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Transcript of Surgical Site Infection (SSI) - Ministry of Public 2).pdf  Surgical Site Infection (SSI) ......

1

Surgical Site Infection

(SSI)

Y. Rongrungruang, MD

Department of Medicine

Faculty of Medicine Siriraj Hospital

Mahidol University

Comprehensive training in Infection Control

15-26 December 2014

Amari Airport Hotel

Focus

Principles & Pathogenesis

Surveillance & Definitions

International guidelines

Conclusions

Focus

Principles & Pathogenesis

Surveillance & Definitions

International guidelines

Conclusions

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

Outcomes associated with SSI 211 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

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;253:10821093

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;253:108293

SS = surgical site

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;253:108293

SS = surgical site

Post-operative (immediate & late)

Hyperglycemia

Hypovolemia

Hypothermia

SS contamination post-op

Extra surgical site infections

Alexander JW, et al. Ann Surg 2011;253:108293

SSI risk factors & stage of operation

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

A 60 yr M patient presented with MSSA

bacteremia and septic arthritis Rt. Knee.

He also underwent TKR Rt. knee last 11

months.

Is this a PJI?

a. Yes, MSSA on top of prosthesis! b. Yes, this is < 1 yr post-op! c. No, this is > 90 days post-op!

Focus

Principles & Pathogenesis

Surveillance & Definitions

International guidelines

Conclusions

Site 2001 2006

LRTI 33.5 27.6

UTI 16.6 27.6

SSI 22.7 20.2

BSI 1.9 4.3

Common sites of HAI in surgical patients

Thailand 2001-2006 (%)

Danchaivijitr S, J Med Assoc Thai 2005 in 42 hospitals & national survey in 20 hospitals, 2006

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) 682686

Benchmarking our procedure-specific SSI

rates with those of resource-rich countries.

What ranking are we at?

a. About the same as those of them b. Variable between different SSI risk

categories c. At lower rankings

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

NNIS risk index category

Knight R, et al. Am J Surgery 182 (2001) 682686

NNIS wound class / risk index & SSI

Knight R, et al. Am J Surgery 182 (2001) 682686

Which of the followings may be the most

widely used SSI definitions?

A. NHSN

B. NICE

C. ACS

CDC, NHSN classification for surgical site infection

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

Focus

Principles & Pathogenesis

Clinical aspects & Antimicrobial Rx

Surveillance & Definitions

International guidelines

Conclusions

Which of the followings may be the latest

SSI guideline & recommendation?

A. SHEA 2008

B. NICE 2008

C. SHEA 2014

Guideline summary: Pre-op

Type SHEA 2014 NICE 2008 SHEA 2008

Glucose control I-II NA AII

Obesity I NA AII

Smoking I NA AII

Immunosuppressive III NA CII

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):S5161.

Risk Factors for and Recommendations to Prevent SSI

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

Risk Factors for and Recommendations to Prevent SSI

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

Guideline summary: Peri-op

Category SHEA 2014 NICE 2008 SHEA 2008

Carrier decolonization II Not routinely Unresolved

Hair removal II Recommended AI

WHO checklist I NA NA

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):S5161.

S. aurues nasal carriage & SSI Herwaldt LA. Surgery 2003;134:S2-9

Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362:9-17

Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362: 9-17

Preoperative hair removal & SSI, Shaving vs Clipping Tanner J, Woodings D, Moncaster K. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3

Time of clipping & SSI, day before vs on the day of surgery Tanner J, Woodings D, Moncaster K. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3

Risk Factors for and Recommendations to Prevent SSI

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

54

Chloroxylenol vs Iodophor/alcohol vs Chlorhexidine/alcohol

skin prep in foot & ankle surgery

Ostrander RV. J. Bone Joint Surg. Am. 2005;87:980-985

Chloroxylenol

Iodophor /alcohol

Chlorhexidine /alcohol

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

ChlorhexidineAlcohol vs PovidoneIodine Surgical Antisepsis

Darouiche RO, et al. N Engl J Med 2010;362:18-26.

Spanish RCT of Perioperative Low vs High Oxygen Supplement Belda FJ, et al. JAMA. 2005;294:2035-2042

Perioperative Normothermia vs hypothermia & SSI Kurz A, et al. N Engl J Med 1996;334:1209-15

Guideline summary: operative

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):25078.

Risk Factors for and Recommendations to Prevent SSI

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

ChlorhexidineAlcohol vs PovidoneIodine Surgical Antisepsis

Darouiche RO, et al. N Engl J Med 2010;362:18-26.

Risk Factors for and Recommendations to Prevent SSI

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

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):S5161.

Ventilation of