Prevention of Perioperative Surgical Infections Michael A. West, MD, PhD, FACS Department of Surgery University California San Francisco San Francisco, CA, USA
Surgical Site Infections (SSI) 2-5% of operated patients will develop SSI 40 million operations annually in the U.S. 800,000 2,000,000 SSI s annually in U.S.!! SSI increases LOS in hospital average 7.5 days Excess cost per SSI: *$5,739-51,191 (adjusted to 2009 USD) US national costs: $250 million $1.7 billion/year *Jarvis, Infect Control HospEpidemiol. 1996;17.
Opportunity to Prevent Surgical Infections An estimated 40-60% of SSIs are preventable Overuse, underuse, improper timing, and misuse of antibiotics occurs in 25-50% of operations
Risk Factors for Infection
Wound Classification I. Clean: uninfected, no inflammation, no mucosal surface transected: Mastectomy, Thyroidectomy Risk of SSI <2% II. Clean/Contaminated: mucosal-lined lumen entered in controlled conditions. Cholecystectomy, Colectomy, Whipple, Laryngectomy, Urologic procedures. III. Contaminated: Open accidental wounds, break in sterile conditions, spillage, stomas. Appendicitis, Diverticulitis, Small bowel GSW. 5-15% 15-30% IV. Dirty/ Infected*: Infection, perforation, devitalized tissue. Abscess, Peritonitis, Enteric fistulas, Remove infected implant. > 30% * Dirty wounds infection - antibiotics indicated as therapy Nichols RL - AmerJ Surg 1996; 172: 68-74
Medical Conditions Increasing Risk of Surgical Site Infection (SSI) Extremes of age Under-nutrition Obesity Diabetes Prior site irradiation Hypoxemia Remote infection Corticosteroid therapy Recent operation Chronic inflammation Antibiotic prophylaxis may be indicated in clean cases when associated conditions increase infection risk
NNIS Risk Index as a Predictor of Risk of Infection NNIS Risk Index Traditional Class 0 1 2 3 All Clean 1.0% 2.3% 5.4% NA 2.1% Clean/Contam 2.1% 4.0% 9.5% NA 3.3% Contaminated NA 3.4% 6.6% 13.2% 6.4% Dirty NA 3.1% 8.1% 12.8% 7.1% All 1.5% 2.9% 6.8% 13.0% 2.8% Nichols RL, Martone WJ. Surgery 2000; 128: S2-S13
NNIS Risk Index as a Predictor of Risk of Infection NNIS Risk Index Traditional Class 0 1 2 3 All Clean 1.0% 2.3% 5.4% NA 2.1% Clean/Contam 2.1% 4.0% 9.5% NA 3.3% Contaminated NA 3.4% 6.6% 13.2% 6.4% Dirty NA 3.1% 8.1% 12.8% 7.1% All 1.5% 2.9% 6.8% 13.0% 2.8% Nichols RL, Martone WJ. Surgery 2000; 128: S2-S13
Preventing Infection
New(er) Developments in SSI Attention to problem New surgical techniques. Better systems for administration of prophylactic antibiotics Duration of antibiotics Recognition of environmental factors that aggravate SSI Technical factors in wound management
Mechanisms to Prevent SSI Minimize (or eliminate) bacteria in wound at time of surgery. - skin decontamination - excellent surgical technique - peri-operative prophylactic antibiotics Maximize delivery (and effectiveness) of host defenses. - pre-op nutritional state. - adequate oxygentation. - excellent perfusion of wound.
Influence of Shaving on SSI No Hair Group Removal Depilatory Shaved Number 155 153 246 Infection rate 0.6% 0.6% 5.6% Seropian. Am J Surg 1971; 121: 251
Impact of Oxygen on SSI 500 patients, randomized, double-blind protocol colorectal resection Subjects received 30% or 80% inspired O 2 during operation and for 2 hours post-op. Wounds evaluated daily Infection = Culture-positive pus 30% O 2 80% O 2 p-value Number of Subjects 250 250 O 2 Saturation 98% 99% N.S. Wound Infection 28 (11.2%) 13 (5.2%) 0.01 Greif R: Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 2000 Jan 20;342(3):161-7
Hypothermia Mechanisms Impaired wound perfusion (thermoregulatory vasospasm) Decreased oxygen levels in wound -impaired collagen synthesis Impaired immune function Decreased delivery of PMNs
Perioperative Normothermia SSI: 6% normothermia vs. 19% hypothermia Kurz et al, N Engl J Med 1996
Impact of Temperature on SSI Prospective-cohort design, 290 surgical patients No active study-specific warming interventions. 90% follow-up Hypothermia Normothermia p Number Patients 156 105 Wound Infection 18 (11.5%) 2 (2%) 0.004 Relative risk of SSI 6.3x increased in hypothermia group Flores-Maldonado A: Mild perioperative hypothermia and the risk of wound infection. Arch Med Res 2001 May-Jun;32(3):227-31
Glucose Control in Diabetics Undergoing Open Heart Surgery Prospective study: 1987-97 2,467 diabetic pts, open heart surgery Control group (N=968) sliding-scale SQ insulin (SQI) Study group (N=1,499) continuous iv insulin infusion to maintian glucose 200 mg/dl. Sternal Wound Infection (%) 4 3.5 3 2.5 2 1.5 1 0.5 0 Insulin Infusion SQI Furnary AP, et al.: Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999 Feb;67(2):352-60
Minimally Invasive Cardiac Surgery Off-Pump CABG Mitral Valve Replacement Example Shown: Axiomat Guidant Corporation Minimal access mitral valve replacement D Richens, RS Jutley, M Baker and M Shajarf J.R.Coll.Surg.Edinb., 47, October 2002, 676-680
Minimally Invasive Surgery Technique for Saphenous Vein Harvest Example Shown: Vasoview 5 Guidant Corporation
Minimally Invasive Vein Harvest 568 patients, Non-randomized. Risk factors for wound complication Open harvesting (p< or =0.001) Diabetes (p< or =0.001) Obesity (p< or =0.02) Histologic evaluation no difference between the groups Open Endoscopic p-value Number Patients 388 180 Wound Complications 14.2% 5% 0.001 Crouch JD : Open versus endoscopic saphenous vein harvesting: wound complications and veinquality. Ann Thorac Surg 1999 Oct;68(4):1513-6
External Bacterial Challenge of Experimental Incisions Time of Challenge 0 hour 0.5 hour 1 hour 4 hours Incisions Infected (%) Closed with Closed with Staples Subcuticular 90 80 70 30 30 None None None Stillman, et al. Arch Surg. 1980.
Impact of Prophylactic Antibiotics on SSI Rates Dellinger EP: Ch 7, Surgical Infections, in, Mulholland et al: Greenfield s Surgery: Scientific Principles and Practice, 4e. Lippincott, Williams & Wilkins, 2005.
Relation Between Antibiotic Timing and Surgical Wound Rate Infection Rate (%) 6% 5% 4% 3% 2% Operation 1% 0% >2 2 1 1 2 3 4 5 6 7 8 9 10 >10 Hours before Incision Hours after incision Classen DC, et al. NEJM 1992;326:281-285
Quality Indicators National Surgical Infection Prevention Project Quality Indicators #1) Receive antibiotics within 1 hour* before surgical incision. #2) Receive prophylactic antibiotics consistent with current recommendations. #3) Prophylactic antibiotics discontinued within 24 hours of surgery end. * Because of the longer required infusion times, vancomycin or fluoroquinolones, when indicated for beta-lactam allergy, may be started within 2 hours before the incision.
Antibiotic Timing Related to Incision Medicare National Baseline Minutes Before or After Incision Bratzler DW, Houck PM, et al. Arch Surg.2005
Discontinuation of Antibiotics Percent 100 80 60 40 20 14.5 0 12 or less >12-24 40.7 26.2 85.8 88 90.7 79.5 73.3 50.7 22.6 10 6.2 6.3 2.2 2.7 >24-36 >36-48 >48-60 >60-72 >72-84 Hours After Surgery End Time >84-96 9.3 > 96 100 80 60 40 20 0 Cumulative Percent Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery. Bratzler DW, Houck PM, et al. Arch Surg.2005
Surgical Infection Prevention National Baseline Performance National Ave.* National Benchmark Percent 100 80 60 40 64.3 91.9 91 99.1 47.6 85.7 20 0 Antibiotics w/in 1 hour Correct Antibiotic Antibiotic DC d in 24 hr * Based on medical record abstraction from the charts of patients discharged in the 2nd quarter of 2004. Benchmark rates were calculated for all hospitals in the US based on discharges during April 2003-March 2004 using the Achievable Benchmarks of Care TM methodology (http://main.uab.edu/show.asp?durki=14527).
Prevention of Surgical Site Infection (SSI) Importance of Systems
-1 to 30 Days 0630 0730 0900 1030 1400 +7-30 Days OR Registration PreOp Holding Ambulatory Surgery Room Inpatient Hospitaliztion Post Anesthesia Recovery (PAR) Outpatient Clinic Surgeon Office Operating Room Outpatient Clinic Surgeon Office
Factors the Surgeon Controls What operation is done. - conduct of operation. When the surgery takes place. - elective vs. emergent. - adequacy of rescucitation. - monitoring employed. Antibiotic administration. - choice of agent. - timing of administration. - intra-operative re-dosing. Blood transfusion.
Project overview available at: www.medqic.org/scip
NSQIP Annual Report Mortality O/E Ratios for All Operations Superior performance Inferior performance
Surgical Care Improvement Project (SCIP) Preventable Complication Modules Surgical infection prevention Cardiovascular complication prevention Venous thromboembolism prevention Respiratory complication prevention
Surgical Care Improvement Project: Why? Medicare could prevent* up to: 13,027 perioperative deaths 271,055 surgical complications There are substantial opportunities to improve outcomes from surgery! * Major surgical cases
UCSF SSI Rate After Major Colorectal Surgery Surgical Site Infection Rate Following Selected Abdominal Surgery Performed by Center for Colorectal Surgery Surgeons 40.0% 35.0% 4/06-3/07: Implement IHI Bundle 4/07-3/08: Monitor IHI Compliance 37.5% 4/08 - present: Tighten up Processes Percentage 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% n = 27.6% Apr '06 May '06 3.7% 16.1% 8.7% 25.8% 21.7% Jun '06 Jul '06 Aug '06 Sep '06 Oct '06 14.3% 19.0% 16.0% 13.0% 17.4% 12.9% 10.3% 7.7% Nov '06 Dec '06 Jan '07 Feb '07 Mar '07 Apr '07 May '07 Jun '07 Jul '07 4.2% 15.0% 22.2% 11.5% 26.1% Aug '07 Sep '07 Oct '07 Nov '07 Dec '07 monthly rate 4.0% 9.7% 26.7% 19.4% 11.5% Jan '08 Feb '08 Mar '08 Apr '08 May '08 29.6% 22.2% Linear (monthly rate) 9.1% 23.3% 0.0% Jun '08* Jul '08* Aug '08* Sep '08* O ct '08* 17.9% 11.8%11.5% Nov '08* Dec '08* Jan '09* 23.1% 5.9% 14.3% 20.7% 9.1% 10.0%11.5% Feb '09* Mar '09* Apr '09* May '09* Jun '09* Jul '09* Aug '09* 22.6% 3.3% Sep '09* O ct '09 Nov '09* 29 27 31 23 31 23 28 16 21 25 23 23 31 29 26 25 40 27 26 23 25 31 30 36 26 27 36 33 30 29 28 18 26 26 34 35 29 33 40 26 30 30 33 27 14.3% 14.8%
Preventing Surgical Site Infections: Evidence-Based Interventions Choose Appropriate Antibiotic Timely Administration of Antibiotics (30-60 min prior to incision) Clip rather than shave operative site. Maintain intraoperative O 2 saturation. Maintain patient body temperature. Tight glucose management. Infection surveillance.
The End