Surgical Site Infections Evidence in Support of SCIP Recommendations

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Surgical Site InfectionsEvidence in Support of
SCIP Recommendations

• Michael Jhung, MD, MPH
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention
• The findings and conclusions in this presentation
  are those of the author and do not necessarily
  represent the views of the Centers for Disease
  Control and Prevention

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Healthcare Associated Infections Due to SSI
290,485 infections 8,205 deaths
BSI Bloodstream Infection PNEU Pneumonia SSI Surgi
cal Site Infection UTI Urinary Tract Infection
Klevens RM, et al. Public Health Reports. 2007
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SSI Definition

• Surgical wound infection occurring within
• 30 days of procedure
• 1 year of procedure for implantable devices

70
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Impact of SSI in the US

• SSIs are associated with
• Increased length of stay by 7-10 days
• Increased cost per episode of up to 30,000
• Increased readmission rate of up to 40
• Up to 10 times increased risk of death compared
  to surgical patients without SSI
• 77 attributable mortality
• 10 billion in annual US healthcare expenditure

Kirkland KB, et al. Clin Infect Dis. 2003
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Trends in Surgical Procedures in the US
Number of Surgeries in Thousands
SSI Rate per 100 Procedures
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Global Burden of SSI

• Worldwide incidence of SSI uncertain
• 234 million major surgical procedures each year
• 75 in developed countries
• SSI rate 4/100
• 2 to gt 10 infection rate
• Increasing demand for elective surgery

Soleto L, Infect Cont Hosp Epid. 2003 Nguyen D,
Infect Cont Hosp Epid 2001 Weiser TG, Lancet 2008
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SSI is a Global Public Health Priority

• 2nd Global Patient Safety Challenge
• Clean surgery
• Safe anesthesia
• Safe operators
• Measurement and quality assurance

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SSI Prevention
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SSI Prevention

• Pathogen
• Degree of contamination
• Virulence
• Antimicrobial resistance

• Procedure
• Duration
• Preparation
• Type and technique
• Equipment sterilization
• OR characteristics
• Introduction of foreign material

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The Surgical Care Improvement Project (SCIP)

• Born from the Surgical Infection Prevention (SIP)
  project (2002)
• SCIP begun in 2003
• 4 components
• Prevention of SSIs
• Prevention of VTE
• Prevention of adverse cardiac events
• Prevention of respiratory complications

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SCIP SSI Recommendations

• SCIP Procedures
• Cardiothoracic and vascular surgery
• Colorectal surgery
• Hip or knee arthroplasty
• Abdominal or vaginal hysterectomy

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SCIP SSI Recommendations

• SCIP recommendations for SSI prevention
• Antimicrobial prophylaxis
• Glucose control
• Proper hair removal
• Temperature control

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SCIP Antimicrobial Prophylaxis (AMP)

• Antimicrobial initiated within 1 hour before
  incision
• 2 hours prior for vancomycin or fluoroquinolones
• Antimicrobial consistent with published
  guidelines
• Antimicrobial discontinued within 24 hours after
  surgery
• 48 hours for adult cardiothoracic patients

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Antimicrobial Prophylaxis (AMP)

• Evidence base is large and long-standing
• Many studies demonstrate efficacy of starting AMP
  prior to incision
• Burke (1961)
• Timing of AMP important in animal studies
• Classen (1992)
• AMP given within 2 hours before incision

Classen DC, NEJM Jan 1992.
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Antimicrobial Prophylaxis TRAPE Study

• Trial to Reduce Antimicrobial Prophylaxis Errors

Infection Rate per 100 procedures
Time (minutes) between AMP and Incision
Steinberg, Society for Healthcare Epidemiology of
America Annual Conference, 2007
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Antimicrobial Prophylaxis
Weber WP, Ann Surgery, June 2008.
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AMP Best Practices Status Check

• Study of 35,000 major surgery patients
• 93 received antimicrobial consistent with
  published guideline

Bratzler DW, Arch Surg, Feb 2005
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AMP Best Practices Status Check
Incision
Bratzler DW, Arch Surg. Feb 2005
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AMP Best Practices Status Check
Incision
Bratzler DW, Arch Surg. Feb 2005
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AMP Best Practices Status Check
24 hours after surgery
Bratzler DW, Arch Surg. Feb 2005
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AMP Best Practices Status Check
24 hours after surgery
Bratzler DW, Arch Surg. Feb 2005
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AMP Best PracticesImprovement Possible
Mandatory AMP Order Form
Hermsen, ED Infect control Hosp Epidemiol, May
2008.
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AMP Best PracticesImprovement Possible
Optimized Antibiotic Policy
93.5 Inappropriate AMP
37.5 Inappropriate AMP
van Kasteren ME, J Antimicrob Chemother, October
2005 Mannien J, Infect Control Hosp Epidemiol,
December 2006.
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AMP Best PracticesImprovement Possible
Automatic Stop-AMP Form
Gomez MI, Infect Control Hosp Epidemiol, December
2006.
Not significant
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SCIP Antimicrobial Prophylaxis (AMP)

• SCIP
• Antimicrobial initiated within 1 hour
  before incision
• Antimicrobial consistent with published
  guidelines
• Antimicrobial discontinued within 24 hours
  after surgery

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Re-dosing AMP for Obese Patients
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SCIP Preoperative Hair Removal

• If hair must be removed, use clippers or
  depilatory, immediately before surgery
• Shaving the surgical site with a razor induces
  small skin lacerations
• Potential sites for infection
• Disturbs hair follicles which may be colonized

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Preoperative Hair Removal

• Cochrane review of 11 randomized controlled trials

3 Hair removal vs. no hair removal
3 Shaving vs. clipping
7 Shaving vs. depilatory
1 Shaving day of surgery vs. day before
1 Clipping day of surgery vs. day before
Tanner J, Preoperative hair removal to reduce
surgical site infection. Cochrane Review, 2008
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Preoperative Hair Removal
3 Hair removal vs. no hair removal

• Abdominal surgery
• Not high quality
• No significant
• difference in SSI rate

3 Shaving vs. clipping
7 Shaving vs. depilatory
1 Shaving day of surgery vs. day before
1 Clipping day of surgery vs. day before
Tanner J, Preoperative hair removal to reduce
surgical site infection. Cochrane Review, 2008
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Preoperative Hair Removal
3 Hair removal vs. no hair removal
3 Shaving vs. clipping

• Pooled RR 2 for
• shaved group
• Significant
• difference in SSI rate

7 Shaving vs. depilatory
1 Shaving day of surgery vs. day before
1 Clipping day of surgery vs. day before
Tanner J, Preoperative hair removal to reduce
surgical site infection. Cochrane Review, 2008
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Preoperative Hair Removal
3 Hair removal vs. no hair removal
3 Shaving vs. clipping

• Variable quality
• Pooled RR 1.5
• Significant
• difference in SSI rate

7 Shaving vs. depilatory
1 Shaving day of surgery vs. day before
1 Clipping day of surgery vs. day before
Tanner J, Preoperative hair removal to reduce
surgical site infection. Cochrane Review, 2008
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Preoperative Hair Removal
3 Hair removal vs. no hair removal

• No significant
• difference in SSI rate

3 Shaving vs. clipping
7 Shaving vs. depilatory
1 Shaving day of surgery vs. day before
1 Clipping day of surgery vs. day before
SCIP If hair must be removed prior to surgery,
use clippers or a depilatory
Tanner J, Preoperative hair removal to reduce
surgical site infection. Cochrane Review, 2008
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SCIP Perioperative Temperature Control

• Hypothermia can increase SSI risk
• Thermoregulatory vasoconstriction
• Direct impairment of immune function
• No side-effects to intervention
• Minimal cost for intervention

SCIP Maintain immediate postoperative
normothermia for colorectal surgery patients
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Perioperative Temperature Control

• RCT of 200 colorectal surgery patients
• Treatment group received 2 C additional
  warming
• Controls received routine thermal care
• SSI rate 3-fold higher in control group
  (19/100)
• RCT of 421 clean surgery patients
• Treatment group received ? 30 min preoperative
  warming
• Controls received no active warming
• SSI rate 3-fold higher in control group (14/100)

Kurz A , NEJM. 1996 Melling AC, Lancet. 2001
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Glucose Control

• Hyperglycemia SSI relationship multifactorial
• Impairment of immune function
• Microvasculature changes
• Abnormal neutrophil activity
• Decreased oxygen radical production
• Impaired antigen presentation
• Increased apoptotic cell death
• Inhibition of wound healing
• Microvasculature changes
• Decreased fibroblast proliferation
• Exacerbation of inflammation
• Most evidence in patients undergoing cardiac
  surgery

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Glucose Control
Studies with significant, independent
associations
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Glucose Control
Studies with significant, independent
associations
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Glucose Control
Studies with significant, independent
associations
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Glucose Control
Intervention studies
Strict glucose control
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Glucose Control

• Risk factors for DSWI after cardiac surgery
• History of diabetes
• Elevated HbA1c level
• Perioperative hyperglycemia
• Glucose control warranted
• 600 AM postoperative serum glucose 200 mg/dl
  for cardiac surgery patients
• Evidence for strict (IV) glucose control
  indeterminate

SCIP 600 AM postoperative serum glucose 200
mg/dl for cardiac surgery patients
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Supplemental Oxygen

• Generation of reactive oxygen species (ROS) by
  neutrophils contributes to oxidative killing of
  pathogenic bacteria
• Rate of ROS production
• depends on PO2
• Tissue PO2 influenced by temperature, anemia,
  fluid management . . .
• . . . inspired O2 concentration

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Evidence Base for Supplemental Oxygen

• 3 Randomized Trials

SCIP No recommendation
Grief R, NEJM 2007. Pryor KO, JAMA 2004. Belda
JF, JAMA 2005
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SSI Prevention Measures
Tobacco cessation SSI surveillance Proper
hair removal Treat preoperative infections
Education of clinical staff Antimicrobial
prophylaxis Asepsis Feedback to staff
Minimize procedure duration OR traffic
control Sterilize equipment properly Prevent
hyperglycemia
Optimize oxygen tension Preoperative CHG
bathing Maintain normothermia Preoperative
decolonization
Maintain vascular volume Incision care
Maintain slight hypercapnia Pain relief
Specific patient populations
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SSI PreventionNext Steps

• Facilitate adoption of recommendations by
  healthcare facilities
• Evaluate SCIP recommendations using outcome
  measures
• Develop surveillance and prevention strategies
  for ambulatory and post-discharge cases
• Investigate unresolved issues
• Supplemental oxygen
• Decolonization

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Thank You

• mjhung_at_cdc.gov
• The findings and conclusions in this presentation
  are those of the author and do not necessarily
  represent the views of the Centers for Disease
  Control and Prevention