Ssi ;problems&prevention

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  • What is OT? Surgery? All entities can participate on a limited basis. Hospitals and outpatient dialysis.

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  • 1. 03/28/11 08:13 AM Surgical Site Infections: Problems and Prevention. Dr. P.S.Reddy, MD De partment of Microbiology & Infectious Diseases NARAYANA MEDICAL COLLEGE.
  • 2. Objectives
    • Provide overview of epidemiology of surgical site infections (SSI)
    • To discuss SSI prevention strategies
    • Provide overview of HICPAC/CDC process for
    • developing recommendations for prevention of healthcare-associated infections
    03/28/11 08:13 AM
  • 3. Why SSI as a Topic?
    • 25% of nosocomial infections are SSI.
    • Long hospital stay and increased costs.
    • SSI leads to blood stream infections in 5% of cases.
    • Pre and post operative measures responsible for existing of resistant microbial flora .
    03/28/11 08:13 AM
  • 4. SSI definition
    • Infection occurs within 30 days after the surgery if no implant is left in place or within one year if implant is in place and the infection appears to be related to the surgery.
    03/28/11 08:13 AM
  • 5. Criteria for Defining SSI
    • Purulent drainage.
    • Organisms isolated from fluid or tissue from
    • the superficial incision.
    • At least one of the following signs or symptoms of infection: Pain or tenderness, localized swelling, redness.
    03/28/11 08:13 AM
  • 6. Do not report the following conditions as SSI:
    • Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration).
    • Infection of an episiotomy or newborn circumcision site.
    • Infected burn wound.
    • Incisional SSI that extends into the facial and muscle layers.
    03/28/11 08:13 AM
  • 7. Public Health Importance of SSI.
    • SSI rate is 3.03% in clean surgeries (drain not used) and 22.41% in clean-contaminated (drain used) surgeries.
    • The most common isolate was  Staphylococcus aureus  followed by  Pseudomonas aeruginosa .
    03/28/11 08:13 AM ( SP Lilani, et al. IJMM 2005   23: 4: 249-252)
  • 8. 03/28/11 08:13 AM
    • In India >50 million inpatient surgical
    • procedures each year.
    • 7-8.3% complicated by SSI.
    • SSIs second most common nosocomial
    • infection (24% of all nosocomial infections)
    • Cost Rs.10,000- 1.5 lakhs/ infection (TOTAL:
    • Rs.7600 - 1,10,000 crores/year)
    (Kirkland KB et al, Infect Control Hosp Epidemiol. 1999 Nov;20(11):725-30).
  • 9. 03/28/11 08:13 AM Cross Section of Abdominal Wall Depicting CDC Classification on SSI(1992).
  • 10. Source of SSI Pathogens
    • Endogenous flora.
    • Operating theater environment
    • Hospital personnel.
    03/28/11 08:13 AM
  • 11. 03/28/11 08:13 AM Microbiology of SSI 1986-1989 1990-1996 Staphylococcus aureus 17% Coagulase neg. staphylococci 12% Escherichia coli 10% Enterococcus spp. 8% Pseudomonas aeruginosa 8% Staphylococcus aureus 20% Coagulase neg. staphylococci 14% Escherichia coli 8% Enterococcus spp. 12% Pseudomonas aeruginosa 8%
  • 12. Microbiology of SSIs
    • Unusual pathogens
    • • Rhizopus oryzea - Elastoplast adhesive
    • bandage
    • • Clostridium perfringens - Elastic bandages
    • • Rhodococcus bronchialis - Colonized health care
    • personnel
    • • Legionella pneumophila - Tap water
    • • Pseudomonas multivorans - Disinfectant solution
    03/28/11 08:13 AM
  • 13. Pathogenesis of SSI
    • Relationship equation Dose of bacterial contamination X Virulence Resistance of host SSI Risk
    03/28/11 08:13 AM
  • 14. SSI Risk Factors
    • Age
    • Obesity
    • Diabetes
    • Malnutrition
    • Prolonged Pre-O stay
    • Systemic steroid use
    • Nicotine use
    • Hair removal/Shaving
    • Duration of surgery
    • Surgical technique
    • Presence of drains
    • Inappropriate antimicrobial prophylaxis
    03/28/11 08:13 AM
  • 15. Are they Preventable?. If so How?. 03/28/11 08:13 AM
  • 16. Antimicrobial Prophylaxis (AP) in SSI.
    • Refers to very brief course of an antimicrobial agent initiated just before the operation.
    • Appropriate administration of AP associated with a 5-fold decrease in SSI rates.
        • Post op AP (3-24 hrs after incision): 3.3%
        • Peri op AP (< 3 hrs after incision): 1.4%
        • Pre op AP (<2 hrs before incision): 0.6%
    03/28/11 08:13 AM Prosepective study of 2,847 cases Classen, 1992 (NEJM 326:281-286)
  • 17. Impact of Prolonged Surgical AP
    • SSI Incidence
    • • < 48 hrs group: 8.7% (131/1502)
    • • >24 hrs group: 8.8% (100/1139)
    03/28/11 08:13 AM (Prosepective study of 2,641 cases Classen, 1992 (NEJM 326:281-286)
  • 18. Enhanced Perioperative Glucose Control in Diabetic Patients
    • • Subcutaneous Insulin: 2.0%
    • • IV Insulin group: 0.8%
    03/28/11 08:13 AM Furnary AP; Ann Thorac Surg, 2000 • Glucose levels < 200 mg%
  • 19. Supplemental Perioperative O 2
    • Study done on Colorectal surgery (N=500)
    • 30% vs 80% inspired oxygen during and up to hours after surgery.
    • RESULTS: SSI incidence 5.2% (80% O 2 ) vs 11.2% (30% O 2 ).
    03/28/11 08:13 AM (Greif, R, et al , NEJM, 2000)
  • 20. 03/28/11 08:13 AM Most studies shows antiseptic showering decreases colony counts. No Shower Shower Cruse, 1973 2.3% 1.3% Ayliffe, 1983 4.9% 5.4% Rooter, 1988 2.4% 2.6% Pre-operative Antiseptic Showers/Baths
  • 21. 03/28/11 08:13 AM Seropian, 1971 Method of hair removal Razor : 5.6% Depilatory : 0.6% No hair removal : 0.6% Timing of hair removal Shaving immediately before : 3.1% Shaving  24 hours before : 7.1% Shaving >24 hours before : 20 % Pre-operative Shaving / Hair Removal
  • 22. 03/28/11 08:13 AM Multiple studies show Clipping immediately before operation associated with lower SSI risk than shaving or clipping the night before operation Pre-operative Shaving/Hair Removal
  • 23. Surgical Attire
    • Scrub suits
    • Cap/hoods
    • Shoe covers
    • Masks
    • Gloves
    • Gowns
    03/28/11 08:13 AM
  • 24. Surgical technique
    • Removing devitalized tissue
    • Maintaining effective hemostasis
    • Gentle handling tissues
    • Eradicating dead space
    • Appropriate usage of drains and suture material .
    03/28/11 08:13 AM
  • 25. Surgery Room Ventilation
    • Temperature : 68 o -73 o F.
    • Humidity : 30%-60%
    • Air movement : From “clean to less clean” areas .
    03/28/11 08:13 AM (American Institute of Architects, 1996)
  • 26. Role of HEPA filters in Preventing SSI
    • Most studies involve only orthopedic operations.
    • Lidwell et al: 8,000 total hip and knee replacements
    • HEPA filters : SSI rate  3.4% to 1.6%
    • HEPA filters + AP : SSI rate  3.4% to 0.7%
    03/28/11 08:13 AM
  • 27. Post operative care
    • Care of the wound & drain.
    • Timely dressing of the wound.
    • Hand- washing with Chlorhexidine-alcohol.
    03/28/11 08:13 AM
  • 28. ? BURDEN OF SSI.
    • Emergence of ANTIBIOTIC RESISTANCE
    • strains of bacteria.
    03/28/11 08:13 AM
  • 29. CDC Surveillance Systems 03/28/11 08:13 AM 1999-2004 1970-2004 1996-present NNIS DSN NaSH Nosocomial infections in critical care and surgical patients Bloodstream and vascular access infections in dialysis outpatients Exposure to blood borne pathogens; TB skin testing and exposure; Vaccine: history, receipt, and adverse events
  • 30. What Is NHSN? N NIS NaS H D SN 03/28/11 08:13 AM Integration of CDC’s three patient and healthcare personnel surveillance systems
  • 31. NHSN Premises
    • Maintain the goals of predecessor systems
    • Minimize data collection and manual data entry burden
      • Streamline existing surveillance protocols
      • Increase capacity for capturing electronic data (e.g., Laboratory information systems, operating room, pharmacy, clinical, administrative databases)
    • Extensible web-based application
    03/28/11 08:13 AM
  • 32. How do we develop policy to prevent SSI? 03/28/11 08:13 AM
  • 33. Healthcare Infection Control Practices Advisory Committee (HICPAC) 03/28/11 08:13 AM
  • 34. Healthcare Infection Control Practices Advisory Committee MISSION
    • Advise the Secretary of Health and the Director of CDC regarding the practice of infection control and strategies for surveillance, prevention and control of antimicrobial resistance.
    03/28/11 08:13 AM
  • 35. Hospital Infection Control Practices Advisory Committee (HICPAC) Partial Recommendations for the Prevention of Surgical Site Infections-1999. 03/28/11 08:13 AM
    • Treat remote infection before elective surgery.
    • Do not remove hair from operative site unless necessary.
    • Control serum blood glucose perioperatively
    • Cessation of tobacco use 30 days before surgery
    • Keep preoperative stay in hospital as short as possible
    • Improve nutritional status
    • Use of mupirocin in nares
    • Improve oxygenation of wound space
    • Select approprite AP agent .
    • Do not routinely use vancomycin for AP.
  • 36. Summary
    • Prevention of SSI require a multifaceted approach targeting pre-, intra-, and postoperative factors
    • Current surveillance systems do collect data on perioperative processes
    • Increasing shift of surgical procedures to outpatient settings and decrease in postoperative length of stay complicate surveillance efforts.
    • Incidence is generally low; so studies would require large sample size
    • Some prevention practices (e.g. hand hygiene) would be difficult to study using traditional randomized controlled trial research design
    03/28/11 08:13 AM
  • 37. 03/28/11 08:13 AM PREVENTION IS PRIMARY! Protect patients…protect healthcare personnel… promote quality healthcare! THANQ