XIV ANNUAL CONFERENCE OF ESS Turin, 25-27 November 2010

SSI Incisional and Organ/Space

Prof. Andrea ImperatoriUniversity of Insubria

Center for Thoracic Surgery

Horan T et al CDC Definitions of Nosocomial Surgical Sites Infections

Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:

identical significance and same clinical relevance?identical significance and same clinical relevance?

•• Postoperative peritonitis vs. wound SSI ? Postoperative peritonitis vs. wound SSI ?

•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)

•• Different risk factors ? Different risk factors ?

•• Different cost ?Different cost ?

•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?

Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:

identical significance and same clinical relevance?identical significance and same clinical relevance?

•• Postoperative peritonitis vs. wound SSI ? Postoperative peritonitis vs. wound SSI ?

•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)

•• Different risk factors ? Different risk factors ?

•• Different cost ?Different cost ?

•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?

Open abdomen treatment

Diffuse peritonitis

Superficial (?) incisional SSI

•• Postoperative peritonitis vs. wound SSI ?Postoperative peritonitis vs. wound SSI ?

•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)

•• Different risk factors ? Different risk factors ?

•• Different cost ?Different cost ?

•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?

Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:

identical significance and same clinical relevance?identical significance and same clinical relevance?

Organ-space SSI - Wound dehiscence

•• Postoperative peritonitis vs. wound SSI ?Postoperative peritonitis vs. wound SSI ?

•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)

•• Different risk factors ? Different risk factors ?

•• Different cost ?Different cost ?

•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?

Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:

identical significance and same clinical relevance?identical significance and same clinical relevance?

Risk factors for the development of postoperative infections

1. Age and (*) associate derangements of physiologic functions

2. Type of surgical procedure (surgical trauma severity)

3. (*) Quality of surgical technique4. Operative field contamination5. Emergency surgical procedure6. (*) Inadequate antibiotic prophylaxis7. (*) Blood loss and transfusions8. (*) Malnutrition/obesity9. (*) Preexisting infection10. (*) Current disease:

a) Diabetesb) Renal failurec) Cirrhosisd) Cardiac diseasee) Chronic pulmonary diseasef) shock

11. (*) Length of preop. hospital stay

12. Immunosuppressive therapy

13. (*) Prolonged corticosteroid therapy

14. Inoperable malignancy15. (*) Invasive devices16. (*) Quality of pre- and

post-operative care

* Modifiable factors

>

National Nosocomial Infections Surveillance (NNIS) risk index

•• Postoperative peritonitis vs. wound SSI ? Postoperative peritonitis vs. wound SSI ?

•• Type of Organ/Space SSI ? Type of Organ/Space SSI ? (peritonitis vs. osteomyelitis)(peritonitis vs. osteomyelitis)

•• Different risk factors ? Different risk factors ?

•• Different cost ?Different cost ?

•• SSI surveillance may be misleading ?SSI surveillance may be misleading ?

Incisional SSI and Organ/Space SSI: Incisional SSI and Organ/Space SSI:

identical significance and same clinical relevance?identical significance and same clinical relevance?

Surgical Site Infection (SSI) Surgical Site Infection (SSI) -- CostCost

SSIs result in:

• Increased morbidity

• Prolonged hospitalization

• Socio-economic cost

Duration of SSIDuration of SSI•• From day of clinical diagnosis until day of From day of clinical diagnosis until day of

clinical resolutionclinical resolution

•• Superficial incisionalSuperficial incisional: 7 days: 7 days

•• Deep incisionalDeep incisional: 10 days: 10 days

•• Organ / SpaceOrgan / Space: 14 days (or > if re: 14 days (or > if re--operation)operation)

Mean duration of SSIMean duration of SSI

Di Leo A. et al

SSI – Classification CDC(Horan TC: Infect Control Hosp Epidemiol, 1992)

• Superficial Incisional SSIs local wound care low

CostTreatment

Cost analysis of superficial SSI in Varese

Excess in-hospital lenght of stay: 2 days

Added hospital costs: 1,000 Euro (500 Euro/day)

About 5 additional wound care procedures

Cost of extra wound care: 50 Euro (10 Euro/each)

Antibiotic therapy (7 days): 10 Euro

Total added costs: 1,060 Euro

SSI – Classification CDC(Horan TC: Infect Control Hosp Epidemiol, 1992)

Deep Incisional SSIs Deep Incisional SSIs prol. hospital stay moderateadditional procedures highantibiotic

CostTreatment

Cost analysis of deep SSICost of re-do surgery: about 3,000 Euro

Excess in-hospital lenght of stay: 5 days

Added hospital costs: 2,500 Euro (500 Euro/day)

About 15 additional wound care procedures

Cost of extra wound care : 150 Euro (10 Euro/each)

Antibiotic therapy (10 days): 400 Euro

Total added cost: 6,050 Euro

Organ or Space infections systemic, local high

ICU – hosp. stay (mortality)

CostTreatment

SSI – Classification CDC(Horan TC: Infect Control Hosp Epidemiol, 1992)

Cost analysis of “chronic” organ/space SSI

Cost analysis of “chronic” organ/space SSI

Cost of re-do surgery: about 3,000 Euro

Extra in-hospital lenght of stay: 10 days

Added hospital costs: 5,000 Euro (500 Euro/day)

About 50 additional wound care procedures

Cost of extra wound care : 500 Euro (10 Euro/each)

Antibiotic therapy (15 days): 820 Euro

Total added cost: 9,320 Euro

Surgical Site Infection (SSI) Surgical Site Infection (SSI) --EpidemiologyEpidemiology

• SSI rate differs from one country to another

according to the system employed for control of

hospital infections

• SSI rate ranges between 3% and 20%

depending on hospital, patient clinical conditions

and type of procedure

Surgical Site Infection (SSI) in ItalySurgical Site Infection (SSI) in Italy

• About 3,000,000 (in-patients) surgical

procedures per year in Italy

• About 5% of all surgeries (150,000/year)

generate SSI in Italy

KIR-NOS Study GroupKIR-NOS Study Group

Incidence Study1 April - 30 June 2002

Follow-up 30 days(visit or phone call and questionnaire at discharge)

3066 surgeries

Torino MolinetteMauriziano

BiellaOspedale Degli Infermi

Borgomanero (NO)Ospedale SS Trinità

Alto Garda Study (2009): 1281 ptsAlto Garda Study (2009): 1281 pts

Site of infection

Deep

Superficial

Organ-space

76/12815.9 %

44%

42% 14%

7.9%

[IC95%:7.0-8.9]

Localizzazione dell'infezione

Superficiale62%

Organo-spazio23%

Profonda15%

Site of infection

Deep

Superficial

Organ-space

KIR-NOS Study (2002): 3066 ptsKIR-NOS Study (2002): 3066 pts

158/30665.2%

Overall SSI Rate

Overall SSI Rate

UnderdiagnosisUnderdiagnosis of SSIof SSI

SSI:SSI:

•• Not diagnosed (not recognized; late signs)Not diagnosed (not recognized; late signs)

•• Not reported Not reported

•• MisclassifiedMisclassified

SSI (%)SSI (%)

0.72 %0.72 %2.3 %2.3 %4.0 %4.0 %7.2 %7.2 %

SSI (%)SSI (%)

0.72 %0.72 %2.3 %2.3 %4.0 %4.0 %7.2 %7.2 %

SSI (%)SSI (%)

0.72 %0.72 %2.3 %2.3 %4.0 %4.0 %7.2 %7.2 %

Authors Year n° pts % wound infection

Vilar-Compte 2009 2338 18.7

Throckmorton 2009 436 7.8

El-Tamer 2007 30474.3 (Mastectomy) 2.0 (Lumpectomy)

Gravatt Wilke 2006 4975 1.0 (axillary surgery)

Leaper 2005 168 10 (axillary surgery)

Leaper 2001 175 10

SSI rate in breast surgery

Infection surveillanceInfection surveillance

• Information concerning factors and procedures associated with increased risk of SSI

• Stratification of SSI rates according to risk factors

• Comparison of SSI rates intra- and inter-Institutions

SSI / NNIS IndexSSI / NNIS Index

• Appropriately stratifies groups of risk when applied to global analysis of surgical procedures

SSI / NNIS Index SSI / NNIS Index -- LIMITATIONSLIMITATIONS

• Incisional and Organ/Space SSIs are not separated

• Overall SSI rate (Incisional and Organ/Space) can be misleading in terms of clinical relevance

Thanks for your kind attention