Preventing Surgical Site Infections

Preventing Surgical Site Infections BC Hip & Knee Arthroplasty Collaborative February 7, 2006 Felicia Laing, BSc MSc CIC, Infection Control Anisha Lakhani, BScPharm Pharm D Fraser Health Authority

It s All About Patient Safety 9000 to 24,000 Canadian patients die annually following an adverse event in hospital. Our report quantified a long-suspected problem in the Canadian healthcare system, and clearly indicates that steps must be taken now to address it. It is time to improve the safety of the care we provide to patients. Dr. Peter Norton on the Canadian Adverse Events Study CMAJ 2004; 170(11): 1678-86. Keys to Safer Hospitals Newsweek Dec 12, 2005

Medical Mishaps 25% 20% 15% 10% 5% 0% Drugrelated Wound infect. Tech comp. Late comp. Diag. mishap Ther. Mishap Nontech. comp. Proc. Related Leape LL et al NEJM 1991; 324:377-84

Burden of Illness Surgical wound $160,900,000 Pneumonia $129,000,000 Bacteremia $36,200,000 Urinary tract $61,500,000 Other sites $65,600,000 Total $453,200,000/year Emerging AROs (MRSA) Additional $24-35 mill/year Shirley Paton, Public Health Agency of Canada, May 2005

Burden of Nosocomial Infections Infection Type Rate per 100 adm No. Infections per Year Extra Days per Case Extra Bed Days/Yr Cost per Infection Cost per Year $000,000 Surgical Wound 1.39 53,421 8.2 438,052 $4,100 $219 Pneumonia 0.60 23,060 20.0 461,200 $10,000 $230 Bacteremia 0.27 10,377 24.0 249,048 $12,000 $125 Urinary 2.39 91,853 2.4 220,447 $1,200 $110 Other 1.07 41,123 4.8 197,390 $2,400 $97 Total 219,834 1,566,137 $781

Surgical Wound Infections Extra LOS Gross and Attributable Wound Infection Related Length of Stay Time Period Mean days Median days Gross Infection LOS 13.6 7.0 Attributable Infection LOS 10.2 4.5 Zoutman et al Infect Control Hosp Epidemiol 1998;19:254-259..

Distribution of SSI Costs Professional Services, 5% Imaging & Other Tests, 2% Operating Room, 3% Outpatient & Emergency, 6% Hotel, 14% Nursing, 51% Pharmacy, 10% Laboratory, 9% Zoutman et al Infect Control Hosp Epidemiol 1998;19:254-259.

SSI Risk Factors Age Obesity Diabetes Malnutrition Prolonged preoperative stay Infection at remote site Systemic steroid use Nicotine use Hair removal/shaving Duration of surgery Surgical technique Presence of drains Inappropriate use of antimicrobial prophylaxis

Prevention of Surgical Site Infections Shorten the length of preoperative stay Eliminate infections at remote sites Avoid the removal of hair Minimize the duration of surgery Use appropriate antimicrobial prophylaxis

Prevention of Surgical Site Infection Preoperative Stay Increased potential for colonization with nosocomial pathogens as pre-op hospital stay increases Presence of Remote Infections NRC study SSI rate by 2.7 times 55% of wound infections with same microorganisms

Pre-operative Hair Removal Shaving the surgical site with a razor induces small skin lacerations Potential sites for infection Disturbs hair follicles which are often colonized with S. aureus Risk greatest when done the night before Patient education Be sure that patients know that they should not do you a favour and shave before they come to the hospital!

Pre-operative Shaving/Hair Removal Alexander, 1983 Method of hair removal SSI rate (RR,CI 95 ) Razor 9.3% Clipper 4.6% (0.5,0.07-0.86) Timing of hair removal SSI rate Clipper night before surgery 6.9% Clipper morning of surgery 2.2% (0.3,0.09-1.13) Arch Surg 1983; 118:347-352

Length of Operation Duration of operation > 2 hours Increase in the contamination of the wound Increase in tissue damage from drying, prolonged retraction and manipulation Increase in the amount of suture and electrocoagulation Greater suppression of host defenses from blood loss and shock Cruse and Foord Surg Clin North Am 1980;60:27-40.

To Drain or not to Drain? Possible contributor to SSI: mixed reviews 84-94% use drains, 33-41% remove after 24 hrs Chandratreya 1998 JR Coll Edinburgh Potential complications Blood transfusion Hematoma Infection Bacterial colonization of interior surface retrograde migration from skin flora Foreign body suppress local tissue defense

Skin Antisepsis Up to 20% of skin-associated bacteria in skin appendages (hair follicles, sebaceous glands) & are not eliminated by topical antisepsis. Transection of these skin structures by surgical incision may carry the patient's resident bacteria deep into the wound and set the stage for subsequent infection. Downloaded from: Principles and Practice of Infectious Diseases 2004 Elsevier

Pre-operative Skin Prep Choices, choices, choices Antiseptic Agent Gram + bacteria Gram neg bacteria Speed of killing sensitive bacteria Inactivated by mucus or proteins Comments Alcohols Good Good Fast Moderate Lacks residual effect; alternative for I 2 allergies Chlorhexidine 2% and 4% aqueous Good Good Intermediate Minimal Persistent antimicrobial effect on skin Iodophors, Iodine in alcohol Good Good Fast/ Intermediate Moderate to Marked Good visualization of prep site Health Canada 1998 http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98pdf/cdr24s8e.pdf

Pre-operative Skin Prep Apply in a manner that preserves skin integrity and prevent injury Avoid pooling Decreases risk of chemical burns Provides a longer duration of action Reduces possibility of fire

Surgical Site Infection Surveillance Of proven efficacy Risk stratification Case finding methods 1-year follow-up for procedures with implants Post- discharge surveillance Reporting rates to surgeons Cruse and Foord Surg Clin North Am 1980; 60:27-40 Olson et al. Arch Surg 1990; 125:794-803.

NNIS Risk Index for SSI Surveillance Patient-specific Risk Score Total 0-3 points Wound class III or IV ASA score 3, 4, 5 Duration of surgery >cutpoint 1 point 1 point 1 point

SSI Rate* by Surgery Type and Risk Category Duration Cutpoint Risk 0 1 2,3 Knee prosthesis 2 hr 0.88 1.65 2.52 Hip prosthesis 2 hr 0.86 1.28 2.26 *Infections per 100 procedures CDC NNIS report December 2004 http://www.cdc.gov/ncidod/dhqp/pdf/nnis/2004nnisreport.pdf

Safer Healthcare Now! Campaign Promote improvements in patient safety Six changes that save lives: Prevent surgical site infections Prevent central line-associated bloodstream infections Prevent ventilator-associated pneumonia Prevent adverse drug events Deploy rapid response teams Deliver reliable, evidence-based care for acute myocardial infarction As of Feb 2006, 146 organizations have joined the campaign

Prevent Surgical Site Infections Implement 4 key components of care Appropriate use of antimicrobial prophylaxis Appropriate hair removal Maintenance of postoperative glucose control for major cardiac surgery patients Post-operative normothermia for colorectal surgery patients

SSI Surveillance Created by the Ministry of Health 2005 Accountable to the Provincial Medical Services Committee Maximize coordination and integration of activities for preventing HAI Surveillance initiatives across BC CDAD SSI http://www.picnetbc.ca/

Bridging the Gap

Preventing Surgical Site Infections Part II Dr. Anisha Lakhani February 7, 2006

Prophylaxis against infection 1969: Infection risk with THR was 9.5% 1972: Institution of antimicrobial prophylaxis, clean air rooms, improved techniques, prosthesis. Infection rates reduced to 1.3% (Charnley 1969, 1972) Reported rate of infections in revision operations Hip revision 3.2% Knee revision 5.6% (Hanssen 1999)

Infections TKR, a study Case control study, Total Knee Replacement 6,120 patients, 1993-1999, New York & Belgium 62% osteoarthritis, 20% had rheumatoid arthritis 116 patients with SSI matched with non infected patients for gender, age, month of surgery All pts got IV antibiotics ~ 30 mins prior OR and were maintained on them for 48 hrs (1995) or 24 hrs (post 1995) Choice: Cefazolin or Vancomycin if allergy Peersman Clin Orthoped Rel Research 2001, 392;

113 patients with infection Superficial wound infection (14%) All within 3 months Deep infection (86%) 29% within 3 months 71% after 3 months

Risk Factors for Infections Prior open surgical procedure Immunocompromised (renal transplant, IVDU, immunosuppressive drugs, infections, open skin.) Poor nutrition Albumin < 35 g/l Recurrent UTIs or infection elsewhere Diabetes Mellitus Obesity Note: There was no change in infection rate when antibiotic duration reduced to 24 hr from 48 hrs

Organisms

Which bugs to cover? Clean surgical procedures (no entry into GI, gynecologic, and respiratory tracts) Staphylococcus aureus from the exogenous environment or the patient's skin flora is the usual cause of infection Cefazolin considered the best choice Gram positive coverage Enteric gram negative coverage Watch for allergies

Cefazolin & Penicillin Allergy 80% - 90% of all patients reporting a penicillin allergy are negative for penicillin allergy with skin testing, Patients with positive skin test for penicillin allergy are at four fold increased risk for allergic reaction to cephalosporin. Note: This is a very select group of patients. A review of almost 16,000 patients treated with cephalosporins 8.1% of patients with a history of penicillin allergy had allergic reactions to this class of antibiotics 1.9% of patients with no reported penicillin allergy history reacted. Skin testing for allergy to cephalosporins is much less standardized than with penicillins and is of questionable clinical benefit

Cefazolin & Pen Allergy Detailed & accurate medical history is important Patient likely has a true allergy to beta lactams if they report urticaria, pruritis, angioedema, bronchospasm, hypotension or arrhythmia Patients with following serious adverse drug reaction should be considered for alternatives to beta lactams: drug induced hypersensitivity syndrome, drug fever or toxic epidermal necrolysis.

Dosing time

Cefazolin A single 1 g dose IV provided average serum levels of cefazolin (in mcg/ml) from 188.4 at 5 minutes 135.8 at 15 minutes, 106.8 at 30 minutes 73.7 at 1 hour 16.5 at 4 hours. The serum half-life is approximately 1.8 hours following IV administration. Excreted unchanged in the urine 60% in the first, up to 80% in 24 hours. Bile levels in patients (without obstruction) can reach or exceed serum levels by up to five times. In synovial fluid, the cefazolin level becomes comparable to that reached in serum at about 4 hours after drug administration.

Cefazolin dose & time Administer 1 g dose within 60 minutes prior to incision Use 2 g dose if over 80 Kg weight Repeat the dose if procedure longer than 3-4 hours

Right Time How? Where? When? The prophylactic antibiotic process Illustrates patient flow Reveals multiple opportunities for ensuring the patient receives the right antibiotic and other appropriate interventions.

Ideal process? Map out the process Find ideal spot Ensure that Right antibiotic is administered At the right time

Impact of blood loss & redosing, a Study 1,548 patients, Massachusetts (1998-99) Cardiac surgery First dose < 90 mins prior to incision (cefazolin 1g) Second dose if procedure lasting > 240 mins and before incision closed

Intra-operative Re-dosing of Cefazolin

Dental Work & Prophylaxis Rationale Risk of bacteremia high in patients with ongoing inflammation in the mouth. REF Bacteremia cause seeding via hematogenous route in patients undergoing total joint implants. REF Critical period - bacteremia can occur up to 2 year REF Evidence?

Hanssen Clin Orthop Rel Research 1999; 369

Table 1. Patients at Potential Increased Risk of Hematogenous Total Joint Infection All patients during the first two (2) years after prosthetic joint replacement. Immunocompromised/immunosuppressed patients Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic lupus erythematosus) Drug -induced immunosuppression Radiation-induced immunosuppression Patients with co-morbidities (e.g.) Previous prosthetic joint infections Malnourishment Hemophilia HIV infection Insulin-dependent (Type 1) diabetes Malignancy American Academy of Orthopedic Surgeons

Dental Prophylaxis Limited to High Risk Procedures Table 2. Incidence Stratification of Bacteremic Dental Procedures* HIGHER INCIDENCE1 Dental extractions Periodontal procedures including surgery, subgingival placement of antibiotic fibers/strips, scaling and root planing, probing, recall maintenance Dental implant placement and replantation of avulsed teeth Endodontic (root canal) instrumentation or surgery only beyond the apex Initial placement of orthodontic bands but not brackets Intraligamentary and intraosseous local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated American Academy of Orthopedic Surgeons

Regimens (Single dose) Suggested antibiotic prophylaxis regimens Patients not allergic to penicillin: cephalexin, cephradine or amoxicillin: 2 grams orally 1 hour prior to dental procedure. Patients not allergic to penicillin and unable to take oral medications: cefazolin 1 gram or ampicillin 2 grams IM/IV 1 hour prior to the procedure. Patients allergic to penicillin: clindamycin: 600 mg orally 1 hour prior to the dental procedure. Patients allergic to penicillin and unable to take oral medications: clindamycin 600 mg IV, 1 hour prior to the procedure. *No second doses are recommended for any of these dosing regimens. American Academy of Orthopedic Surgeons

Key Points On Surgical Prophylaxis OVERVIEW 1. Administer prophylactic antibiotic within 60 minutes prior to the incision. 2. Use Cefazolin 2 g dose if patient weighs > 80 kg. 3. Assess cephalosporin allergy appropriately. 4. Alternative for cephalosporin allergy is Clindamycin 600 mg IV, unless resistant organisms. 5. Repeat the dose in 3 4 hours if long procedure. 6. Maximum duration of prophylaxis is no more than 24 hours after surgery unless prosthesis. 7. Limit Vancomycin: use in patients with MRSA colonization, unless allergic to it. Vancomycin must be infused over 1 hour and infusion must begin 1 2 hours prior to surgery.