Tract Surgery A wound protector is a plastic sheath that lines a wound and can facilitate retraction of an incision during surgery without the need for additional mechanical retractors. A meta-analysis of 6 randomized clinical trials in 1,008 patients reported that use of a plastic wound protectors was associated with a 45% decrease in SSIs. Edwards JP et al. Ann Surg 2012;256(1):53 59.

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25 SSI Surveillance Hallmark of SSI prevention Many SSIs occur post discharge Sensitivity of surveillance is poor for superficial SSI Deep, organ/space SSI usually require readmission Sensitivity greater Use of automated data and alerts can improve and facilitate surveillance Return to hospital, return to OR

26 Other Recommended Strategies for WHO Checklist SSI Prevention Feedback of data to surgeons Risk-adjusted preferred Anonymize Education of providers and patients

27 Special Approach: Screening/Decolonization of Patients for Staphylococcus aureus Considered a special approach Consider for cardiothoracic, orthopedic surgeries (involving prostheses) Consider once other strategies have been trialed/are in place Often a 5-day pre-operative regimen of CHG bathing (eg hibiclens) + intra-nasal mupirocoin is used Role of intra-nasal same day nasal povidone-iodine + CHG bathing Newer product: intra-nasal alcohol

28 Unresolved: Pre-Operative CHG Bathing Bathing night before and day of surgery Not currently recommended (listed as unresolved ) Many experts believe it works If done correctly, likely effective Potential advantage of CHG wipes

29 Unresolved: Antimicrobial Sutures Use for deep suturing has been reported to reduce SSI No current recommendation for routine use Stay tuned

30 Challenges in SSI Prevention: Movement to Ambulatory Surgery Setting Progressive movement to surgery in ambulatory setting More than ¾ of all surgeries in US performed in outpatient setting Infrastructure, data systems often unique compared to those used in inpatient settings Infection control activities and processes frequently less established in outpatient settings

31 Surveillance Requires a LOT of Data Collection Required data from surgical databases patient name, medical record number, date, type of procedure, surgeons, anesthesiologists, incision time, wound class, ASA score, closure time, and presence of an SSI Additional process data: Prophylactic agent and dose and time(s) of administration of prophylactic agent. For patients diagnosed with SSI, necessary microbiological data include type of SSI, infecting organism and antimicrobial susceptibilities, and date of infection. Additional information that may be useful for some procedures, including use of general anesthesia, emergency or trauma-related surgery, body mass index, and diagnosis of diabetes Infection Control / Volume 35 / Issue 06 / June 2014, pp

32 SSI Surveillance is Time-Consuming In one report, estimated time for an infection preventionist (IP) to abstract a chart for a surgical implant case 60 minutes (based on one-year post-op surveillance period) NJ hospital estimated that SSI surveillance took ~ 7 hours per work week of IP time (average daily census 192 patients) CDC estimates that SSI surveillance requires 540,000 IP hours annually in the US Automated programs can greatly reduce surveillance Average time needed per case 6 minutes for manual abstraction 2 minutes for automated abstraction Major limitation of automated surveillance is cost and effort for implementation Sarvareddi et al, APIC, 2010, New Orleans, LA; Parillo, AJIC, 2015, S3-S17; CACC Meeting Report. Sacramento, CA: California APIC Coordinating Council, May5, 2011;

33 Increased Scrutiny on Infection Control Preventionist The old days: SSI surveillance was traditionally performed solely as part of quality improvement activities Current times: SSI rates used as a quality measure Often publically reported Impacts insurance reimbursement Surveillance definitions are not always relevant and can lead to friction between ICPs and clinicians, administrators

34 Additional Ongoing Challenges Many strategies sound simple but implementation can be complex S. aureus screening/decolonization Pre-operative CHG bathing Supplemental oxygen/patient warming

35 What Recommendations are New and Might Not Yet Be Implemented at Your Site Supplemental oxygen Was controversial; data now clearly support SSI reduction HICPAC likely to recommend in ALL surgeries, not just colon Glucose control New target is 180 mg/dl HICPAC likely to recommend for ALL surgeries, not just colon Wounds protectors for GI surgery Make available to surgeons, share data regarding SSI reduction

36 What Recommendations are New and Might Not Yet Be Implemented (continued) Screening/decolonization of S. aureus Screening and then implementing 5 day regimen challenging CHG bathing - difficult to get patient to perform correctly For targeted surgeries, might be easier to implement same day approaches for all patients (ie screen none, decolonize all) Streamlined/automated surgical data Facilitate surveillance Facilitate benchmarking, feedback

37 Summary SSI is common and can be deadly Many evidence-based approaches exist to prevent SSI Multi-disciplinary OR team makes SSI prevention challenging Implementation of preventive processes can be complex When possible, Keep It Simple... (KISS) Don t assume that basic strategies are being practiced at your hospital If you look hard, you might be surprised by what you find

38 Questions?