surgical site infection (ssi) - ministry of public...

Surgical Site Infection

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

• 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 • 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

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

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

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

SS = surgical site

Post-operative (immediate & late)

Hyperglycemia

Hypovolemia

Hypothermia

SS contamination post-op

Extra surgical site infections

SSI risk factors & stage of operation

Types (mean) Songkla Thailand USA

Extra cost

(bahts)

43,658 5,192

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!

• 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) 682–686

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) 682–686

NNIS wound class / risk index & SSI

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

• Clinical aspects & Antimicrobial Rx

• 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

NICE clinical guideline 74 guidance.nice.org.uk/cg74

Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.

Risk Factors for and Recommendations to Prevent SSI

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

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

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

Chlorhexidine–Alcohol vs Povidone–Iodine 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

Mangram AJ, et al. Infect Control Hosp Epidemiol1999;20(4):250–78.

Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis

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

Guideline summary: OR characters

Ventilation III NA CI

Traffic III NA BII

Environment cleaning III NA BIII

Sterilization of devices II NA BI

Ventilation of Surgery & Crititcal care, Design parameter

ANSI/ASHRAE/ASHE Standard 170-2008, addendum

Guideline summary: Surgical prophylaxis

Timing < 30-60 min II Recommended AI

Antimicrobial of choices II Recommended AI

Duration of prophylaxis I NA AI

Antimicrobial prophylaxis in clean surgery

Timing of Antibiotic Prophylaxis & SSI following Total Hip Arthroplasty Van Kasteren ME, et al. Clin Infect Dis 2007 : 44

1 dose vs 7 doses of perioperative antimicrobial prophylaxis

in elective gastric cancer surgery.

Mohri Y, et al. Brit J Surgery 2007; 94: 683–688

Prolonged ( > 48 h) surgical antimicrobial prophylaxis &

antimicrobial resistant organisms. Harbath S. circulation 2000;101;2916-2921

Bone5: 7%–13%

Vancomycin Penetration

Sternal Bone1: 57%

Heart Valve4:

CNS: <10%

Fat4: 14%

Muscle4: 9%

Epithelial lining fluid3:

Lung tissue2: 17%–24%

1. Massias L et al. Antimicrob Agents Chemother. 1992;36:2539-2541; 2. Cruciani M et al. J Antimicrob Chemother.

1996;38:865-869. 3. Lamer C et al. Antimicrob Agents Chemother. 1993;37:281-286; 4. Daschner FD et al. J

Antimicrob Chemother. 1987;19:359-362; 5. Graziani AL et al. Antimicrob Agents Chemother. 1988;32:1320-1322.

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

Bratzler DW. Surgical Infection Prevention Guidelines Writer Workgroup The American Journal of Surgery 2005:189;395–404 Clinical Infect Diseases 2004;38:1706-15

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)

Preventing SSI : Antimicrobial choice & procedure

Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283

Preventing SSI : Antimicrobial & dosing

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)

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

Establishing surgical prophylaxis ASP

• Assess the motivations

• Ensure accountability and leadership

• Set up structure and organization

• Define priorities, how to measure outcome

• Identify effective interventions

• Identify key measurements

• Educate and Train

• Communicate

Surgical Antimicrobial Prophylaxis Form

Given the evidence of ertapenem vs

comparator in preventing colorectal SSI,

general surgeons in your center considering

replace “cefoxitin” with “ertapenem” for colorectal surgical prophylaxis.

A. What’d be the evidence of erta vs cefox

against colorectal SSI?

B. Any drawback of using erta vs cefox?

C. What’d you recommend in this regard?

Itani K, et al N Engl J Med 2006;355:2640-51

In a urology unit, there is a growing

concern of ESBL-producing

Enterobacteriaceae SSI,

“cefazolin” switched to “fosfomycin” for invasive urological surgical prophylaxis.

A. What’d be the evidence of fosfo vs cefa

against SSI?

B. Any drawback of using fosfo vs cefa?

Ishisaka K, et al. J Infect Chemother (2007) 13:324–331

In your center with busy CVT services, the

unit staffs have been switching “cefazolin”

to “vancomycin” as a routine surgical

prophylaxis for CABG, given the concern of increasing incidence of MRSA SSI.

A. What’d be the evidence of vanco vs cefa

against MRSA SSI?

B. Any drawback of using vanco vs cefa?

A diabetic pt with high risk TKR

A 75-yr-old female patient with DM

• 2005 Dec : TKR rt. knee

• 2006 June : MSSA septic arthritis rt.knee, prosthesis removal & complete antimicrobial therapy

• 2006 November : scheduled for elective TKR rt. knee

Investigation results

• Hct 36% WBC 8,000/mm3, PMN

70% L30%, plt 298,000/mm3

• ESR 24 mm/h

• FBS 120, HbA1C 6.5 %, BUN 24, Cr

1.5 mg/L, Chest X-ray & UA WNL

Your choice of surgical prophylaxis?

A. Vancomycin

B. Cefazolin

C. Fosfomycin

• Nasal mupirocin & bodywash with 4%

chlorhexidine bath

• 2006 November : elective TKR rt. knee

with perioperative cefazolin x 48 hrs

• Good post-operative recovery up to 3

years of follow-up

• 2006 November: elective TKR rt. knee

• 2009 December readmission :acute

monoarthritis rt. knee

• Jt. fluid : WBC & PMN elevated

• Culture + for group A streptococci

% (no/total)

Chlorhexidine 2.8 (5/185)

Povidone iodine 3.6 (7/195)

SSI reduction 23.4 (2/195)

Type of antiseptic & SSI in surgery unit

Jan – Nov 2007

Hair removal technique & SSI in surgery unit

Jan – Nov 2007

Category SSI rate

% (no/total)

Shaving 4.1 (13/320)

Non-shaving 1.8 (2/111)

Risk reduction 53.4 (11/320)

year 2550 2551 (11 mo)

total patients 7,877 6,602

SSI no. (%) 27 (3.4) 12 (1.8)

Annual SSI rate

Thai periorbital flora & antiseptics

N = 51 (no of pt)

Type coag-

Dipthe

Gr-rod

no Rx 43 20 9 7

CHG Rx 40 14 4 6

PID Rx 7 1 0 0

Rongrungruang Y, et al. J Med Assoc Thai 2005

Prophylactic antibiotics prescribing practices

Prescribing Practice N (%)

Number of Antibiotic (420 patients) 1 antibiotic > 2 antibiotics

301 (71.7) 119 (28.3)

Timing of Initiation of the First Antibiotic (420 patients)

Before Operation

- at OR prior to incision 253 (60.2)

- at Ward 49 (11.7)

After Incision in OR 72 (17.1)

After Operation 46 (11.0)

Timing of Antibiotic prior to incision (253 patients)

within 30 minutes 184 (72.7)

31 to 60 minutes 59 (23.3)

31 to 120 minutes 10 (4.0)

Prophylactic antibiotics prescribing practices (cont.)

Type of Antibiotic (580 antibiotics & 420 patients)

Cefazolin 198 (47.1)

Cetriaxone 60 (14.3)

Metronidazole 48 (11.4)

Fosfomycin 47 (11.2)

Cefoxitin 36 (8.6)

Clindamycin 24 (5.7)

Ampicillin + Sulbactam 18 (4.3)

Ciprofloxacin 15 (3.6)

Cefotaxime 14 (3.3)

Cefepime 13 (3.1)

Amoxicillin + Clavulanate 12 (2.9)

Meropenem 11 (2.6)

Others 84 (20.0)

Duration of Antibiotic Prophylaxis in Before Operation Group (302 patients)

Single dose 47 (15.6)

1 day 6 (2.0)

2 days 81 (26.8)

> 2 days 168 (55.6)

Duration of Antibiotic Prophylaxis (420 patients)

Single dose 60 (14.3)

1 day 17 (4.0)

2 days 127 (30.2)

> 2 days 216 (51.4)

Department/Devision

Type of Antibiotic

within 30 minutes

31-60 minutes

61-120 minutes

Cardio/CVT cefazolin 18 6 2 26

maxipime=cefepime 3 0 0 3

clindamycin 1 1 0 2

fosfomycin 1 0 0 1

gentamicin 0 0 1 1

cefepime 1 0 0 1

Total 24 7 3 34

% 70.6 20.6 8.8 100.0

Neuro fosfomycin 16 12 1 29

cefazolin 7 2 1 10

unasyn=ampi+sulbac 3 3

vancomycin 1 1

gentamicin 1 1

Total 26 16 2 44

% 59.1 36.4 4.5 100.0

Uro cetriaxone 11 1 12

cefoxin 1 1

cefotaxime 1 1

ciprofloxacin 1 1

Total 13 2 15

% 86.7 13.3 100.0

Vascular cefazolin 4 3 7

clindamycin 1 0 1

Total 5 3 8

% 62.5 37.5 100.0

Department/

Devision Type of Antibiotic

within 30

minutes

61-120

minutes Total

Department/ Devision

Type of Antibiotic within 30 minutes

31-60 minutes

61-120 minutes

H&Neck cefazolin 5 1 6

unasyn=ampi+sulbac 2 1 3 augmentin 1 1 2 cetriaxone 1 1

clindamycin 1 1 Total 9 4 13 % 69.2 30.8 100.0

Plastic cefazolin 1 1

unasyn=ampi+sulbac 1 1 Total 2 2 % 100.0 100.0

31-60 minutes 61-120 minutes

Gen surg metronidazole or flagyl 15 1 2 18 cefazolin 10 3 13 cetriaxone 9 1 1 11 cefotaxime 4 1 5

unasyn=ampi+sulbac 1 2 3 ciprofloxacin 1 2 3 claforam=cefotaxime 1 1 1 3 ampicilin 1 1 gentamicin 1 1 claroxim 1 1 Total 44 11 4 59 % 74.6 18.6 6.8 100.0

Ortho cefazolin 33 13 2 48 clindamycin 3 1 4 zinnacef=cefuroxime 1 2 3 unasyn=ampi+sulbac 2 2 fosfomycin 1 1 2 cetriaxone 1 1 Total 40 18 2 60 % 66.7 30.0 3.3 100.0

Gynae cefoxin 12 12

cefoxitin 9 9 cefazolin 6 6 cetriaxone 2 2 clindamycin 1 1 metronidazole or flagyl 1 1 ampicillin 1 1 cefotaxime 1 1 Total 33 33 % 100.0 100.0

OB cefazolin 2 1 3 cefoxin 1 1 Total 3 1 4 % 75.0 25.0 100.0

ENT cefazolin 2 2 clindamycin 1 1 Total 2 1 3 % 66.7 33.3 100.0

31-60 minutes

61-120 minutes

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