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ICPIC 2011 Abstract | 3M Health Care | Infection Prevention


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  • 1. 3M Health Care Reducing the risk ofSurgical Site Infections today: Successful Recent Strategies 3M Satellite Symposium, ICPIC 2011 Wednesday, 29th of June 15:00 - 16:30 3
  • 2. 3M Satellite Symposium, ICPIC 2011 Reducing the risk of Surgical Site Infections today: Successful Recent Strategies Table of Content Programme 3 Prof. Dr. Andreas Widmer 4-5 Prof. Dr. Andrea Kurz 6-7 Dr. Philip Roberts 8-9 Prof. Dr. Jan Kluytmans 10-112
  • 3. Programme 15:00 - 15:05 Introduction by Chairman Prof. Dr. Jan Kluytmans015:05 - 15:25 Surgical Site Infections Prof. Dr. Andreas Widmer, Switzerland The role of normothermia in Prof. Dr. Andrea Kurz, 15:25 - 15:45 prevention of Surgical Site Infections USA Dr. Philip Roberts, 15:45 - 16:05 Who cares wins UK Prevention of Surgical Site Infections: Prof. Dr. Jan Kluytmans, 16:05 - 16:25 How to become a champion The Netherlands 16:25 - 16:30 Symposium Conclusions Prof. Dr. Jan Kluytmans 3
  • 4. Prof. Dr. Andreas Widmer Board in Internal Medicine and Infectious Diseases Basel, Switzerland Current Responsibilities Deputy Chief Infectious Diseases Head Hospital Epidemiology Division of Infectious Diseases & Hospital Epidemiology University Hospital Basel, Switzerland Consultant for 9 Hospitals Lecturer for the Faculty of Medicine at the University Basel Associations - Regulatory Bodies • Advisory Board of the World Health Organization (WHO), Geneva Section: Patient Safety: Taskforce Hand Hygiene Section: Patient Safety: Taskforce Safe Surgery • Secretary of the Swiss Society for Infectious Diseases • Advisory Board of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) • Treasurer of the European Study Group for Nosocomial Infections (ESGNI) under the umbrella of ESCMID • Founding member of Swiss-NOSO • Guidelines Committee of the Society for Healthcare Epidemiology of America (SHEA) • Official representative ESCMID for IDSA and Editorial Advisory Board of the Journal “Clinical Infectious Diseases” of IDSA Main Work Interests Infection control and prevention of multi-resistant pathogens such as MRSA, surgical site infections, in particular implant-associated infections, and Clostridium difficile infections. Background Medical training on internal medicine, microbiology and infectious diseases at the University of Basel, Switzerland. Master of Science (Epidemiology) at the University of Iowa, USA.4
  • 5. AbstractSurgical Site InfectionsSurgical site infections are the most common nosocomial infections in surgical patients. They lead to increased morbidity and mortality and on average double the cost for medical care. Therefore, prevention has become paramount not only to decrease morbidity and mortality, but also to decrease cost for healthcare. In the last decade, many landmarks studies have been published that decrease the incidence of post operative surgical site infections (SSI). The studies included prevention by interoperative heating of the patients to avoid low body temperatures, control of glucose levels and other interventions to improve support if care. More recently, targeted interventions to decrease the incidence of SSI have been developed. The disinfection of the surgical sites with chlorhexidine/alcohol has been shown to be most superior in terms of infections compare to PVP iodine without alcohol. This study has received great attention since the disinfection of the surgical site was regarded as not very important in the past. Now, it is proven that it is a definite risk factor for surgical site infections. Our own study, Tschudin and Widmer, Annals of Surgery 2011 (in press), has shown that PVP iodine in alcohol reduces the bacterial load in over 1’000 patients to a level that the residual bacteria are not any more associated with the incidence of surgical site infections. However, at this time the clinical data for disinfection of the surgical sites with chlorhexidine are superiorcompare to PVP iodine. Our own data clearly indicate that PVP iodine in alcohol is equally effective as chlorhexidine in alcohol, but a randomized crossover clinical trial is needed to ultimatively resolve this clinically important question. The Dutch colleagues have studied the colonization of Staphylococcusaureus and the incidence of SSIs for more than 15 years. Observational studies, case control studies and most recently a randomized control clinical trial clearly show that decolonization of patients for electivesurgery decreases or even eliminates the incidence of Staphylococcus aureus surgical site infections. The decolonization procedure is simple: Application of mupirocin in the nose and chlorhexidine mouth rinse 5 days and shower before prior to surgery is a cheap, simple and very effective method to decrease SSIs. Punctures in the glove are also associated with the incidence of SSIs and (Misteli et al Archives of Surgery 2009), demonstrated that the relative risk is more than four times higher for SSIs if an interoperative puncture of the surgical glove is detected. This effect wins if appropriate antimicrobial prophylaxis is given. The timing of the antimicrobial prophylaxis is crucial: Currently WHO recommends antimicrobial prophylaxis in implant surgery and clean-contaminated surgery 0 to 60 minutes prior to incision. Our own data indicate that this window of opportunity is even smaller: Our own data show that 30 to 60 minutes prior to incision is optimal. These observations also supported by pharmacokinetic data that an application of an antibiotic 1 minute to prior to incision will never succeed to lead to appropriate antimicrobial concentration at the site of incision. The main problem today is to ensure compliance with this procedure which is very difficult in the clinical setting. Data generated by WHO as well by the Dutch surgeons show that the use of checklists dramatically can decrease site effects of surgical interventions includinginfections, just by using simple routine checklists. In conclusion a lot of clinically very important information has been generated during the last decade, but very few hospitals have applied this new knowledge into routine clinical practice. Application of science will be a major challenge for the next decade. 5
  • 6. Prof. Dr. Andrea Kurz MD, Outcome Research - Cleveland Clinic Cleveland, USA Current responsibilities Guiding and organizing clinical research and outcomes research in the Anesthesiology Institute at the Cleve- land Clinic as well as in the Outcomes Research Consortium. Associations and Regulatory Bodies • American Society of Anesthesiologists • Missouri Society of Anesthesiologists • Association of University Anesthesiologists • Austrian Society of Anesthesiologists • European Society of Anesthesiologists • International Anesthesia Research Society • Wound Healing Society • Society for Ambulatory Anesthesia • Swiss Society of Anesthesiology • International Society for the Perioperative Care of the Obese Patient Main Work Interest Evaluating interventions in the pre, intra and postoperative period which might effect long term outcomes of anesthesia and surgery. Main interventions: temperature management, fluid management, anti-inflamma- tory interventions such as regional anesthesia, lidocaine, ketamine, beta-blockers, alpha agonists, steroids, blood management. Main outcomes: postoperative 30-day complications, acute and chronic pain, postop- erative cognitive dysfunction and cancer recurrence. Background M.D., University of Vienna 1979-1986 Postdoctoral Fellow, Department of Anesthesiology and General 1987-1988 Intensive Care, University of Vienna; Anesthesia Internship, Hospital of St. Pölten, Austria 1988-1990 Anesthesia Residency, Department of Anesthesiology and General Intensive Care, University of Vienna 1990-19946
  • 7. AbstractThe role of normothermia in prevention ofSurgical Site InfectionWound infections are common and serious complications of anesthesia and surgery. For example, the wound infection risk in patients undergoing colon surgery is approximately 10%1. Surgical wound infections prolong hospitalization by 5 to 20 days per infection, and substantially increase costs.Hypothermia may facilitate perioperative wound infections in two ways. First, intraoperative hypothermia triggers thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension in humans. Wound infection risk correlates with subcutaneous oxygen tension1. Second, mild core hypothermia directly impairs immune function including T-cell-mediated antibody production and „non-specific“ oxidative bacterial killing by neutrophils. Furthermore vasoconstriction-induced tissue hypoxia also impairs wound healing by reducing oxygen supply to the wound. The first few hours following bacterial contamination, which essentially reflects the perioperative period, constitute a decisive period during which infection is established. The effects of antibiotic administration and of hypoperfusion are especially important during this period. Similarly, maintenance of perioperative normothermia is essential during this time period to avoid hypothermia related postoperative complications. Most surgical patients become 2-3°C hypothermic, if active warming is not used. This is due to the combination of anesthetic-induced impairment of thermoregulatory control and exposure to a cool operating room environment. Only approximately 2°C core hypothermia is associated with major complications such as coagulopathy and myocardial adverse events. Most importantly 2°C of core hypothermia triple the incidence of surgical wound infection following colon resection and other abdominal surgeries2,3. This is clinically important as indicated by the fact that patients with wound infections on average have longer duration of hospitalization than patients without infection2. Many warming devices are currently available for maintenance of perioperative normothermia and in many hospitals active warming has become clinical standard. Forced air warming has been proven a simple and effective method of warming patients in the perioperative period. Even though active warming after induction of anesthesia significantly reduces postoperative hypothermia, many patients become slightly hypothermic after induction of anesthesia. This is due to anesthetic induced redistribution of body heat. Pre-warming (30-60 minutes before induction of anesthesia) halves redistribution hypothermia4. Thus, the combination of pre-warming and intraoperative active warming is the most efficient method of maintaining normothermia during the perioperative period. and has most potential to decrease hypothermia-related postoperative complications such as surgical wound infections.References1. Greif R, Akc ̧a O, Horn EP et al. Supplemental perioperative oxygen to reduce the incidence of surgical wound infection. Outcomes Research Group. New England Journal of Medicine 2000; 342: 161–1672. Kurz A, Sessler DI, Lenhardt RA, and the Study of Wound Infection and Temperature Group. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med 1996;334:1209-1215.3. Melling AC, Ali B, Scott EM et al. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet 2001; 358: 876–880.4. Sessler DI, Schroeder M, Merrifield B et al. Optimal duration and temperature of pre-warming. Anesthe- siology 1995; 82: 674–681. 7
  • 8. Dr. Philip Roberts Consultant Orthopaedic Surgeon Stoke on Trent, UK Current Responsibilities Dr. Roberts is clinical lead for the fractured neck of femur specialist unit at the University Hospital of North Staffordshire, managing over 600 NoF (Neck of Femur) patients. His elective list is 400 primary THR (Total Hip Replacement) per year. As Chair of the Trust resuscitation committee he is responsible for equipment, protocols, service and training. Dr. Roberts is also standing member of the UHNS Clinical Governence Committee. Associations - Regulatory Bodies • British Medical Association • Royal College of Surgeons of England • British Orthopaedic Association • British Hip Society Main Work Interests Dr. Roberts’ work is focused on the hip. Passionate about infection prevention, Dr. Roberts believes if man- aged aggressively this is the most important avoidable complication for surgical patients. Background Dr. Roberts completed his first degree in Infection and Immunity in 1989 and qualified from St. Mary’s Hospital in 1992 in London. He started Orthopaedics at Oxford and gained a registrar position on the Stoke/Oswestry rotation, finishing with a fellowship in Cardiff. He was awarded The Royal College of Surgeons Lamming-Evans Fellowship for his research into fragility fractures, 1996. He was presented the Walter Mercer Gold Medal from the Combined Orthopaedic Col- leges 2002. Dr. Roberts was appointed Consultant Orthopaedic Surgeon at the UHNS 2003. He was appointed NHS Institute Clinical Lead for service improvement for fractured neck of femur patients and Vice-lead for total knee and hip replacement patients in 2008-10. 8
  • 9. AbstractWho Cares WinsCare pathways regulate and make excellence the default for the standard of any surgical patient’s care. The most challenging complication affecting both low case for mortality and morbidity is infection. Ortho-paedics hip surgery with both elective and emergency trauma patients is the most sensitive barometer of how your hospital is performing. Care is a chain and it is incumbent upon us all to find and improve the weak links. The presentation discusses the 8 years experience of the University Hospital of North Stafford-shire. How cumulative, apparently small changes, surmount to a significant reductions in wound infection. The battle to control MRSA in a patient population in which 20% are chronic carriers is presented. Avoiding the complication of Clostridium difficile and remembering the adage “First Do No Harm” is a key topic. Does this translate in both elective and emergency practice? Finally, good care costs less, how we can use quality to support a hospital’s finances. 9
  • 10. Prof. Dr. Jan Kluytmans MD, PhD, Amphia Hospital Breda, Netherlands Current Responsibility Dr. Kluytmans is a Professor of Medical Microbiology and Infection Control at the VU University Medical Center in Amsterdam and also serves as a consultant microbiologist and Head of infection control at the Amphia Hospital in Breda, Netherlands. Associations - Regulatory Bodies • Chair of the National Working Group on Infection Control • Member of the Scientific Affairs Committee of ESCMID • Member of the Publications Committee of SHEA • Member of The National Health Council Committee on MRSA • Member of the executive board of AAIDF • Member European Expert Group on MRSA, ECDC • Faculty Member European Course on Hospital Epidemiology and Infection Control (SHEA/ESCMID) • Faculty Member ASM Conference on Emerging Technologies of Medical Importance for the Diagnosis of Infectious Diseases and the Detection of Pathogenic Microbes Main Work Interests Dr. Kluytmans is specialised in the field of infection control and focuses on the epidemiology and control of nosocomial infections. He has a special interest in Staphylococcus aureus, surgical site infections, catheter-related infections and antimicrobial resistance. Background Dr. Kluytmans did his medical training and subsequent specialization in Clinical Microbiology at Erasmus Medical University in Rotterdam. His PhD thesis (October 1996) was called: Nasal carriage of Staphylo- coccus aureus: The key to preventing Staphylococcal disease. In 1995 he started working at the Amphia Hospital in Breda as a consultant microbiologist and in 2006 he accepted a position at The VU University medical Center in Amsterdam as a Professor of Microbiology and Infection Control. His current projects focus on the epidemiology and control of methicillin resistant S. aureus, the control of antimicrobial resistance and the control of nosocomial infections.10
  • 11. AbstractPrevention of Surgical Site Infections:How to become a championNosocomial infections are frequent complications of healthcare all around the world. Especially, surgical site infections are serious problems that affect patient safety.Despite the availability of extensive guidelines and protocols these infections are insufficiently controlled in most healthcare institutes. One important issue is the deficient implementation of the many recommendations. Recently, bundles of care have been proposed to facilitate the implementation of patient safety measures. In The Netherlands a surgical “bundle of care” has been proposed as part of a national patient safety program. This bundle consists of perioperative normothermia, preoperative hair removal, perioperative antibiotic prophylaxis and limiting the number of door openings. This bundle was implemented in the Netherlands as part of a nationwide project. The average compliance with the bundle at the start of the project in all hospitals that participated was below 5%. In our hospital compliance has meanwhile improved to 70%. This was associated with a marked reduction of the SSI-rate. The hurdles and successes to improve bundle compliance are presented. 11
  • 12. ,Visit us on stand no. 19Hall 2 Notes 3 3M Health Care Western Europe Hammfelddamm 11 41453 Neuss - Germany Phone +49 (0)2131 14 3000 Fax + 49(0)2131 14 4443 3M and Tegaderm are trademarks of the 3M Company. © 3M 2011. All rights reserved. 12