Prevention of Surgical Site Infections
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Prevention of Surgical Site Infections Sinil Nair, CIC Infection Control Expert Clinical Quality and Healthcare Accreditation Department, MOHAP Background a) The second most common (20%) of all HAIs in hospitalized patients. b) Occurs in 2%–5% of patients undergoing inpatient surgery. c) One of the most preventable HAIs. a) Up to 60% of SSIs are preventable by using evidence-based guidelines. d) Each SSI is associated with ≈ 7–11 additional hospital-days. Background e) 3% Mortality f) Patients with an SSI have a 2–11-times higher risk of death compared with operative patients without an SSI. g) 77% of deaths in patients with SSI are directly attributable to SSI. h) The most costly HAI i) Long term disabilities Types of SSI NHSN Definitions 1. Superficial incisional SSI Must meet the following criteria: a) Infection occurs within 30 days after any operative procedure (where day 1 = the procedure date) AND a) involves only skin and subcutaneous tissue of the incision AND c) patient has at least one of the following: i. purulent drainage from the superficial incision. ii. organisms identified from an aseptically-obtained specimen from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture). iii. superficial incision that is deliberately opened by a surgeon, attending physician or other designee and culture or non-culture based testing is not performed. AND patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat. A culture or non- culture based test that has a negative finding does not meet this criterion. iv. diagnosis of a superficial incisional SSI by the surgeon or attending physician or other designee. NHSN Definitions… There are two specific types of superficial incisional SSIs: a) Superficial Incisional Primary (SIP) – a superficial incisional SSI that is identified in the primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CABG) b) Superficial Incisional Secondary (SIS) – a superficial incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CABG) NHSN Definitions… 2. Deep incisional SSI Must meet the following criteria: a) Infection occurs within 30 or 90 days after the operative procedure (where day 1 = the procedure date) AND b) involves deep soft tissues of the incision (e.g., fascial and muscle layers) AND c) patient has at least one of the following: i. purulent drainage from the deep incision. ii. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician or other designee and organism is identified by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture) or culture or non-culture based microbiologic testing method is not performed AND iii. patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. A culture or non-culture based test that has a negative finding does not meet this criterion. iv. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test. NHSN Definitions… There are two specific types of deep incisional SSIs: a) Deep Incisional Primary– a deep incisional SSI that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C- section incision or chest incision for CABG) b) Deep Incisional Secondary – a deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CABG) NHSN Definitions… Organ/Space SSI Must meet the following criteria: a) Infection occurs within 30 or 90 days after the operative procedure (where day 1 = the procedure date). AND b) infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure AND c) patient has at least one of the following: i. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) ii. organisms are identified from an aseptically-obtained fluid or tissue in the organ/space by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture). iii. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test AND d) meets at least one criterion for a specific organ/space infection site listed in next slide. Organ/Space SSI Specific Sites of an Organ/Space SSI http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf SSI- Factors Influencing Pathogenesis a) Microbial characteristics (eg, degree of contamination, virulence of pathogen) b) Patient characteristics (eg, immune status, comorbid conditions); and c) Surgical characteristics (eg, type of procedure, introduction of foreign material, amount of damage to tissues) SSI- Sources of Pathogens: 1. Endogenous a) Patient flora i. – skin ii. – mucous membranes iii. – GI tract b) Seeding from a distant focus of infection 2. Exogenous a) Surgical Personnel (surgeon and team) i. – Soiled attire ii. – Breaks in aseptic technique iii. – Inadequate hand hygiene b) OR physical environment and ventilation c) Tools, equipment, materials brought to the operative field Organisms Causing SSI (CDC January 2006-October 2007) Staphylococcus aureus 30.0% Coagulase-negative staphylococci 13.7% Enterococcus spp. 11.2% Escherichia coli 9.6% Pseudomonas aeruginosa 5.6% Enterobacter spp 4.2% Klebsiella pneumoniae 3.0% Candida spp. 2.0% Klebsiella oxytoca 0.7% Acinetobacter baumannii 0.6% Risk Factors Patient Related 6. Coexistent infections at a 1. Age remote body site 2. Nutritional status 7. Colonization with 3. Diabetes pathogens 4. Smoking 8. Altered immune response 5. Obesity 9. Length of preoperative stay Risk Factors Procedure Related 1. Preoperative shaving 7. OR ventilation 2. Duration of surgical 8. Inadequate sterilization scrub of instruments 3. Skin antisepsis 9. Foreign material in surgical site and drains 4. Preoperative skin prep 10. Hypothermia 5. Duration of procedure 11. Surgical technique 6. Antimicrobial prophylaxis 1. Poor hemostasis 2. Failure to obliterate dead space 3. Tissue trauma Surgical Wound Classification Emerging Challenges 1. Challenges in detecting SSIs a) Lack of standardized methods for post- discharge/outpatient surveillance i. Increased number of outpatient surgeries ii. Shorter postoperative inpatient stays 2. Antimicrobial Prophylaxis b) Increasing trend toward resistant organisms may undermine the effectiveness of existing recommendations for antimicrobial prophylaxis Important Modifiable Risk Factors 1. Antimicrobial prophylaxis a) Inappropriate choice (procedure specific) b) Improper timing (pre-incision dose) c) Inadequate dose based on body mass index, procedures >3h, or increased blood loss 2. Skin or site preparation ineffective a) Removal of hair with razors 3. Colorectal procedures a) Inadequate bowel prep/antibiotics b) Improper intraoperative temperature regulation Additional Modifiable Risk Factors 1. Excessive OR traffic 2. Inadequate wound dressing protocol 3. Improper glucose control 4. Colonization with preexisting microorganisms 5. Inadequate intraoperative oxygen levels Strategies To Detect SSI Surveillance: a) A measure of the magnitude of the problem. b) Identify and investigate trends. c) Guide the identification of improvement actions d) Evaluate the effectiveness of these interventions. e) Decrease SSI rates from the feedback f) Investigation of why SSI rates are higher than the benchmark g) Prompt local initiatives to improve performance. Methods for Surveillance of SSI A. The direct method: daily observation of the surgical site starting 24–48 hours postoperatively is the most accurate method. B. The indirect method: a combination of, 1. Review of microbiology reports and patient medical records. 2. Surgeon and/or patient surveys. 3. Screening for readmission and/or return to the operating room. 4. Other information, such as coded diagnoses, operative reports, or antimicrobials ordered. C. The indirect method of SSI surveillance is both reliable (sensitivity, 84%–89%) and specific (specificity, 99.8%) compared with direct surveillance. Post-discharge Surveillance 1. Superficial incisional SSIs are most commonly detected and managed in the outpatient setting 2. Deep incisional and organ/space infections typically require readmission for management. 3. SSI rates will be underestimated without post discharge surveillance. 4. No standardized or reliable method for post- discharge surveillance has been established. Post-discharge Surveillance In the Netherlands, the proportion of deep SSIs identified after discharge from the hospital ranged from 6% for colon resections to 88% for knee arthroplasties (the duration of post-discharge surveillance was 30 days versus 1 year for an implant- related procedure). A pilot study in general surgery reported that 10.5% of SSIs