Surgical Site Infections

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Surgical Site Infections

• Michael H. Metzler, MD, FACS, FCCM
• Director Trauma Services
• Sunrise Hospital Medical Center
• Sunrise Childrens Hospital
• Las Vegas, NV

2
DISCLOSURE

• I have speaking arrangements with
• Merck
• Pfizer
• Sanofi-Aventis

3
The Problem
1. National Center for Health Statistics.
Combined surgery data (NHDS and NSAS) data
highlights. http//www.cdc.gov/nchs/data/ 2.
Dimick JB, et al. J Am Coll Surg 2004 199

• gt30 Million operations annually in U.S.
• Average complication rates1
• 6 non-cardiac surgery (1.8 million)
• gt30 high-risk procedures (10 million)
• Average increase hospital stay for surgical
  complication 3-11days1
• Attributable Costs2
• 1,398/infection
• 7,789/ cardiovascular
• 52,466/ respiratory
• 1,810/ thromboembolic

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Surgical Site Infection (SSI) Occurring After
Hospital Discharge

• 5572 HMO healthcare records screened for SSI
  132 (2.4 overall rate)
• 84 ocurred post discharge
• 63 managed as out pt
• Average of 4.6 extra ambulatory visits needed
• Conclusion Most SSIs not detectable by
  conventional surveillance, but consume
  significant resources.

Sands K, Vinyard G, and Platt R. JID
173(4)963-70.
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The Usual Presentation of the Data
Source NNIS data from Barnard BM 4/1/02
Infection Control Today
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From CMS Perspective 1
Center for Medicare Medicaid Services
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From CMS Perspective 2
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What Can be Done?The Usual Presentation

• Virtually All Professional Societies and
  Regulatory Bodies Develop Guidelines
• SIP and SCIP
• NSQIP
• Joint Commission
• 5 Million Lives
• Etc., etc. ,etc., etc., etc., etc., etc. etc.

Good ideas, but who is really doing anything?
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New Twists to an Old Theme

• As of October 2008, hospitals will not be
  reimbursed for preventable infection.1 Vascular
  catheter-associated sepsis, SSI (mediastinitis)
• SSI data kept and displayed by surgeon name.
• Government and other organizations very
  interested in publicizing data.

.
1. Federal Register at www.access.
gpo.gov/su_docs/fedreg/a070822c.html.
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2008 Reporting Capability
Let the Public Conclusions be Drawn
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Potential Fallout

• Patient selection of Best Doctors
• Economic credentialing by payors
• Institutional medical staff adjustments

Dead Certain
Decreased SSI rate Decreased morbidity,
mortality, cost Improved care
Hopefully Will Happen
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What Can We Do?
What Should We Do?

• Understand the alphabet soup of agencies that
  have a stake in this.
• Understand the scientific basis for these
  initiatives.
• Make details of healthcare delivery an important
  part of our care.

.
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Alphabet Soup
CMS, CDC, VA, ACS,ASA,AHRQ, AHA,IHI 2003 SCIP2 Pre
vention of infection Prevention VTE Prevention
cardiac events Prevention of respiratory
complications
CMS1 2002 SIP Perioperative antibiotics
NSQIP3 (for measurement)
1. Center for Medicare Medicaid Services 2.
Surgical Care Improvement Project 3. National
Surgical Quality Improvement Program
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What are the initiatives regarding Surgical Site
Infection (SSI)?

• Antibiotic choice, dose, delivery, duration
• Surgical site preparation
• Perioperative control of glucose
• Maintenance of normothermia
• Supplemental perioperative oxygen

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Definitions
Infection here may cause
Delayed healing
Hernia Possible evisceration
Abscess Fistula Other procedures needed
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Definitions
Infection Rates1 2-5 I-II Extra-abdominnal 20
Intra-abdominal

• Categories of wounds in regard to bacterial
  contamination
• Clean (CABG, Hernia, THR)
• Best situation you can have
• Clean-Contaminated (Gallbladder, Hysterectomy)
• Areas of bacterial growth entered in controlled
  manner without spillage
• Contaminated (All traumatic wounds)
• Spilled bacterial contents
• Dirty (perforated viscus, abscess)
• Established infection

I
II
III
IV
1. Bratzler DW, et al. Arch Surg 2005 140174-182
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Practical ExamplesSSI Initiatives as Applied to

• Elective surgical procedures
• Colon resection for cancer
• CABG
• Emergency operative procedures
• GSW / SW colon
• Emergency Department procedures
• ED lacerations

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Elective Surgical ProceduresPeri-operative
Antibiotics Choice of Drug

• Antibiotic appropriate for indigenous microflora
• More is not better in dealing with antibiotics
• In cases where patients known to be MRSA carriers
  or come from known reservoirs - MRSA prophylaxis
  is warranted for CABG and THR

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History of Anti-infective Drugs for Surgical
Prophylaxis in Colorectal Surgery (CRS)

• 1961 Animal studies by Burke demonstrated the
  importance of timing in preventing dermal or
  incisional infection.1
• 1969 Landmark study by Polk and Lopez-Mayor
  demonstrated a significant reduction of wound and
  intraabdominal sepsis among patients treated with
  antimicrobial prophylaxis.2
• 1970s Key Veterans Affairs trials showed
  benefit of antibiotic prophylaxis over placebo
  in elective CRS
• 9 wound infection rate in antibiotic-treated
  patients vs 35 in placebo group3
• Infection in 0 of 69 patients receiving
  neomycin-erythromycin base vs 3 of 16 patients
  receiving mechanical preparation only4
• 1981 Baum and colleagues recommended elimination
  of no-treatment control groups in trials of
  antibiotic prophylaxis in colon surgery5
• 1998 Song and Glenny review of 147 trials
  between 1984 and 1995.6

1. Burke JF. Surgery. 196150161167. 2. Polk HC
Jr, et al. Surgery. 19696697103. 3. Clarke JS,
et al. Ann Surg. 1977186251258.
4. Nichols RL, et al. Ann Surg.
1973178453459. 5. Baum ML, et al. N Engl J
Med. 1981305795799. 6. Song F, et al. Br J
Surg. 19988512321241.
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Elective Surgical Procedures Antibiotic
Prophylaxis in CRS
Baum ML et al. N Engl J Med. 1981305795799.

2
5
2
0
1
5
1
0
Favor Treatment
5
0
Favor Control
5
1
0
6
6
6
8
7
0
7
2
7
4
7
6
7
8
8
0
Year
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Microbial Populations Within the Human
Gastrointestinal (GI) Tract
Oral Cavity
1.03.0 Log10 CFU/gm
Lactobacilli
Streptococci Lactobacilli Enterobacteriaceae
3.05.0 Log10 CFU/gm
Aerobic Anaerobic Microbial Populations
10.012.0 Log10 CFU/gm
Rectum
CFUcolony forming unit, gmgram. Reprinted from
Edmiston CE Jr et al. Microbiology of
intraabdominal infections. Infect Dis Clin Pract.
19965(suppl 1)S16, with permission from
Lippincott Williams Wilkins WKHPS, Inc.
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Elective Surgical Procedures Peri-operative
Antibiotics Drug Administration Timing

• Give before the incision
• Allows achievement of maximal tissue levels
  before blood supply is interrupted by incision
• Stop post operatively for prophylaxis and if
  source of contamination is removed

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Fundamentals of Antibiotic Administration
ABX
Once the incision is made, antibiotic delivery to
the wound is impaired. Must give before incision!
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Elective Surgical Procedures Importance of
Timing of Surgical Antimicrobial Prophylaxis
Temporal relationship between the administration
of prophylactic antibiotics and rates of
surgical-wound infection
P 0.001. P0.23. P0.0001. NA not
applicable.
Classen DC et al. N Engl J Med. 1992326281286.
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Perioperative Prophylactic Antibiotics Timing of
Administration
14/369
4
15/441
3
1/41
1/47
Infections,
2
1/61
2/180
5/699
1
5/1,009
0
3
gt2
gt1
0
1
2
3
4
5
Hours From Incision
Classen DC et al. N Engl J Med. 1992326281286
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Single- vs Multiple-Dose Surgical Prophylaxis
Systematic Review
28 Studies
Favors multiple dose
Favors single dose
McDonald M et al. Aust NZ J Surg. 199868388396
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Impact of Prolonged Antibiotic Prophylaxis

• 2,641 patients undergoing CABG
• Group 1 lt48 hours of antibiotics
• Group 2 gt48 hours of antibiotics
• SSI rates
• Group 1 9 (131/1,502)
• Group 2 9 (100/1,139)
• Odds ratio 1.0 (95 CI 0.81.3)
• Increased antibiotic resistant pathogens Group
  2
• Odds ratio 1.6 (95 CI 1.12.6)

• Treating gt 48hrs
• More resistant bugs
• Higher cost

CABG coronary artery bypass grafting CI
confidence interval. Harbarth S et al.
Circulation. 200010129162921.
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Elective Surgical ProceduresHair Removal

• Clipping hair just before case is best

Alexander JW, et al. Arch Surg 1983 118347-352
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Hair-Removal Techniques and SSIs
Discharge 30-Day Follow-up
1
2
10(26/260)
8.8(23/260)
7.5(18/241)
6.4(17/266)
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Infection,
5.2 (14/271)
4(10/250)
3.2(7/216)
4
1.8(4/226)
0
PM AM PM AM Razor Razor Clipper Clipper
Alexander JW et al. Arch Surg. 1983118347352.
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Elective Surgical Procedures Prevention of
Hyperglycemia

• 80 mg/dlgt BGlt110mg/dl decreased
• ICU mortality (8-4.6)
• Sepsis (blood stream infection by 46)
• ARF requiring HD (41)
• RBC transfusion (50)
• Polyneuropathy (44)
• Independent variable with conventional care

Volume 3451359-1367 November 8, 2001 Number
19 Intensive Insulin Therapy in Critically Ill
Patients Greet Van den Berghe, M.D., Ph.D.,
Pieter Wouters, M.Sc., Frank Weekers, M.D.,
Charles Verwaest, M.D., Frans Bruyninckx, M.D.,
Miet Schetz, M.D., Ph.D., Dirk Vlasselaers,
M.D., Patrick Ferdinande, M.D., Ph.D., Peter
Lauwers, M.D., and Roger Bouillon, M.D., Ph.D.
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SSIs and Glucose Levels CTS pts
8
6.7
7
6
P0.002
5
Deep Infection Rate,
4
2.5
3
1.3
1.6
2
1
0
100150
150200
200250
250300
Day 1 Blood Glucose (mg/dL)
Zerr KJ et al. Glucose control lowers the risk of
wound infection in diabetics after open heart
operations, page 360. Reprinted from The Annals
of Thoracic Surgeons, Vol. 63.
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Elective Surgical Procedures Perioperative
Normothermia

• Warm Patient Strategies
• Start with warm room
• Use Bair Hugger
• Cool room for procedure
• Use 40o irrigation
• Warm room on closing
• GOAL gt36oC (98.6oF)

• 200 CRS patients
• Control Routine intraoperative thermal care
  (mean temperature 34.7C)
• Treatment Active warming (mean temperature
  36.6C)
• Incidence of SSI
• Control 19 (18/96)
• Treatment 6 (6/104) P0.009

Kurz A et al. N Engl J Med. 199633412091215.
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Elective Surgical Procedures Supplemental Oxygen

• 500 CRS patients
• 80 or 30 inspired oxygen during operation and
  for 2 hours post surgery
• All patients received prophylactic antibiotics
• Results
• Arterial and subcutaneous PO2 higher in 80
  oxygen group
• Lower incidence of SSIs with higher supplemental
  oxygen (5.2 vs 11.2 P0.01)

• Oxygen Strategy
• Supplemental O2 for 2hrs in RR

Greif et al. N Engl J Med. 2000342161167.
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Emergency Procedures

• GSW / SW ABD
• GI perforations
• Bowel infarctions

Clean up spillage Disrupt loculations Debride
non-viable tissue

• Insure appropriate antibiotic choice
• Insure adequate levels peri-operatively
• Stop post op.
• If abscess
• Afebrile, NL WBC, GI function
• 5 days 7 days
• Control Glucose
• Normothermic patient
• Peri-op oxygen supplementation

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Simple Lacerations

• Adequate analgesia to clean and debride the
  wound.
• Antibiotics do not make up for inadequate wound
  care prior to closure.

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Summary

• Problem Patients have SSIs that cause morbidity,
  mortality and increased healthcare costs.
• Solution We have proven methodology to decrease
  SSI

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Summary

• Optimal antibiotic choice, dose, delivery,
  duration
• Optimal surgical site preparation
• Perioperative control of glucose
• Maintenance of normothermia
• Supplemental perioperative oxygen

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Summary

• We must make the details of healthcare delivery a
  priority. If we do not, we are not giving our
  patients the best treatment no matter how good
  their operation or how expensive and
  broad-spectrum their antibiotic was.

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Thank You!
Questions ? Comments !