CURRENT CONCEPTS IN THE PREVENTION OF SURGICAL SITE INFECTIONS

CURRENT CONCEPTS IN THE PREVENTION OF SURGICAL SITE INFECTIONS Walter L. Biffl, M.D. Assistant Director, Patient Quality and Safety Denver Health Medical Center Associate Professor of Surgery University of Colorado - Denver

SURGICAL SITE INFECTIONS (SSIs( SSIs) - Why You Should Care SSI Basics OUTLINE What You Can / Should Do About It - The Obvious - The Not-So-Obvious

SSIs SCOPE OF THE PROBLEM CDC s National Nosocomial Infections Surveillance (NNIS) System: Third Most Common Nosocomial Infection (14-16%) Emori et al, Clin Microbiol Rev 1993; 6:428 38% of Nosocomial Infections in Surgical Pts Mangram et al, Infect Control Hosp Epidemiol 1999; 20:247 SSI in 2.6% of 30 M Operations

CONSEQUENCES OF SSIs 255 Matched (Age, Procedure, NNIS Risk Index, Surgeon) Pairs, 1991-1995 SSI No SSI Mortality 7.8% 3.5% ICU Admit 29% 18% Median LOS 11 6 Costs $7531 $3844 Readmission 41% 7% Total Excess LOS 12 days, Costs $5038 Kirkland et al, Infect Control Hosp Epidemiol 1999; 20:725

CONSEQUENCES OF SSIs Extrapolated to U.S. 20,000 In-hospital Deaths $3 Billion / Year Inpatient Care Kirkland et al, Infect Control Hosp Epidemiol 1999; 20:725

WHO PAYS FOR SURGICAL COMPLICATIONS? Hospital Reimbursement ($) Costs of Care ($) Profit ($) Profit Margin (%) 14,266 (uncomplicated) 10,978 3288 23.0 21,911 (complicated) 21,156 755 3.4 Dimick JB et al. J Am Coll Surg 2006; 202:933

EXTERNAL FORCES IOM- To Err is Human (2000) Medical injuries result in 44,000-98,000 deaths and $17 B in health care costs annually 44,000 Operations 1977-1990 5.4% Complications Nearly 50% attributable to error

IMPACT OF ERRORS Zhan et al, JAMA 2003; 290:1868 AHRQ Patient Safety Indicators identified medical injuries among 7.45 M hospital discharge abstracts, 994 hospitals / 28 states, 2000 20% Sample of U.S. Hospitals

IMPACT OF ERRORS Zhan et al, JAMA 2003; 290:1868 Consequences of These 18 Types of Medical Injuries: 2.4 M Hospital Days $4.6 B Cost 32,591 Attributable Deaths

#4 Zhan et al, JAMA 2003; 290:1868

QUALITY IS JOB 1 Quality health care is a high priority for the Bush administration, the Department of Health and Human Services (HHS), and the Centers for Medicare & Medicaid Services (CMS). In November 2001, HHS announced the Quality Initiative to assure quality health care for all Americans through accountability and public disclosure. CMS, December 2005

QUALITY IS JOB 1 Quality health care is a high priority for the Bush administration, the Department of Health and Human Services (HHS), and the Centers for Medicare & Medicaid Services (CMS). In November 2001, HHS announced the Quality Initiative to assure quality health care for all Americans through accountability and public disclosure. CMS, December 2005

American College of Surgeons American Hospital Association American Society of Anesthesiologists Association of peri- Operative Registered Nurses Agency for Healthcare Research and Quality (AHRQ) Centers for Medicare & Medicaid Services Centers for Disease Control and Prevention Department of Veteran s Affairs Institute for Healthcare Improvement Joint Commission on Accreditation of Healthcare Organizations

2005 - Improve Safety of Surgical Care Through Reduction of Postoperative Complications Ultimate Goal: Reduce Surgical Complications 25% by 2010

Prevent: SCIP INITIATIVES Surgical Site Infections Perioperative Myocardial Infarction Postoperative Pneumonia Venous Thromboembolism

SCIP PROCESS AND OUTCOME MEASURES RELATED TO SSI Prophylactic Antibiotic <1 hr Prior to Incision Appropriate Prophylactic Antibiotic Prophylactic Antibiotic Discontinued w/i 24 hr Cardiac Surgery Pts with Perioperative (24 hr Pre-, 48 hr Post-op) Serum Glucose <200 mg/dl Appropriate Hair Removal Colorectal Surgery Pts with Immediate Postoperative Normothermia

INCENTIVE Section 501(b) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003: A hospital that does not submit performance data for ten stipulated quality measures will receive a 0.4 percentage points reduction in its annual payment update from CMS for FY 2005, 2006, and 2007

INCENTIVE Hospitals will receive bonuses based on their performance Composite scores will be calculated annually Hospitals in the top 50% will be reported as top performers Those in the top 20% will be recognized and given a financial bonus In year three, hospitals will receive lower payments if they score below clinical baselines set in the first year for the bottom 20%

Reporting Hospitals (Voluntary) Deficit Reduction Act of 2005 4000 3500 3000 Proposed IPPS rule suggested that hospitals needed to start reporting SIP measures in January to avoid losing 2% of their Medicare annual payment update. Final rule did not require reporting until July 2006. 3247 3240 3670 3668 3720 3680 3725 2500 # Hospitals 2000 1500 1297 1492 1623 1718 1000 808 894 500 0 2002 Q3 30 42 2002 Q4 2003 Q1 337 237 265 271 2003 Q2 2003 Q3 2003 Q4 2004 Q1 470 450 2004 Q2 2004 Q3 2004 Q4 2005 Q1 2005 Q2 2005 Q3 2005 Q4 2006 Q1 2006 Q2 2006 Q3 2006 Q4 2007 Q1 2007 Q2 2007 Q3

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF COLORADO 84% 84% CENTURA HEALH- ST. ANTHONY CENTRAL HOSPITAL 91% DENVER HEALTH MEDICAL CENTER 94% EXEMPLA ST. JOSEPH HOSPITAL ROSE MEDICAL CENTER 73% 90% UNIVERSITY OF COLORADO HOSPITAL ANSCHUTZ INPATIENT 61% Percent of Surgical Patients Receiving Prophylactic Antibiotics One Hour Before Incision www.hospitalcompare.hhs.gov

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF COLORADO 91% 92% CENTURA HEALH- ST. ANTHONY CENTRAL HOSPITAL 99% DENVER HEALTH MEDICAL CENTER 90% EXEMPLA ST. JOSEPH HOSPITAL ROSE MEDICAL CENTER 97% 97% UNIVERSITY OF COLORADO HOSPITAL ANSCHUTZ INPATIENT 67% Percent of Surgical Patients Receiving Appropriate Prophylactic Antibiotics www.hospitalcompare.hhs.gov

AVERAGE FOR ALL REPORTING HOSPITALS IN THE UNITED STATES AVERAGE FOR ALL REPORTING HOSPITALS IN THE STATE OF COLORADO 82% 82% CENTURA HEALH- ST. ANTHONY CENTRAL HOSPITAL 82% DENVER HEALTH MEDICAL CENTER 88% EXEMPLA ST. JOSEPH HOSPITAL ROSE MEDICAL CENTER 80% 77% UNIVERSITY OF COLORADO HOSPITAL ANSCHUTZ INPATIENT 87% Percent of Surgical Patients With Prophylactic Antibiotics Stopped Within 24 Hours After Surgery www.hospitalcompare.hhs.gov

SCIP PROCESS MEASURES Barriers to Compliance Lack of awareness / familiarity Disagreement with guideline / evidence Complex multi-step systems that result in confusion and lack of accountability

Final IPPS Rule No Pay for Complications Effective for Payment October 1, 2008 Catheter-associated urinary tract infections Pressure ulcers (decubitus ulcers) Never events (serious preventable events) - Object left in surgery - Air embolism - Blood incompatibility reactions Vascular catheter-associated infections Surgical site infection mediastinitis after CABG Hospital-acquired injuries fractures, dislocations, intracranial injury, crushing injury, burn, and other unspecified effects of external causes CMS-1533-FC: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates; Final Rule with comment period went on display in the Federal Register on August 1, 2007 (Publication Date: August 22, 2007).

Proposed Inpatient Payment Rule April 14, 2008 Proposed no-pay conditions: Surgical site infections following elective procedures: Total knee replacement Laparoscopic gastric bypass and gastroenterostomy Ligation and stripping of varicose veins Legionnaire s disease Glycemic control (diabetic coma, ketoacidosis, hypoglycemic coma, nonketotic hyperosmolar coma) Iatrogenic pneumothorax Ventilator-associated pneumonia Delirium Deep vein thrombosis/pulmonary embolism Staphylococcus aureus septicemia Clostridium difficile-associated disease Entire list of NQF never events

DEFINING SSIs Superficial incisional (skin / subcutaneous) Infection 30 days after procedure and at least 1 of the following: Purulent drainage from superficial lesion/organisms isolated aseptically At least 1: pain/tenderness, swelling, redness, heat Superficial incision deliberately opened by surgeon unless culture negative or SSI diagnosed by surgeon or attending physician Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606 608. Figure reproduced with permission. Copyright 1992 University of Chicago Press. All rights reserved.

DEFINING SSIs Deep Incisional (deep soft tissue at site) Infection 30 days after procedure (no implant) or 1 year (with implant) and at least 1 of the following: Purulent drainage from deep in incision but not from organ/space Spontaneous dehiscence or surgical opening of deep incision with fever, pain, or tenderness Abscess or other evidence of infection involving deep incision or SSI diagnosed by surgeon or attending physician Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606 608. Figure reproduced with permission. Copyright 1992 University of Chicago Press. All rights reserved.

DEFINING SSIs Organ/Space (any site other than incision) Infection 30 days after procedure (no implant) or 1 year (with implant) and at least 1 of the following: Purulent drainage from a drain placed through a stab wound into organ/space Organisms isolated from a cx of fluid/tissue Abscess or other evidence of infection involving the organ/space found by histopathologic examination, x-ray, or reoperation or SSI diagnosed by surgeon or attending physician Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606 608. Figure reproduced with permission. Copyright 1992 University of Chicago Press. All rights reserved.

WOUND CLASSIFICATION Clean: No Break in Sterile Field / Resp / GI / GU Tract Clean-Contaminated: Minor Break in Field, or Resp / GI / GU w/o Spillage Contaminated: GI Spillage; Infected Urine / Bile; Major Break; Trauma Dirty / Infected: Infection Encountered

WOUND INFECTION RATES 1967-1977 62,939 pts Clean 1.5 Clean-Contaminated 7.7 Contaminated 15.2 Dirty / Infected 40.0 Cruse et al, Surg Clin North Am 1980; 60:27 Weiss et al, Arch Surg 1999; 134:1041

WOUND INFECTION RATES 1967-1977 1993-1998 62,937 pts 20,007 pts Clean 1.5 2.6 Clean-Contaminated 7.7 3.6 Contaminated 15.2 10.5 Dirty / Infected 40.0 - Cruse et al, Surg Clin North Am 1980; 60:27 Weiss et al, Arch Surg 1999; 134:1041

INFECTION FACTORS Meakins et al, ACS Surgery 2005

RISK FACTORS Patient factors Ascites Chronic inflammation Corticosteroid therapy (controversial) Obesity Diabetes Extremes of age Hypocholesterolemia Hypoxemia Peripheral vascular disease (esp lower extremity) Postoperative anemia Prior site irradiation Recent operation Remote infection Skin carriage of staphylococci Skin disease in the area of infection (eg, psoriasis) Undernutrition Environmental factors Contaminated medications Inadequate disinfection/sterilization Inadequate skin antisepsis Inadequate ventilation Treatment factors Drains Emergency procedure Hypothermia Inadequate antibiotic prophylaxis Oxygenation (controversial) Prolonged preoperative hospitalization Prolonged operative time National Nosocomial Infections Surveillance System (NNIS) System Report: Data summary from January 1992 June 2001. Am J Infect Control 2001; 29:404.

RISK ASSESSMENT Study on the Efficacy of Nosocomial Infection Control (SENIC) Risk within Clean Wounds 1 15% 4 Independent Risk Factors: Abdominal Operation Operation Lasting > 2 hr Contaminated / Dirty Wound > 3 Discharge Diagnoses

RISK ASSESSMENT NNIS Risk Index Operation-Specific (Duration) ASA Physical Status Classification Score Used as a Surrogate Measure of Comorbid Medical Conditions More Accurate than SENIC Index

ASA CLASSIFICATION ASA I: Normal, Healthy ASA II: Mild/Mod Systemic Dis w/o Functional Limitations ASA III: Severe Systemic Dis w/ Functional Limitations ASA IV: Life-Threatening Systemic Dis ASA V: Not Expected to Survive E: Emergency Procedure

WOUND INFECTION RATES Risk Factors: Contaminated / Dirty Wound ASA Class 3-5 Operative Time > 75 th Percentile 0 1 2 3 All Clean 1.0 2.3 5.4-2.1 Clean-Contaminated 2.1 4.9 9.5-3.3 Contaminated - 3.4 6.6 13.2 6.4 Dirty / Infected - 3.1 8.1 12.8 7.1 All 1.5 2.9 6.8 13.0 2.8 National Nosocomial Infections Surveillance (NNIS) System Report: Data summary from January 1992 June 2001. Am J Infect Control 2001; 29:404.

WOUND INFECTION RATES M 0 1 2 3 Cholecystectomy.45.68 1.8 3.3 5.7 Colon - 4.0 5.7 8.5 11.3 Appendectomy.67 1.3 2.6 4.9 Gastric.68 2.6 4.7 8.3 M = 0 risk, laparoscopic Duration cut points (hr): Cholecystectomy = 2; Colon = 3; Appendectomy = 1; Gastric = 3 National Nosocomial Infections Surveillance (NNIS) System Report: Data summary from January 1992 June 2004. Am J Infect Control 2004; 32:470

PREVENTION STRATEGIES Preoperative Intraoperative Postoperative Mangram et al, CDC Guidelines 1999

RECOMMENDATIONS Category IA: Supported by well-designed studies Category IB: Supported by some studies + Strong theoretical rationale Category II: Suggested based on suggestive studies or theoretical rationale

PATIENT PREPARATION Eradicate remote site infections (IA) Encourage tobacco cessation (IB) Patient bath with antiseptic agent (IB)? Remove gross contamination before prep (IB) Antiseptic skin prep (IB) in concentric circles over large area (II) Minimize preoperative hospital stay (II) No recommendations on altering steroid use or enhancing nutritional support

BEST No Hair Removal (Depilatory) HAIR REMOVAL Clipping Immediately Prior to Incision Shaving Immediately Prior to Incision Patient Shaving the Day Before Surgery WORST Clip immediately before surgery (IA)

SURGICAL TEAM No artificial nails (IB) or jewelry (II) Scrub 2-5 minutes (IB) Keep hands up and away; dry with sterile towel (IB) Encourage personnel to report signs and symptoms of a transmissible infectious illness (IB) Exclude surgical personnel who have draining skin lesions (IB)

Relative Benefit From Antibiotic Surgical Prophylaxis Operation Prophylaxis (%) Placebo (%) NNT Colon 4-12 24-48 3-5 Other (mixed) GI 4-6 15-29 4-9 Vascular 1-4 7-17 10-17 Cardiac 3-9 44-49 2-3 Hysterectomy 1-16 18-38 3-6 Craniotomy 0.5-3 4-12 9-29 Total joint repl 0.5-1 2-9 12-100 Breast & hernia 3.5 5.2 58 NNT = number needed to treat; repl = replacement

OPTIMAL ANTIMICROBIAL PROPHYLAXIS Active Against Pathogens Most Likely to Contaminate Wound Adequate Concentration at Incision Site at Time of Potential Contamination Safe Administered for a Brief Period to Minimize Complications, Resistance, and Cost

ANTIMICROBIAL PROPHYLAXIS Prophylactic abx when indicated, based on efficacy against likely pathogens (IA) Time initial dose of abx so bactericidal tissue concentration is established when incision is made; maintain therapeutic levels until after incision is closed (IA) Before elective colorectal operations, also mechanically prepare the colon and administer nonabsorbable oral antimicrobials (IA)? Do not routinely use vancomycin for antimicrobial prophylaxis (IB)

Perioperative Prophylactic Antibiotics: Timing of Administration 4 14/369 15/441 Infections, % 3 2 1 5/699 5/1009 2/180 1/61 1/41 1/47 0 3 > 2 > 1 0 1 2 3 4 5 Hours From Incision Classen DC et al. N Engl J Med 1992; 326:281

ANTIMICROBIAL PROPHYLAXIS Esophageal, Gastroduodenal: Cefazolin for high risk (morbid obesity, esophageal obstruction, decreased gastric acidity or GI motility) Biliary: Cefazolin for high risk (Age >70, acute cholecystitis, non-functioning gallbladder, obstructive jaundice, choledocholithiasis) Appendiceal: Cefoxitin/Cefotetan or Cefazolin + Metronidazole Perforated Viscus: Cefoxitin/Cefotetan +/- Gentamicin The Medical Letter 2004; 2:27

ANTIMICROBIAL PROPHYLAXIS Thoracic: Cefazolin/Cefuroxime OR Vancomycin Clean (Breast, Hernia): No antibiotics necessary unless implanting prosthetic material Penicillin Allergy: Vancomycin/Clindamycin; If gram-negative is desirable, add Gentamicin, Ciprofloxacin, Levofloxacin, or Aztreonam Re-dose if procedure lasts two drug half-lives No need for postoperative dosing The Medical Letter 2004; 2:27

COLORECTAL SURGERY Meta-Analysis of PRCTs No evidence that mechanical bowel prep decreases SSIs (7.4% w/, 5.7% w/o, p=ns) Mechanical bowel prep appears to be associated with higher rates of anastomotic dehiscence (5.5% w/, 2.9% w/o, p<0.05) Wille-Jorgensen P et al, Dis Colon Rectum 2003; 46:1013

ANTIMICROBIAL PROPHYLAXIS Baseline Data for National Surgical infection Prevention Project 34,133 Medicare inpatients undergoing select operative procedures at 2965 acute-care hospitals, 2001 Bratzler et al, Arch Surg 2005; 140:174

ANTIMICROBIAL PROPHYLAXIS Bratzler et al, Arch Surg 2005; 140:174

ANTIMICROBIAL PROPHYLAXIS Bratzler et al, Arch Surg 2005; 140:174

Discontinuation of Antibiotics 100 80 73.3 79.5 85.8 88 90.7 100 80 % 60 40 20 0 14.5 12 40.7 26.2 >12 24 >24 36 50.7 22.6 10 6.2 6.3 2.2 2.7 >36 48 >48 60 >60 72 >72 84 Hours After Surgery End Time >84 96 9.3 >96 60 40 20 0 %, Cumulative Bratzler et al, Arch Surg 2005; 140:174

Antibiotic Prophylaxis Duration Most studies have confirmed efficacy of 12 hours. Many studies have shown efficacy of a single dose. Whenever compared, the shorter course has been as effective as the longer course.

Single- vs Multiple-Dose Prophylaxis: Systematic Review Favors single dose Favors multiple dose 100 10 1 0.1 0.01 All studies, fixed All studies, random Multi > 24h Multi < 24h McDonald M et al, Aust NZ J Surg 1998; 68:388

Duration of Prophylaxis: Infection and Antibiotic Resistance Risk in Cardiac Surgery Number SSI Acq Ab Res <48 Hr Short >48 Hr Long 1502 1139 131 (8.7%) 100 (8.8%) 6% Odds Ratio 1.0 (0.8-1.3) 1.6 (1.1-2.6) Acq ab res = acquired antibiotic resistance. Harbarth. Circulation. 2000;101:2916.

OPERATING ROOM Positive pressure (IB) 15 air changes/hr (3 fresh air) (IB) Filter air; Introduce air at the ceiling, exhaust at the floor (IB) Do not use UV radiation (IB) Keep OR doors closed except as needed (IB) and limit the number of personnel entering (II) Consider performing orthopedic implant operations in rooms supplied with ultraclean air (II)

OPERATING ROOM Use EPA-approved hospital disinfectant to clean visible blood/body fluid soiling or contamination before the next operation (IB) Do not perform special cleaning or closing of OR after contaminated or dirty operations (IB) Do not use tacky mats at the OR entrance (IB) Wet vacuum the OR floor after the last operation of the day with EPA-approved disinfectant (II)

INSTRUMENTS Sterilize all surgical instruments according to published guidelines (IB) Perform flash sterilization only for patient care items that will be used immediately (IB)

BARRIERS Surgical mask that fully covers mouth and nose (IB) Cap or hood to fully cover hair on the head and face (IB) Sterile gloves after sterile gown (IB) Use gowns and drapes that are effective barriers when wet (IB) Change scrub suits that are visibly soiled, contaminated, and/or penetrated by blood or other potentially infectious materials (IB)

SURGICAL TECHNIQUE Adhere to principles of asepsis when placing devices or when dispensing or administering intravenous drugs (IA) Assemble sterile equipment and solutions immediately prior to use (II) Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies and eradicate dead space (IB) Use delayed primary skin closure or leave an incision open if it is heavily contaminated (IB) Use closed-suction drains placed through a separate incision (IB)

POSTOPERATIVE CARE Protect incision with a sterile dressing for 24-48 hours (IB) Wash hands before and after dressing changes and any contact with the surgical site (IB) Use sterile technique to change an incision dressing (II) Educate the patient and family regarding incision care and infection prevention (II)

WARMING Hypothermia is Common in Surgery - Impaired Thermoregulation - Altered Heat Distribution, Exposure

Hypothermia is Common in Surgery - Impaired Thermoregulation - Altered Heat Distribution, Exposure...and Increases Susceptibility to Infection - Vasoconstriction WARMING - Decreased Wound Oxygen - Impaired Immune Functions - Impaired Wound Healing

WARMING Kurz A et al, NEJM 1996; 334:1209 200 Colorectal Surgery Pts Routine Care (Hypothermia) vs Warming (Normothermia) - I.V. Abx, Hydration, O 2 6 L/min - Forced Air Heat, Fluid Warmer Wound Evaluation Daily x 2 Wk Collagen Deposition

CORE TEMPERATURES Kurz A et al, NEJM 1996; 334:1209

OUTCOMES Variable Warm Hypo p n 104 96 - Infection 6 (6%) 18 (19%).009 ASEPSIS Score 7 + 10 13 + 16.002 Collagen g/cm 328 + 135 254 + 114.04 Days to Solids 6 + 3 7 + 2.006 Days to SR 10 + 3 11 + 2.002 Hospital LOS 12 + 4 15 + 7.001 Kurz A et al, NEJM 1996; 334:1209

RISK FACTORS Multivariate Analysis Risk Factor Odds Ratio Tobacco Use 10.5 Hypothermia 4.9 Rectum vs Colon 2.7 NNISS Score 2.5 Age 1.6 Kurz A et al, NEJM 1996; 334:1209

WARMING Melling AC et al, Lancet 2001; 358:876 421 Clean Surgery Pts Routine Care (Standard) Local Warming (Radiant Heat) Systemic Warming (Forced Air) 30 min Pre-Op F/U 2 & 6 Wks

OUTCOMES Core Temp Inc w/ Local or Systemic Warming Wound Infxn 5% vs 14% ASEPSIS Scores Lower w/ Warming Melling AC et al, Lancet 2001; 358:876

PERIOPERATIVE GLUCOSE CONTROL Hyperglycemia adversely affects granulocyte adherence, chemotaxis, phagocytosis, and bactericidal activity Postoperative hyperglycemia (>200 mg/dl) is associated with SSIs in cardiac surgery pts. Preoperative glucose control is not related to SSIs Latham R et al, Infect Control Hosp Epidemiol 2001; 22:607 Prospective trials have demonstrated reduced SSIs among diabetics with tight glucose control (<150-200 mg/dl) Furnary AP et al, Endocr Pract 2004; 10S:21 Lazar HL et al, Circulation 2004; 109:1497

OXYGEN Strong Anecdotal Evidence and Expert Opinion Indicate that Oxygen is Beneficial to Patients Bactericidal Activity of Neutrophils is Oxygen- Dependent Subcutaneous Wound Oxygen Tension is Inversely Correlated with Wound Infection Rates Hopf et al, Arch Surg 1997; 132:997 Hypothesis: Supplemental Oxygen Decreases Wound Infections

OXYGEN 500 Colorectal Surgery Pts 30% O 2 / 70% N 2 vs 80% O 2 / 20% N 2 Intraop + 2 Hr Postop - I.V. Abx, Hydration, Forced Air Heat, Fluid Warmer - Wound Evaluation Daily x 2 Wk - Collagen Deposition Grief et al, NEJM 2000; 342:161

OUTCOMES Variable 30% 80% p n 250 250 - Infection 28 (11%) 13 (5%).01 ASEPSIS Score 5 + 9 3 + 7.01 Collagen g/cm 267 + 109 258 + 118.38 Days to Solids 4 + 2 5 + 2.27 Hospital LOS 12 + 4 12 + 6.26 Grief et al, NEJM 2000; 342:161

OXYGEN Pryor et al, JAMA 2004; 291:79 165 Surgical Pts 35% O 2 vs 80% O 2 Intraop + 2 Hr Postop

OUTCOMES Variable 35% 80% p n 80 80 - Infection 9 (11%) 20 (25%).02 Reoperation 0 4 (5%).07 Hospital LOS 6.4 8.3.06 Pryor et al, JAMA 2004; 291:79

CRITICISMS Retrospective chart review for infections Small, heterogeneous Did not consider anesthetic / fluid management, temperature, pain control Obesity, operative time, blood loss, fluid volume, postoperatvie intubation greater in the 80% group

OXYGEN Belda et al, JAMA 2005; 294:2035 291 Colorectal Surgery Pts 30% O 2 vs 80% O 2 Intraop + 2 Hr Postop

OUTCOMES Variable 30% 80% p n 143 148 - Infection 35 (24%) 22 (15%).04 Hospital LOS 10.5 11.7.09 Belda et al, JAMA 2005; 294:2035

O 2 OR NO O 2? It defies logic that colorectal surgery patients have opposite response to oxygen Turn up the oxygen- there is NO downside!

ERADICATION OF NASAL Carried in nares of 20-30% healthy persons Carriers are at risk of S. aureus SSIs Intranasal mupirocin: S. AUREUS -Prevents sternal wound infxns Cimochowski GE et al, Ann Thorac Surg 2001; 71:1572 -Prevents orthopedic MRSA SSIs Wilcox MH et al, J Hosp Infect 2003; 54:196

ERADICATION OF NASAL PRCT 3864 pts S. AUREUS Low rate (2.3-2.4%) of S. aureus SSIs 891 (23%) nasal carriers of S. aureus Fewer S. aureus nosocomial infxns (4.0% vs 7.7%) among carriers Perl TM et al, N Engl J Med 2002; 346:1871 Potential cost-effective strategy Farr BM, N Engl J Med 2002; 346:1905

TRANSFUSIONS AND POSTOPERATIVE INFECTION Transfusion is Associated with Increased Postop Infection Rates Penetrating Abdominal Trauma Colon Resection Coronary Artery Bypass Orthopedic Surgery Hysterectomy Landers DF et al, Anesth Analg 1996; 82:187

BLOOD TRANSFUSION Bowel Surgery 1472 Pts / 31 Centers Independent SSI Risk Factors: -Transfusion (OR 1.64) -Infection (OR 2.46) Walz JM et al, Arch Surg 2006; 141:1014

Surgical Infection Prevention Collaborative Process measure Median performance, by quarter 1 st 2nd 3rd 4th Antibiotic timing within 1 h Appropriate antibiotic selection Discontinuation of antibiotic within 24 h Normothermia Avoid shaving surgical site Oxygenation Glucose control 72 82 89 92 90 94 95 95 67 69 74 85 57 64 69 74 59 83 90 95 75 81 84 94 46 49 53 54 Dellinger et al, Am J Surg 2005; 190:9

Monthly (April 2002 - February 2003) surgical infection rates in the National Surgical Infection Prevention Collaborative. Dellinger et al, Am J Surg 2005; 190:9

Changes in National Performance Baseline to Q3, 2007 Abx 60 min Guideline Abx Abx discontinued Percent 100 80 60 40 20 0 92.6 55.7 40.7 2001* Q1 2002 Q2 2002 Q3 2002 Q4 2002 Q1 2003 Q2 2003 Q3 2003 Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004 Data source changed from independently abstracted to hospital self-collected. Medicare Modernization Act Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Deficit Reduction Act and STS recommendation of antibiotics for up to 48 hours for cardiac surgery Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007 94.1 84.6 89.3 390,296 cases submitted Q3, 2007 *National sample of 39,000 Medicare patients undergoing surgery in US hospitals during 2001. Bratzler DW et al. Arch Surg. 2005;140:174-182.

EFFICACY OF PROTOCOL IMPLEMENTATION Colorectal Surgery Pts Abx, Normothermia, Normoglycemia SSIs decreased 39% Hedrick TL et al, J Am Coll Surg 2007; 205:432 Colorectal, Hepatobiliary Surgery Pts Intervention to improve abx, normothermia, normoglycemia SSIs decreased 14.3% to 8.7% Forbes SS et al, J Am Coll Surg 2008; 207:336

SUMMARY Prepare the patient- and yourself Use antibiotic prophylaxis appropriately Maintain normothermia Maintain serum glucose <200 mg/dl Give oxygen Eradicate S. aureus if you find it Avoid transfusion Perform surveillance, analyze SSIs