surgical site infections: known risk factors
TRANSCRIPT
Surgical Site Infections: Known Risk Factors
Lena M. Napolitano MD, FACS, FCCP, FCCMProfessor of Surgery, Chief, Acute Care Surgery
Chief, Surgical Critical Care Associate Chair, Department of Surgery
University of MichiganAnn Arbor, Michigan
Surgical Site Infections (SSI)Epidemiology
• Incidence: 2.6% of all operations• Third most common nosocomial infection
(14%–25%)• Most common nosocomial infection among
surgical patients (38%)• 7.3 mean additional postoperative days at
an additional cost of $3,152 per patient
Wilson. Am J Surg. 2003;186:35S-41S.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Surgical Site Infection (SSI)
• Laparotomy for intestinal resection for Crohn’s disease
• SSI at laparotomy site• Wound opened fully• Wound debridement• IV antibiotics
SSI: Laparoscopic Ventral Hernia Repair
• Recurrent ventral hernia
• Prior mesh repair with postop SSI
• Diabetic, CRI• Required mesh
removal
SSI: Laparoscopic Ventral Hernia Repair
• Mesh removal, I&D
• V.A.C. dressing• Partial closure• LOS 12 days
I&D = incision and drainage; LOS = length of stay;V.A.C. = Vacuum-Assisted Closure.
CDC Classification of SSI(within 30 days of OR, 1 year if implant)
• Incisional– Superficial
• involve only skin and subcutaneous tissue
– Deep• involve deep
soft tissues• Organ/space
– involving any part of anatomy other than incision opened or manipulated
Mangram et al. Guideline for Prevention of Surgical Site Infection. 1999, with permission.
Subcutaneous tissue
Deep soft tissue (fascia and muscle)
Organ/space
SkinSuperficial incisional SSI
Organ/space SSI
Deep incisional SSI
National Nosocomial Infections Surveillance System (NNIS)
3
2
1
0
Wound Class
Dirty-infected
Contaminated:Open, fresh, traumatic woundsinfected urine, bile
gross spillage from GI tract
Clean-contaminated:GI/GU tracts entered in a controlled manner
Lower
Higher
Clean
SSI RiskClassification
SSI – Risk StratificationNNIS Project (CDC)
• 3 independent variables associated with SSI risk:– ASA score > 2
• 1 to 5, from 1=“normal, healthy” to 5=“patient not expected to survive for 24 hours with OR without operation
– Contaminated or dirty/infected wound classification
• Clean, clean-contaminated, contaminated, dirty– Length of operation > 75th percentile
of the specific operation being performed
NNIS. CDC. Am J Infect Control. 2001;29:404-421.
ASA = American Society of Anesthesiology
NNIS = National Nosocomial Infection Surveillance
SSI: Wound Class versus NNIS Class
13.0%6.8%2.9%1.5%2.8%All
12.8%8.1%3.1%N/A7.1%Dirty infected
13.2%6.8%3.4%N/A6.4%Contaminated
N/A9.5%4.0%2.1%3.3%Clean contaminated
N/A5.4%2.3%1.0%2.1%Clean
NNIS 3NNIS 2NNIS 1NNIS 0AllWound Class
NNIS. CDC. Am J Infect Control. 2001;29:404-421.
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Incidence of Surgical Site
Infection
Thoracic Hemiorraphy Mastectomy VascularType of Operation
012 to 3
Percent of SSI by type of operation and number of NNIS risk data, January 1992 to June 2004. Patients with 2 or 3 risk factors are combined, as there
was no difference between 2 or 3 risk factors for these particular procedures.Am J Infect Control 2004;32:470-485.
Risk Factors for SSI
Mangram et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Patient FactorsEnvironmental Factors
Treatment Factors
Risk Factors for SSI:Patient Factors
• Diabetes• Under-nutrition• Extremes of age• Skin or nasal carriage of staphylococci• Obesity• Ascites• Peripheral vascular disease (especially for lower extremity surgery)• Postoperative anemia• Prior site irradiation• Recent operation• Remote infection• Skin disease in the area of infection (e.g. psoriasis)• Chronic inflammation• Hypocholsterolemia• Hypoxemia• Corticosteroid therapy (controversial)
SSI: Reanalysis of Risk Factors• 5031 noncardiac surgery patients (1995 – 2000)• NSQIP prospective data collection• All preoperative risk factors evaluated as independent
predictors of SSI• SSI occurred in 162 (3.2% of study cohort)• Gram-positive organisms most common• Risk factors for SSI by multiple logistic regression
analysis:– Diabetes (IDDM and NIDDM)– Weight loss (within 6 months)– Ascites– Low postoperative hematocrit
Napolitano LM et al. J Surg Res. 2002 Mar;103(1):89-95.
Abdominal Hernias: Risk Factors for SSI
• 487 abdominal wall hernia patients (1995 – 2000)• NSQIP prospective data collection• SSI occurred in 4.3% of study cohort• Recurrent hernia in 15.1%• Risk factors for SSI by multiple logistic regression
analysis:– Low preoperative serum albumin– COPD– Steroid use
Napolitano LM et al. J Surg Res. 2003 May;111(1):78-84.
Risk Factors for SSI:Patient Factors
• Diabetes• Under-nutrition• Extremes of age• Skin or nasal carriage of staphylococci• Obesity• Ascites• Peripheral vascular disease (especially for lower extremity surgery)• Postoperative anemia• Prior site irradiation• Recent operation• Remote infection• Skin disease in the area of infection (e.g. psoriasis)• Chronic inflammation• Hypocholsterolemia• Hypoxemia• Corticosteroid therapy (controversial)
Nasal Mupirocin and SSI• 4030 patients enrolled, 3864 ITT• Prospective randomized double-
blind placebo controlled trial, intranasal mupirocin
• 891 patients (23.1%) had S aureusin anterior nares
• 444 mupirocin, 447 placebo• S aureus SSI: 2.3% mupirocin vs.
2.4% placebo• Among patients with nasal carriage
of S aureus, nosocomial S aureusinfections occurred in 4% of mupirocin pts vs. 7.7% placebo (OR 0.49, 95% CI 0.25-0.92, P = .02)
ITT = intent to treat.Perl et al. N Engl J Med. 2002;346:1871-1877.
1
1.5
2
2.5
3
Mupirocin Placebo
SSI
0
2,5
5
7,5
10
Mupirocin Placebo
S.aureus
P = NS
P = .02
Mupirocin and SSI• Prospective randomized study, n=395, Japan• Abdominal digestive surgery• Mupirocin 30 mg intranasal preoperative – 3 days,
no placebo control• All postoperative infections evaluated• 21 gram-positive SSI (10 vs 11)• Pneumonia decreased (0 vs 5, P = .028),
4 of 5 patients with MRSA in culture• Intranasal mupirocin had no significant impact on
SSI after digestive surgery
Suzuki et al. Br J Surg. 2003;90:1072-1075.
Mupirocin and SSI: Orthopedic Surgery
• University of Leeds, UK• Perioperative nasal
mupirocin for 5 days• Shower or bath with 2%
triclosan preoperative• Point prevalence nasal
MRSA carriage decreased (P < .001) at six-month intervals post-intervention
Wilcox et al. J Hosp Infect. 2003;54:196-201.
3.36 months after
MRSA SSI per 1000 CasesTime Period
4
23
12 months later
6 months prior
8%10%7%20%23%38%
beforeImmediately
after 6 months 6 months 6 months 6 months
Risk Factors for SSI:Environmental Factors
• Inadequate disinfection/sterilization• Inadequate skin antisepsis• Hair removal with shaving• Inadequate ventilation• Contaminated medications
Risk Factors for SSI:Environmental Factors
• Inadequate disinfection/sterilization• Inadequate skin antisepsis• Hair removal with shaving• Inadequate ventilation• Contaminated medications
Mitka. JAMA. 2000;283:44-45.
Preventing Surgical Infection Is More Important Than Ever
• The advent of antibiotic-defying pathogens reinforces the need for vigilance regarding strict sterile technique in the operating suite for prevention of SSI
SSI Preventive Strategies
• Hand Hygiene– Single most important method to limit cross
transmission of nosocomial pathogens• Strict sterile technique in OR• Strict infection control practices
Alcohol based hand hygiene solutions
Quick Easy to use
Very effective antisepsis due to bactericidal properties of alcohol
Infection Control
Risk Factors for SSI:Environmental Factors
• Inadequate disinfection/sterilization• Inadequate skin antisepsis• Hair removal with shaving• Inadequate ventilation• Contaminated medications
Chlorhexidine Prep• Kills more bacteria than all iodophors• Rapid activity against gram-positive and
gram-negative bacteria • Persistent antibacterial activity— prevents regrowth
of microorganisms on the skin for at least 48 hours • One application of ChloraPrep exceeds FDA criteria
for a patient preoperative skin preparation antiseptic • Unlike povidone iodine, ChloraPrep (CHG) remains
active in the presence of blood, serum, and other protein-rich biomaterials
• 50% reduction in the incidence of catheter-related bloodstream infections compared to povidone iodine (as shown in randomized, controlled trials)
Chlorhexidine Prep• Prospective study, n=125, foot/ankle surgery• Randomized to 3 preps
– DuraPrep (0.7% iodine, 74% isopropyl alcohol)– Techni Care (3% chloroxylenol)– Chlora Prep (2% chlorhexidine, 70% alcohol)
• Quantitative cultures from surgical site• ChloraPrep most effective in bacterial elimination
Ostrander et al. J Bone Joint Surg Am. 2005;87:980-985.
Risk Factors for SSI:Environmental Factors
• Inadequate disinfection/sterilization• Inadequate skin antisepsis• Hair removal with shaving• Inadequate ventilation• Contaminated medications
Pre-operative shaving• Shaving the surgical site with a razor induces
small skin lacerations– potential sites for infection– disturbs hair follicles which are often colonized
with S. aureus– Risk greatest when done the night before– Patient education
• be sure patients know that they should not do you a favor and shave before they come to the hospital!
What worked to eliminate razors in the preoperative patients?
• Many hospitals physically removed razors from the operating rooms and holding areas
• Clippers had to be readily available and training provided
• Patient education regarding no shaving of surgical site preoperatively
Risk Factors for SSI:Treatment Factors
• Inadequate antibiotic prophylaxis• Hypothermia• Prolonged operative time• Emergency procedure• Open vs. laparoscopic surgery• Hyperglycemia• Drains• Prolonged preoperative hospitalization• Supplemental Oxygen
Risk Factors for SSI:Treatment Factors
• Inadequate antibiotic prophylaxis• Hypothermia• Prolonged operative time• Emergency procedure• Open vs. laparoscopic surgery• Hyperglycemia• Drains• Prolonged preoperative hospitalization• Supplemental Oxygen
Classen, et al. N Engl J Med. 1992;328:281.
Perioperative AntibioticsTiming of Administration
0
1
2
3
4
≤-3 -2 -1 0 1 2 3 4 ≥5
Hours from Incision
Infe
ctio
ns (%
)
14/369
5/6995/1009
2/180
1/81
1/411/47
15/441
Risk of SSI and Timing of Antimicrobial Prophylaxis
*p<0.0001 as compared to preoperative group.Classen DC, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992;326:281-286.
More than 2 h after skin
incision
Within 2 h after skin incision
(≤ 2 h before skin incision
> 2 hrs preop
Definition
44 (1.50)2847All
5.8*(2.4-13.8)
5.8* (2.6-12.3)
16* (3.30)488Postoperative
2.1(0.6-7.4)
2.4(0.9-7.9)
4 (1.40)282Perioperative
1.010 (0.59)1708Preoperative
4.3*(1.8-10.4)
6.7*(2.9-14.7)
14 (3.80)369Early
OR(95% CI)
RR(95% CI)
SSIn (%)
Patients(n)
Timing
Principles of Antibiotic Prophylaxis
Mangram et al. Infect Control Hosp Epidemiol. 1999;20:250-278.
Preoperative administration, serum levels adequate throughout procedure with a drug active
against expected microorganisms.
High Serum Levels1. Preoperative timing2. IV route3. Highest dose
of drug
During Procedure1. Long half-life2. Long procedure–
redose3. Large blood
loss–redose
Duration1. None after wound
closed2. 24 hours
maximum
www.medqic.org/sip
Bratzler et al. Arch Surg. 2005;140:174-182.
To reduce preventable surgical morbidity and mortality by 25% by 2010
www.medqic.org/scip
National Data Collection
• State-level baseline description from random sample of 788 cases per state, 2,965 hospitals
• Data collected from records by two professional clinical data abstraction centers
• Abstraction tool for hospitals is available and is JCAHO compatible
Bratzler DW et al. Arch Surg. 2005;140:174-182.
Surgical Infection Prevention (SIP):Results
205 (0.52)1,817 (4.7)
2 (0.01)1,461 (3.74)1,432 (3.66)
36 (0.09)
General ExclusionsSurgery of interest not performedInfection present pre-operativelyMissing antibiotic dates and timesPatient on antibiotics prior to admissionPatient on antibiotics for more than 24 hours pre-opOther
39,086 (100)Number of cases reviewedN (%)
34,133 (87.3)Cases eligible for analysis
Bratzler DW et al. Arch Surg. 2005;140:174-182.
Surgical Infection PreventionPerformance Stratified by Surgery1
55.7 (54.8-56.6)All Surgeries (11,220)
54.8 (51.4-58.3)Hysterectomy (432)46.0 (43.5-48.4)Colon (732)59.7 (58.3-61.2)Hip/knee (2,694)47.0 (44.0-49.9)Vascular (1,116)58.5 (56.8-60.2)Cardiac (3,287)
Antibiotic within 1 hour2
% (95% CI)Surgery (N)
1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.2 Reflects data for only 11 220 cases that had an explicitly documented incision time.
These results include patients who received vancomycin between one and two hours before the incision (N=213).
Cases were excluded from this performance measure if there was insufficient data to determine the time interval between prophylactic antimicrobial dose and surgical incision (N=22,902). In addition, patients undergoing colon surgery who received oral antimicrobials only for prophylaxis were excluded from the denominator (N=11).
Bratzler DW et al. Arch Surg. 2005;140:174-182.
Antibiotic Timing Related to Incision
2.7 1.24.3
20.3
56
2.8 1.4 0.9 0.9
9.6
0
10
20
30
40
50
60
> 240
240-1
8118
0-121
120-6
1
60-0
0-60
61-12
012
1-180
181-2
40
> 240
Minutes Before or After Incision
Perc
ent
Inci
sion
Bratzler DW et al. Arch Surg. 2005;140:174-182.
Surgical Infection PreventionPerformance Stratified by Surgery1
92.6 (92.3-92.8)All Surgeries (33,229)
90.2 (89.0-91.3Hysterectomy (2,395)75.8 (74.6-77.0)Colon (4,855)97.2 (96.7-97.5)Hip/knee (14,996)91.5 (90.5-92.5)Vascular (3,140)95.1 (94.7-95.6)Cardiac (7,843)
Correct Antibiotic% (95% CI)Surgery (N)
1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.
Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery.
Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination on timing (N=336). In addition, because there are no published guidelines for antimicrobial selection for beta-lactam allergic patients undergoing colon surgery or hysterectomy, cases with a documented beta-lactam allergy that did not pass the performance measure for these two operations were excluded from the denominator (N=568).
Bratzler DW et al. Arch Surg. 2005;140:174-182.
Surgical Infection PreventionPerformance Stratified by Surgery1
40.7 (40.2-41.2)
77.9 (76.3-79.5)40.8 (39.5-42.2)36.7 (35.9-37.4)45.2 (43.4-47.0)34.4 (33.4-35.5)
Antibiotic Stopped within 24 hours
% (95% CI)
40.4
21.457.039.042.740.9
Median Time to Discontinuation
(Hours)
All Surgeries (32,603)
Hysterectomy (2,569)Colon (4,911)Hip/knee (14,575)Vascular (2,913)Cardiac (7,635)Surgery (N)
1 All results are weighted to reflect adjustment based on the state-specific sampling scheme.
Antimicrobials were considered “prophylactic” if they were given before surgery, given intraoperatively, or given within 24 hours after the end of surgery.
Cases were excluded from this performance measure if no antimicrobials were administered, if no antimicrobials administered were considered “prophylactic,” or if there was insufficient data to make the determination of timing (N=344). Any patient with documentation in the medical record of an infection during surgery or within 48 hours after the end of surgery was excluded fromthe denominator (N=634). In addition, patients who underwent more than one surgical procedure of interest during the hospitalization were excluded from the denominator (N=552).
Bratzler DW et al. Arch Surg. 2005;140:174-182.
Discontinuation of Antibiotics
Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery.
26.2
10
22.6
6.2 6.32.2 2.7
9.3
14.5
40.7
50.7
73.379.5
85.8 88 90.7
0
20
40
60
80
100
12 or le
ss
>12-2
4
>24-3
6
>36-4
8
>48-6
0
>60-7
2
>72-8
4
>84-9
6
> 96
Hours After Surgery End Time
Perc
ent
0
20
40
60
80
100
Cum
ulat
ive
Perc
ent
National SIP Project
Conclusion:
“Substantial opportunities exist to improve the use of prophylactic antimicrobials for patients undergoing major surgery.”
Bratzler DW et al. Arch Surg. 2005;140:174-182.
* Based on medical record abstraction from the charts of patients discharged in the 1st quarter of 2004. Benchmark rates were calculated for all hospitals in the US based on discharges during calendar year 2003 using the Achievable Benchmarks of CareTM
methodology (http://main.uab.edu/show.asp?durki=14527).
Surgical Infection PreventionNational Baseline Performance, Qtr. 1, 2004
64.1
91
44.3
91.998.8
84.2
0
20
40
60
80
100
Antibiotics w/in 1 hour Correct Antibiotic Antibiotic DCed w/in 24hours
Perc
ent
National Ave.* National Benchmark
Surgical Infection Prevention ProjectNational Performance – 4th Quarter, 2004
*Denominator for the aggregate is 5,210
91
42
28
650
100All Three Measures*
Abx in 1 hour
Guideline Abx
Abx DCed in 24 h
*Denominator for the aggregate is 5,210
•Based on medical record abstraction from the charts of patients discharged in the 2nd quarter of 2005. Benchmark rates were calculated for all HQA reporting hospitals (N=1487) in the US based on discharges during the 2nd quarter of 2005 using the Achievable Benchmarks of CareTM methodology (http://main.uab.edu/show.asp?durki=14527).
Surgical Infection PreventionHospital Voluntary Self-Reporting, Qtr. 2, 2005
80
90
67.2
96.5 98.994.7
0
20
40
60
80
100
Antibiotics w/in 1 hour Correct Antibiotic Antibiotic DCed w/in 24hours
Perc
ent
Average* Benchmark
Surgical Infection Prevention ProjectMedicare Quality Improvement Community
Bratzler et al. Clin Infect Dis. 2004;38:1706-1715.
Risk Factors for SSI:Treatment Factors
• Inadequate antibiotic prophylaxis• Hypothermia• Prolonged operative time• Emergency procedure• Open vs. laparoscopic surgery• Hyperglycemia• Drains• Prolonged preoperative hospitalization• Supplemental Oxygen
Temperature Control
• Control:– routine
intraoperative thermal care
– mean temp 34.7°C on arrival to PACU
• SSI 19% (18/96)
• Treatment:– active warming to
maintain normothermia
– mean temp 36.6°C on arrival to PACU
• SSI 6% (6/104)• P = 0.009
Kurz A, et al. N Engl J Med. 1996.
Melling AC, et al. Lancet. 2001. (preop warming)
200 colorectal surgery patients
Risk Factors for SSI:Treatment Factors
• Inadequate antibiotic prophylaxis• Hypothermia• Prolonged operative time• Emergency procedure• Open vs. laparoscopic surgery• Hyperglycemia• Drains• Prolonged preoperative hospitalization• Supplemental Oxygen
Laparoscopic Surgery and SSI• Decreased incidence of SSI• For biliary, gastric, and colon surgery, subtract
one risk factor if procedure done laparoscopically• Laparoscopic appendectomy: decreased SSI if no risk
factors, but no difference if one risk factor present
Risk Factors for SSI:Treatment Factors
• Inadequate antibiotic prophylaxis• Hypothermia• Prolonged operative time• Emergency procedure• Open vs. laparoscopic surgery• Hyperglycemia• Drains• Prolonged preoperative hospitalization• Supplemental Oxygen
Perioperative Glucose Control• 1,000 cardiothoracic surgery patients• Diabetics and non-diabetics with hyperglycemia
Patients with a blood sugar > 300 mg/dL during or within 48 hours of surgery had more than 3X the likelihood of SSI!
Latham R, et al. Infect Control Hosp Epidemiol. 2001.
Risk Factors for SSI:Treatment Factors
• Inadequate antibiotic prophylaxis• Hypothermia• Prolonged operative time• Emergency procedure• Open vs. laparoscopic surgery• Hyperglycemia• Drains• Prolonged preoperative hospitalization• Supplemental Oxygen
Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infection
• Double-blind randomized controlled trial
• 3 hospitals (2 in Austria, 1 in Germany)
• N = 500, colorectal resection (cancer, inflammatory bowel disease)
• July 1996–October 1998
• FiO2 0.8 vs 0.3 during and 2 hours postoperative
• SSI during 14 days postoperative
Greif et al. N Engl J Med. 2000;342:161-167
Greif et al. N Engl J Med. 2000;342:161-167.
0.0113 (5.2)28 (11.2)SSI - no. (%)
PValue
Patients Who Received
80% Oxygen(N=250)
Patients Who Received
30% Oxygen(N=250)Characteristic
Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infection
SSI and the Routine Use of PerioperativeHyperoxia in a General Surgical Population:
A Randomized Controlled Trial
• Double-blind randomized controlled trial• Cornell University• N = 165, general surgery, general anesthesia• September 2001–May 2003• FiO2 0.8 vs 0.35 during and 2
hours postoperative• Overall SSI incidence = 18.1% (14 days)• No significant difference
Pryor et al. JAMA. 2004;291:79-87.
Supplemental Perioperative Oxygen and the Risk of Surgical Wound Infection:
A Randomized Controlled Trial
• Prospective, Randomized, Double Blind, Controlled Trial, n=300, age 18–80 years
• Elective colorectal surgery• 14 Spanish hospitals,
3/1/03 to 10/31/04• Randomized to 30% vs
80% FiO2
• FiO2 intraoperative and for 6 hours after surgery
Belda et al. JAMA. 2005;294:2035-2042
Belda et al. JAMA. 2005;294:2035-2042
Supplemental Perioperative Oxygen and the Risk of Surgical Wound Infection:
A Randomized Controlled Trial
Belda et al. JAMA. 2005;294:2035-2042
Bacteriologic Etiology of Infection
42
3127
15
50
10
20
30
40
50
MRSA CNS VRE
Taylor M and Napolitano L. Surg Infect. 2004;5:180-187
Perc
enta
ge In
fect
ed P
atie
nts
%
79 infected pts of 772 vascular surgery pts over 2 years (1/2000-12/2001)
MSSA Enterocococus
S aureus
MRSA in Cardiac Surgery– All 3,443 CABG patients received antimicrobial
prophylaxis– June 1997 through December 2000– Sternal SSI developed in 122 (3.5%)
• 71 (58.2%) were superficial SSI • 51 (41.8%) were deep SSI
– Gram-positive cocci most frequently recovered (81%)– S aureus most frequently isolated pathogen (49%)– Bacteremia in 18%, associated with deep SSI
(P = .002) and identified only in patients with S aureus infection
Sharma et al. Infect Control Hosp Epidemiol. 2004;25:468-471.
MRSA in Orthopedic SSI
• Prospective study; London, UK; 12 months, 2000• 1.6% of total with MRSA infection/colonization• Higher risk for MRSA infection
– Hip surgery– Emergency surgery for femoral neck fracture– Presence of wound was associated with
higher risk for MRSA infection• MRSA increased hospital LOS (88 vs 11d)• 41% MRSA patients still carried MRSA on discharge
Tai et al. Int Orthop. 2004;28:32-35.
Risk Factors for MRSA SSI
• Nasal or wound colonization with MRSA• Prior infection with MRSA• Prior antibiotic use• Previous cSSTI
Preventing Surgical Site Infections
Focus on modifiable risk factors
Streptococcus
Staphylococcus
SSI: Benchmarking for Prevention
• Prevention is key!!!– Antimicrobial prophylaxis – OR ventilation– Aseptic strict technique– Barriers, no shaving (clipping)– Surgical prep, surgical techniques– Normothermia– Glucose control– Supplemental oxygen
Clinicians hold the solution!
Campaign to Prevent
Antimicrobial Resistance
Centers for Disease Control and PreventionNational Center for Infectious Diseases
Division of Healthcare Quality Promotion
12 Steps to Prevent Antimicrobial Resistance Among Surgical Patients
• Step 1: Prevent surgical site infections (SSI)– Monitor and maintain normal
glycemia– Maintain normothermia– Perform proper skin preparation
using appropriate antiseptic agent and, when necessary, hair removal techniques
– Think outside the wound to stop surgical site infections