Prevention of Surgical Site Infection 2017 Guidelines & Antimicrobial Stewardship

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1 Prevention of Surgical Site Infection 2017 Guidelines & Antimicrobial Stewardship Phenelle Segal RN, CIC, FAPIC President Infection Control Consulting Services home.com home.com Objectives Discuss the components of the newly published guidelines for prevention of surgical site infection Identify prevention strategies that pertain to the ASC setting Assess antimicrobial stewardship and how it plays a role in the ASC setting 1

2 General Facts SSI costs continue to rise directly impacting human and fiscal resources Costs can exceed $90,000 in infected prosthetic joint implants or a multi drug resistant organism Increasingly complex co morbidities play a role in the rising rates of SSI General Facts Public reporting of process, outcome and other quality improvement measures now required Reimbursements for treating SSIs reduced or denied Evidence based strategies is estimated to prevent approximately 50% of infections 2

3 General Facts In 2006, roughly 80 million surgical procedures were performed at inpatients and ambulatory settings (hospital affiliated and freestanding) approximately 1.9% of procedures were complicated by SSIs Percentage of SSIs could be higher due to approximately 50% appearing after discharge General Facts Last version of CDC guidelines published in 1999 Was evidence informed but most recommendations based on expert opinion before evidence based guidelines were identified Updated evidence based recommendations introduced in May

4 General Facts Addresses new and updated strategies for the prevention of SSIs Guideline focuses on a few select areas, and not all of the recommendations that were made in 1999 were reviewed General Facts Recommendations useful for healthcare professionals and a resource for professional societies and organizations Several unresolved issues in the guideline reveals substantial gaps that warrant future research Ongoing research and newer technologies will guide future revisions 4

5 General Facts New guidance should be incorporated into comprehensive surgical quality improvement programs If new guidance strategies are adopted, policies and procedures should be developed and/or updated General Facts The guidelines cover several core areas and are intended for incorporation into existing surgical quality improvement programs for greater patient safety Developed in close partnership with the specialty surgical societies, and their designated [guideline] coauthors, ensuring that recommendations meet the needs of the field 5

6 General Facts CDC/HICPAC recognized that several 1999 recommendations remain important and have been followed as infection control standards for many years In 2014, HICPAC reviewed the 1999 strong recommendations for which the evidence was not re assessed as part of the development of the 2017 Guideline. This was to reaffirm them as accepted practices (e.g., standard of care.) Standard of Care Re emphasis CDC and HICPAC recommend that facilities should continue to follow these practices: Preparation Of The Patient Whenever possible, identify and treat all infections remote to the surgical site before elective operations and postpone elective operations on patients with remote site infections until the infection has resolved 6

7 Preparation Of The Patient Do not remove hair preoperatively unless necessary. Remove immediately before the operation, with clippers Encourage tobacco cessation for a minimum of at least 30 days before elective operations Ensure skin around incision site is free of gross contamination before performing antiseptic skin preparation Hand/Forearm Antisepsis For Surgical Team Perform preoperative surgical hand/forearm antisepsis according to manufacturer s recommendations for the product being used See 2002 Guidelines for Hand Hygiene in Healthcare Settings for additional surgical hand antisepsis recommendations 7

8 Operating Room Ventilation Maintain positive pressure ventilation in the operating room and adjoining spaces Maintain the number of air exchanges, airflow patterns, temperature, humidity, location of vents, and use of filters in accordance with recommendations from the most recent version of the Facilities Guidelines Institute Guidelines for Design and Construction of Hospitals and Outpatient Facilities (current version 2014) Cleaning And Disinfection Of Environmental Surfaces Do not perform special cleaning or closing of operating rooms after contaminated or dirty operations 8

9 Reprocessing Of Surgical Instruments Sterilize all surgical instruments according to published guidelines and manufacturer s recommendations Immediate use steam sterilization should be reserved only for patient care items that will be used immediately in emergency situations when no other options are available. Not for routine reprocessing Surgical Attire And Drapes Wear a surgical mask that fully covers the mouth and nose when entering the operating room if an operation is about to begin or already under way, or if sterile instruments are exposed. Wear the mask throughout the operation 9

10 Surgical Attire And Drapes Wear a new, disposable, or hospital laundered head covering for each case, when entering the operating room Ensure it fully covers all hair on the head and all facial hair not covered by the surgical mask Surgical Attire And Drapes Wear sterile gloves if serving as a member of the scrubbed surgical team. Put on sterile gloves after donning a sterile gown Use surgical gowns and drapes that are effective barriers when wet (i.e., materials that resist liquid penetration) Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials 10

11 Sterile And Surgical Technique Adhere to principles of sterile technique when performing all invasive surgical procedures If drainage is necessary, use a closed suction drain Place a drain through a separate incision distant from the operative incision Remove the drain as soon as possible Post op Incision Care Protect primarily closed incisions with a sterile dressing for hours postoperatively 11

12 Updated Guidelines Summary of Key Components Advise patients to have a full body shower or bath with soap (antimicrobial only as needed) or an antiseptic agent no earlier than the night before the day of surgery Before cesarean delivery, administer antimicrobial prophylaxis before incision In most cases, use an alcohol based agent for skin preparation in the operating room It is not necessary to use plastic adhesive drapes with or without antimicrobial properties to prevent SSIs For clean and clean contaminated procedures, do not give additional prophylactic antimicrobial doses after closing the surgical incision, even if the patient has a drain in place 12

13 Do not apply topical antimicrobial agents to the incision Maintain intraoperative glycemic control in diabetic and nondiabetic patients, targeting blood glucose levels of less than 200 mg/dl Maintain patient normothermia In patients with normal lung function undergoing general anesthesia with endotracheal intubation, administer a higher fraction of inspired oxygen during surgery and after extubation in the immediate postoperative period Do not withhold transfused blood products as a means to prevent SSI 13

14 Recommendation Categories Similar to 1999 guidelines reflecting the level of supporting evidence or regulations Category 1A: A strong recommendation supported by high to moderate quality evidence suggesting net clinical benefits or harms Category 1B: A strong recommendation supported by low quality evidence suggesting net clinical benefits or harms or an accepted practice (e.g. Aseptic technique) supported by low to very low quality evidence Recommendation Categories Category 1C: A strong recommendation required by state or federal regulation Category II: A weak recommendation supported by any quality evidence suggesting a trade off between clinical benefits and harms 14

15 Recommendation Categories No recommendation/unresolved issues: An issue for which there is low to very low quality evidence with uncertain trade offs between the benefits and harms or no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention Parenteral Antimicrobial Prophylaxis Should be administered only when indicated based on published clinical practice guidelines Timed to establish bactericidal concentration of the agents in serum and tissues when the incision is made. (Category 1B strong recommendation; accepted practice) 15

16 Updated Guidelines Details Parenteral Antimicrobial Prophylaxis Administer the appropriate parenteral prophylactic antimicrobial agents before skin incision in all cesarean section procedures. (Category 1A strong recommendation; highquality evidence.) Nonparenteral Antimicrobial Prophylaxis Do not apply antimicrobial agents (ie, ointments, solutions, or powders) to the surgical incision. (Category 1B strong recommendation; low quality evidence.) Application of autologous platelet rich plasma is not necessary for the prevention of SSI (Category II weak recommendation) 16

17 Nonparenteral Antimicrobial Prophylaxis Consider the use of triclosan coated sutures for the prevention of SSI (Category II weak recommendation) Unnecessary to use plastic adhesive drapes with or without antimicrobial properties. (Category II weak recommendation) Glycemic Control Implement perioperative glycemic control and use blood glucose target levels less than 200mg/dL in patients with and without diabetes. (Category 1A strong recommendation; high to moderate quality evidence.) Normothermia 1. Maintain perioperative normothermia. (Category 1A strong recommendation; high to moderate quality evidence.) 17

18 Oxygenation Administer increased FIO2 during surgery and after extubation in the immediate postoperative period to patients with normal pulmonary function under general anesthesia and endotracheal intubation (Category 1Astrong recommendation; high to moderatequality evidence.) Blood Transfusion Do not withhold transfusion of necessary blood products from surgical patients as a means to prevent SSI. (Category IB strong recommendation; accepted practice.) 18

19 Antiseptic Prophylaxis Advise patients to shower or bathe (full body) with soap (antimicrobial or non antimicrobial) or an antiseptic agent on at least the night before the operative day. (Category IB strong recommendation; accepted practice) Perform intraoperative skin preparation with an alcohol based antiseptic agent unless contraindicated (Category 1A strong recommendation; high quality evidence) Antimicrobial Stewardship Definition Antimicrobial stewardship refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration 19

20 Antimicrobial Stewardship History Antibiotic resistance remains a critical threat to the health and wellbeing of the public Multi drug resistant infections cause at least 2 million illnesses and 23,000 deaths a year in the US Antimicrobial Stewardship History Antimicrobial stewardship must be the responsibility of all healthcare institutions across the continuum of care Process and outcome measures as well as goals must be developed to monitor these interventions 20

21 Antimicrobial Stewardship History This focus coincides with and complements the Department of Health and Human Services Action Plan to Prevent Healthcare Associated Infections, developed during the previous White House Administration 21

22 Antimicrobial Stewardship History The Action Plan outlines Federal activities over the next five years These activities are consistent with investments in the President s FY 2016 Budget, which nearly doubles the amount of Federal funding for combating and preventing antibiotic resistance to more than $1.2 billion Antimicrobial Stewardship History By 2020, significant outcomes in this area will include: Establishment of antimicrobial stewardship programs in all acute care hospitals and improved stewardship across all healthcare settings Reduction of inappropriate antibiotic use by 50% in outpatient settings and by 20% in inpatient settings Establishment of State Antibiotic Resistance (AR) Prevention (Protect) Programs in all 50 states 22

23 Antimicrobial Stewardship CDC recommends that outpatient care facilities take steps to implement AMS activities Outpatient care facilities include but are not limited to primary care and specialty clinics, ambulatory surgical centers, office based practices, dental practices and dialysis centers Antimicrobial Stewardship AAAHC AMS Toolkit: Core Elements Commitment Action Tracking and Reporting Education and Expertise 23

24 Antimicrobial Stewardship Health Services Advisory Group (HSAG) Antimicrobial Stewardship Program Components Leadership Support Formal written statement of support from leadership Budgeted financial support Accountability Physician champion/leader Pharmacist leader 24

25 Antimicrobial Stewardship Program Components Policies Facility policy requiring prescribers to document in the medical record or during order entry, a dose, duration and indication for all antimicrobial prescriptions Treatment recommendations, based on national guidelines and local susceptibility Monitor adherence to the policy and facility specific treatment recommendations Antimicrobial Stewardship Program Components Interventions to Improve Antibiotic Use Physician or pharmacist approval prior to dispensing specified antimicrobial agent Physician or pharmacist review of courses of therapy for specified antimicrobial agents Education Provide education to clinicians and other relevant staff members on improving antimicrobial prescribing 25

26 References 1. Guideline for the Prevention of Surgical Site Infection, Downloaded From: 2. Supplementary Online Content. Berríos Torres SI, Umscheid CA, Bratzler DW, et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, JAMA Surg. Published online May 3, Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS) References 4. Reference: FACT SHEET: Obama Administration Releases National Action Plan to Combat Antibiotic Resistant Bacteria. March press office/2015/03/27/fact sheetobama administration releases national action plan combat ant 5. Antimicrobial Stewardship Checklist for Ambulatory Surgery Centers (ASCs). Health Services Advisory Group (HSAG). Available online at 6/rbrndcdchsagaschecklistforascs.pdf 6. AAAHC Institute for Quality Improvement. Patient Safety Toolkit: Antibiotic Stewardship. Available for purchase at 26

27 Phenelle Segal RN, CIC, FAPIC President Infection Control Consulting Services home.com home.com 27