SSI Incisional and Organ/Space

XIV ANNUAL CONFERENCE OF ESS Turin, 25-27 November 2010 SSI Incisional and Organ/Space Prof. Andrea Imperatori University of Insubria Center for Thoracic Surgery

Horan T et al CDC Definitions of Nosocomial Surgical Sites Infections

Incisional SSI and Organ/Space SSI: identical significance and same clinical relevance? Postoperative peritonitis vs. wound SSI? Type of Organ/Space SSI? (peritonitis vs. osteomyelitis) Different risk factors? Different cost? SSI surveillance may be misleading?

Diffuse peritonitis Open abdomen treatment

Superficial (?) incisional SSI

Organ-space SSI - Wound dehiscence

Risk factors for the development of postoperative infections 1. Age and (*) associate derangements of physiologic functions 2. Type of surgical procedure (surgical trauma severity) 3. (*) Quality of surgical technique 4. Operative field contamination 5. Emergency surgical procedure 6. (*) Inadequate antibiotic prophylaxis 7. (*) Blood loss and transfusions 8. (*) Malnutrition/obesity 9. (*) Preexisting infection 10. (*) Current disease: a) Diabetes b) Renal failure c) Cirrhosis d) Cardiac disease e) Chronic pulmonary disease f) shock 11. (*) Length of preop. hospital stay 12. Immunosuppressive therapy 13. (*) Prolonged corticosteroid therapy 14. Inoperable malignancy 15. (*) Invasive devices 16. (*) Quality of pre- and post-operative care * Modifiable factors

National Nosocomial Infections Surveillance (NNIS) risk index >

Surgical Site Infection (SSI) - Cost SSIs result in: Increased morbidity Prolonged hospitalization Socio-economic cost

Duration of SSI From day of clinical diagnosis until day of clinical resolution Di Leo A. et al Mean duration of SSI Superficial incisional: 7 days Deep incisional: 10 days Organ / Space: 14 days (or > if re-operation)

SSI Classification CDC (Horan TC: Infect Control Hosp Epidemiol, 1992) Treatment Cost Superficial Incisional SSIs local wound care low

Cost analysis of superficial SSI in Varese Excess in-hospital lenght of stay: 2 days Added hospital costs: 1,000 Euro (500 Euro/day) About 5 additional wound care procedures Cost of extra wound care: 50 Euro (10 Euro/each) Antibiotic therapy (7 days): 10 Euro Total added costs: 1,060 Euro

SSI Classification CDC (Horan TC: Infect Control Hosp Epidemiol, 1992) Treatment Deep Incisional SSIs prol. hospital stay additional procedures antibiotic high Cost moderate

Cost analysis of deep SSI Cost of re-do surgery: about 3,000 Euro Excess in-hospital lenght of stay: 5 days Added hospital costs: 2,500 Euro (500 Euro/day) About 15 additional wound care procedures Cost of extra wound care : 150 Euro (10 Euro/each) Antibiotic therapy (10 days): 400 Euro Total added cost: 6,050 Euro

SSI Classification CDC (Horan TC: Infect Control Hosp Epidemiol, 1992) Treatment Organ or Space infections systemic, local ICU hosp. stay Cost (mortality) high

Cost analysis of chronic organ/space SSI

Cost analysis of chronic organ/space SSI Cost of re-do surgery: about 3,000 Euro Extra in-hospital lenght of stay: 10 days Added hospital costs: 5,000 Euro (500 Euro/day) About 50 additional wound care procedures Cost of extra wound care : 500 Euro (10 Euro/each) Antibiotic therapy (15 days): 820 Euro Total added cost: 9,320 Euro

Surgical Site Infection (SSI) - Epidemiology SSI rate differs from one country to another according to the system employed for control of hospital infections SSI rate ranges between 3% and 20% depending on hospital, patient clinical conditions and type of procedure

Surgical Site Infection (SSI) in Italy About 3,000,000 (in-patients) surgical procedures per year in Italy About 5% of all surgeries (150,000/year) generate SSI in Italy

KIR-NOS Study Group Torino Molinette Mauriziano Biella Ospedale Degli Infermi Borgomanero (NO) Ospedale SS Trinità Incidence Study 1 April - 30 June 2002 Follow-up 30 days (visit or phone call and questionnaire at discharge) 3066 surgeries

Overall SSI Rate 158/3066 5.2% Deep Profonda 15% Localizzazione Site of infection dell'infezione Superficiale 62% spazio Organspace Organo- 7.9% 23% [IC95%:7.0-8.9] KIR-NOS Study (2002): 3066 pts Overall SSI Rate 76/1281 5.9 % Deep 42% Superficial 44% Site of infection Organspace 14% Alto Garda Study (2009): 1281 pts

Underdiagnosis of SSI SSI: Not diagnosed (not recognized; late signs) Not reported Misclassified

SSI (%) 0.72 % 2.3 % SSI (%) 0.72 % 2.3 % 4.0 % 7.2 % 4.0 % 7.2 %

SSI rate in breast surgery Authors Year n pts % wound infection Vilar-Compte 2009 2338 18.7 Throckmorton 2009 436 7.8 El-Tamer 2007 3047 4.3 (Mastectomy) 2.0 (Lumpectomy) Gravatt Wilke 2006 4975 1.0 (axillary surgery) Leaper 2005 168 10 (axillary surgery) Leaper 2001 175 10

Infection surveillance Information concerning factors and procedures associated with increased risk of SSI Stratification of SSI rates according to risk factors Comparison of SSI rates intra- and inter- Institutions

SSI / NNIS Index Appropriately stratifies groups of risk when applied to global analysis of surgical procedures

SSI / NNIS Index - LIMITATIONS Incisional and Organ/Space SSIs are not separated Overall SSI rate (Incisional and Organ/Space) can be misleading in terms of clinical relevance

Thanks for your kind attention