Surgical Site Infection (SSI) -...
Transcript of Surgical Site Infection (SSI) -...
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1
Surgical Site Infection
(SSI)
Y. Rongrungruang, MD
Department of Medicine
Faculty of Medicine Siriraj Hospital
Mahidol University
Comprehensive Training in Infection Control
14-25 December 2015
Westgate Residence Hotel
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คุณดาวกิา โหแน่ (คุณใหม่กว่า) อายุ 35 ปี เป็นเบาหวาน, HbA1C 7.4 gm/L, ไม่สูบบุหร่ี, น า้หนักตัว 65 กก., BMI 31 kg/m2,
ได้รับการผ่าตัด mammoplasty, ก่อนผ่าตัดแพทย์ส่ัง shave หน้าอกถึงรักแร้, skin paint ด้วย betadine และให้ cefazolin 1 gm
IV drip on call to OR, การผ่าตัดเสร็จส้ินภายใน 20 นาที หลงัผ่าตัดให้ cefezolin 1 gm q 8 h x 3 วนั
เปลีย่นเป็น dicloxacillin (500) 1 x 4 pc x 5 วนัและให้กลบับ้านได้
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คุณดาวกิา โหแน่ (คุณใหม่กว่า) อายุ 35 ปี เป็นเบาหวาน HbA1C 7.4 gm/L, ไม่สูบบุหร่ี, น า้หนักตวั 65 กก., BMI 31 kg/m2, ได้รับการผ่าตดั mammoplasty กลบับ้านไป 14 วนั วนันีม้าพบแพทย์เน่ืองจากแผลผ่าตดับวมแดงมหีนอง
เพาะเช้ือขึน้ Methicillin-sensitive S. aureus
ก. ปัจจัยเส่ียงใดบ้างที่น่าจะเกีย่วข้องกบัการติดเช้ือข้างต้น
ข. Intervention ใดบ้างที่อาจลดความเส่ียงการติดเช้ือข้างต้น
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Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
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Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
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Principles of SSI
• Patients undergoing surgery at risk of
SSI during pre-op, peri-op and post-
operative periods
• Acquisition of SSI organisms may be
via colonization/contamination/extra-
surgical site ID
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Outcomes associated with SSI • 2–11 times higher risk of death
among patients with SSI
• 70% of deaths in patients with SSI
are directly attributable to SSI
• 60% of SSIs estimated preventable
by evidence-based guidelines
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
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Principles of SSI & prevention
• SSI risk more effectively reduced during
pre & peri-op > post-op periods, esp in
elective surgery
• Target to reduce SSI < 0.5% in clean, 1% in
clean contaminated, 2% in highly
contaminated wounds*
*Alexander JW, et al. Ann Surg 2011;253:1082–1093
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Modifiable Non modifiable
Smoking Age
Hyperglycemia Co-morbidities
Obesity (BMI, PBF) History of radiation
Skin colonization History of SSTI
Extra SS infections
SSI risk factors & stage, Pre-operative
Alexander JW, et al. Ann Surg 2011;253:1082–93
SS = surgical site
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Peri-operative
Hyperglycemia Blood transfusion
SS contamination peri-op Skin injury s/p razor
OR air contamination Hypothermia
Glove perforation Hypotension
Drain & SS colonization Oxygen desaturation
SSI risk factors & stage of operation
Alexander JW, et al. Ann Surg 2011;253:1082–93
SS = surgical site
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Post-operative (immediate & late)
Hyperglycemia
Hypovolemia
Hypothermia
SS contamination post-op
Extra surgical site infections
Alexander JW, et al. Ann Surg 2011;253:1082–93
SSI risk factors & stage of operation
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Types (mean) Songkla Thailand USA
Extra cost
(bahts)
43,658 5,192
(ATB
only)
120,000
Extra LOS
(days)
23.5 12.7 7.5
SSI : extra Cost & LOS
Kasatpibal N, J Med Assoc Thai 2005; 88(8): 1083-91
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Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
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Type of wound Thailand USA
Clean 1.5 2.1
Clean-contam 3.4 3.3
Contam 6.7 6.4
Dirty 7.8 7.1
SSI rates (%) by wound class
Danchaivijitr S, J Med Assoc Thai 2005 Knight R, et al. Am J Surgery 182 (2001) 682–686
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Category NNIS 0 NNIS 1 NNIS 2
CABG 0/1.0 2.2/1.7 3.7/2.5
craniotomy 0.9/0.7 1.7/1.9 2.4/3.8
hernia repair 0.8/0.2 2.1/0.2 4.5/0.0
USA vs Thailand 2004 , SSI rate (%) by
surgical procedures & risk index category
Am J Infect Control 2004;32:470-85 J Med Assoc Thai 2005; 88 (Suppl 10): S75-82
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NNIS risk index category
Knight R, et al. Am J Surgery 182 (2001) 682–686
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A 60 yr M patient developed MSSA septic
arthritis Rt. Knee. Total knee replacement
Rt. knee was performed 11 months earlier.
Is this a PJI?
a. Yes, MSSA with prosthesis b. Yes, this is < 1 yr post-op c. No, this is > 90 days post-op
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CDC, NHSN classification for surgical site infection
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
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Focus
• Principles & Pathogenesis
• Clinical aspects & Antimicrobial Rx
• Surveillance & Definitions
• International guidelines
• Conclusions
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Guideline summary: Pre-op
Type SHEA 2014 NICE 2008 SHEA 2008
Glucose control I-II NA AII
Smoking I NA AII
Obesity I NA AII
Immunosuppressive III NA CII
Periop infection Rx II Recommended AII
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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Guideline summary: Pre-op
Category Recommendations
Glucose
control
For DM , reduce hemoglobin A1c < 7% before
surgery (I)
Obesity Increase dosing of prophylactic antimicrobial agent
for morbidly obese patients (I)
Smoking Encourage smoking cessation within 30 days (I)
Pre-op ID
outside
surgical
site
Identify and treat infections (eg, urinary tract
infection) remote to the surgical site prior to elective
surgery, do not routinely treat colonization or
contamination (II)
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61
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Guideline summary: Peri-op
Category SHEA 2014 NICE 2008 SHEA 2008
Clipping for hair removal II Recommended AI
Skin preparation I Recommended AII
Normothermia I Recommended Unresolved
Supplemental oxygen I Recommended Unresolved
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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Guideline summary: Peri-op
Category Recommendations
Hair removal If necessary, remove hair outside OR using clippers or a depilatory agent (II)
Skin prep Use alcohol-containing skin paint if not contraindicated.
Unclear which combo with alcohol: alcohol + CHG >
betadine, alcohol + iodine > betadine (I)
Normothermia Maintain normothermia (temp > 35.5°C ) (I)
Oxygen
supplement
Optimize tissue oxygenation with supplemental oxygen
& adequate fluid during and immediately following
surgery esp patient on ventilator (I)
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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Category Povidone-iodine
(n=250)
CHG/Alc
(n=250)
95% CI
class II-III,
no (%)
167 (65.2) 164 (65.6) 0.91
operative
time, hr
1.43 (0.4-3) 1.45 (0.45-3) 0.93
SSI, no (%) 8 (3.2) 5 (2) 1.6 (1.4-1.8)
Peri-operative antiseptic & SSI in abd surgery
Paocharoen V, J Med Assoc Thai 2009;92:898-902
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Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis
Darouiche RO, et al. N Engl J Med 2010;362:18-26.
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Guideline summary: intraoperative
Type SHEA 2014 NICE 2008 CDC 1999
Surgeon skill &
technique
III NA AIII
Double glovings III Recommended AIII
Aseptic technique III Recommended AIII
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Mangram AJ, et al. Infect Control Hosp Epidemiol1999;20(4):250–78.
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Guideline summary: OR characters
Type SHEA 2014 NICE 2008 SHEA 2008
Ventilation III NA CI
Traffic III NA BII
Environment cleaning III NA BIII
Sterilization of devices II NA BI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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OR ventilation & air filtration
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Standards compliance
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Standards compliance
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Design Condition
Clean room class : ISO 7 (10,000)
Room pressure : > +7.5 Pa
Fresh air intake : > 4 ACH
Air circulation : 20-25 ACH
Temperature : 20 – 24 C
Relative humidity : 30-60 %RH
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Principles of surgical prophylaxis
• Aimed to reduce burden of specific
organism at risk of inoculating surgical site
• Reduced effectiveness associated with
emerging antimicrobial resistance
• Surgical prophylaxis needs to be “adequate”
as well as antimicrobial therapy
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47
Considerations in Antibiotic Dosing PK/PD Markers
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48
Vancomycin Pharmacokinetics in Cardiac
Surgery With or Without Cardiopulmonary Bypass
Vancomycin concentration/ time curves, Values expressed as median, Cotogni P. Ann Pharmacother 2013;47:455-63
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Preventing SSI : Antimicrobial & dosing
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
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Guideline summary: Surgical prophylaxis
Type SHEA 2014 NICE 2008 SHEA 2008
Timing < 30-60 min II Recommended AI
Antimicrobial of choices II Recommended AI
Duration of prophylaxis I NA AI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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Surgical prophylaxis: Timing
Category Recommendations
Timing Administration within 1 hour before incision.
< 1 hour is effective, some studies show superior
efficacy for between 0 and 30 min prior to incision
compared with between 30 and 60 min
Two hours for the vancomycin and
fluoroquinolones
Antimicrobials infused prior to inflation of
tourniquets in procedures using “bloodless”
techniques: data insufficient
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
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Surgical prophylaxis: choice & duration
Category Recommendations
Choice &
duration of
prophylaxis
Select appropriate agents on the basis of the
surgical procedure, the most common pathogens
causing SSIs for a specific procedure, and
published recommendations
Discontinue agent within 24 hours after surgery
No evidence of efficacy after closure, but
increased resistance & Clostridium difficile
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
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Guidelines developed jointly by the American Society
of Health-System Pharmacists (ASHP), the Infectious Diseases
Society of America (IDSA), the Surgical Infection Society (SIS),
and the Society for Healthcare Epidemiology of America (SHEA)
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Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
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Types Vancomycin
n = 452
Cefazolin
n = 433
p value
Overall SSI
no (%)
43 (9.5) 39 (9.0) NS
MRSA 8 (1.8) 15 (3.5) NS
MSSA 17 (3.7) 6 (1.3) 0.04*
Choice of surgical prophylaxis : covering
antimicrobial resistance or sensitive? n (%)
Finkelstein R. J Thorac Cardiovasc Surg 2002;123:326-32
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Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
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Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
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Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
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Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
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Surgical Antimicrobial
Therapy & Prophylaxis
• Readministration may be warranted for
prolonged or excessive bleeding,
extensive burns, cardiopulmonary bypass
• Readministration may not be warranted
in patients in whom the half-life of the
agent may be prolonged (e.g., patients
with renal insufficiency or failure)
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Guideline summary: Post-op
Category Recommendations
Glucose
control
For DM , The recommendation of maintaining
postoperative blood glucose less than 200 mg/dL at 6
am on postoperative days 1 and 2 is being replaced
Blood glucose during post-op for cardiac surgery (I)
and noncardiac surgery (II) (180 mg/dL or lower) in
the time frame of 18–24 hours after anesthesia end
time
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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Guideline summary: special approach
Category SHEA 2014 NICE 2008 SHEA 2008
Carrier decolonization II Not routinely Unresolved
Perform antiseptic wound
lavage
II NA NA
Perform an SSI risk
assessment
III NA NA
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
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Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362: 9-17
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Preoperative Decontamination on SSI in
Elective Orthopedic Surgery & Hardware
Bebko SP. JAMA Surg. 2015;150(5):390-5
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SSI Bundle among Patients Undergoing
Cardiac, Hip, or Knee Surgery
Schweizer ML, Herwaldt LA. JAMA 2015;313(21):2162-71
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SSI Bundle among Patients Undergoing
Cardiac, Hip, or Knee Surgery
Schweizer ML, Herwaldt LA. JAMA 2015;313(21):2162-71
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Conclusions
• Selected SSI interventions may be
effectively implemented in selected settings
• Overuse of surgical prophylaxis may be
comparable to those of antimicrobial Rx,
but highly manageable