SSI (ICAN-ISC workshop)

318 views

Published on

ICAN-ISA workshop on HAI control. Talk on surgical site infections (SSI)

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
318
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

SSI (ICAN-ISC workshop)

  1. 1. Surgical  Site  Infec/ons   November  2012   Andreas  Voss   iPrevent   UMCN  &  CWZ   Nijmegen,  The  Netherlands   OCCUR WITHIN 30 DAYS POST SURGERY UNLESS IMPLANT UP TO 1 YEAR ¤ Surgical  site  infec/ons  account  for  20%  of  all   nosocomial  infec/ons   ¤ Approximately  3-­‐5%  of  surgical  opera/ons   result  in  an  infec/on   ¤ 77%  of  deaths  among  pa/ents  with  SSI  are   directly  aQributable  to  SSI   Your are entering the There are many pre-and perioperative factors that determine whether or not ¤ AQributable  cost  of  SSI  vary  -­‐  $3,000-­‐$29,000   operating theatre a patient will develop a SSI   ¤ Pa/ent-­‐related   ¤ Pa#ent-­‐related   ¤ Procedure-­‐related   ¤ Procedure-­‐related   ¤ Structure-­‐related   ¤ Structure-­‐related  Andreas  Voss,  MD,  PhD   1  
  2. 2. Surgical  Site  Infec/ons   November  2012   ¤ Pa/ent-­‐related   ¤ Pa/ent-­‐related   ¤ Procedure-­‐related   ¤ Procedure-­‐related   ¤ Structure-­‐related   ¤ Structure-­‐related   No  influence  possible   Influence by hospital •  Laminar  air-­‐flow   ¤  Age   ¤  Avoid  shaving  opera/ve  site   •  Steriliza/on   ¤  Underlying  disease   •  Pre-op hospitalization ¤  Maintain  Post-­‐op  Glucose  Control  for  Major  Cardiac  Surgery   ¤  Malignancy   ¤  Wound  classifica/on   Can & should be influenced ¤  Maintain  Post-­‐op  Normothermia  for  Colorectal  Surgery   ¤  Prosthe/c  material   •  Surveillance •  S. aureus colonization ¤  Use  Prophylac/c  An/bio/cs  appropriately   Influenced by patient •  Normothermia/hyperoxia ¤  Use  Basic  Preven/ve  Strategies  from  CDC   •  BMI >30 •  Glucose levels •  Hair-removal ² exclude  pa/ents  w/infec/on,  stop  tobacco  use,  keep  OR  doors  closed,   •  Nicotine use wear  masks,  prepare  skin  w/appropriate  agent.     •  Antimicrobial prophylaxis •  Malnutrition   •  Skin disinfection •  Infection at remote site hQp://www.ihi.org/IHI/Topics/Pa/entSafety/SurgicalSiteInfec/ons/Changes/   Disinfec/on  and  steriliza/on   not … orAndreas  Voss,  MD,  PhD   2  
  3. 3. Surgical  Site  Infec/ons   November  2012   ¤  63  surgical  departments  par/cipa/ng  in  KISS   ¤  >99.000  opera/ons   ¤  Turbulent  +  HEPA  versus  laminar  airflow  +  HEPA   ¤  Mul/variate  analyis  to  comtrol  fot  other  factors  influencing   outcome  (SSI)   Brandt et al, Ann Surg 2008; 248:695-700. Significant                              ns                                              ns                                              ns                                              ns                                            ns                           Follow-­‐up  study  taking  in  account  the  size  of  the  LAF   plenum  shows  no  difference  in  outcome       Brandt et al, Ann Surg 2008; 248:695-700. Brandt et al, Ann Surg 2008; 248:695-700. ¤ S.  aureus  coloniza/on   ¤ An/microbial  prophylaxis   ¤ Surveillance   ¤ Normothermia   ¤ Hyperoxia   ¤ Glucose  levels   CAN & SHOULD ¤ Hair-­‐removal   ¤ Skin  disinfec/on  Andreas  Voss,  MD,  PhD   3  
  4. 4. Surgical  Site  Infec/ons   November  2012   Nasal  decoloniza/on   ¤ S.  aureus  coloniza#on   ¤ An/microbial  prophylaxis   ¤ Surveillance   ¤ Normothermia   ¤ Hyperoxia   ¤ Glucose  levels   ¤ Hair-­‐removal   ¤ Skin  disinfec/on   ¤ S.  aureus  coloniza/on   ¤ An#microbial  prophylaxis   ¤ Surveillance   ¤ Normothermia   ¤ Hyperoxia   ¤ Glucose  levels   ¤ Hair-­‐removal   ¤ Skin  disinfec/on   ¤ S.  aureus  coloniza/on   14/369 15/441 ¤ An/microbial  prophylaxis   Infections (%) 1/41 ¤ Surveillance   1/47 1/81 ¤ Normothermia   2/180 ¤ Hyperoxia   5/699 5/1009 ¤ Glucose  levels   ¤ Hair-­‐removal   Hours From Incision ¤ Skin  disinfec/on   Classen. NEJM 1992;328:281.Andreas  Voss,  MD,  PhD   4  
  5. 5. Surgical  Site  Infec/ons   November  2012   Li>le  things  can   have  great  impact   (on  hygiene)   ¤ Reduc/on  of  Nosocomial              Infec/ons     %  SSI   ¤ S.  aureus  coloniza/on   ¤ An/microbial  prophylaxis   No  significant  risk   reduc#on  was   ¤ Surveillance   observed  for  pa#ents   operated  on  during   ¤ Normothermia   the  second  and  third   year   surveillance  years   ¤ Hyperoxia   ¤ Glucose  levels   ¤ Hair-­‐removal   Geubels et al Intern J Qual Health Care 2006;18:127-133 ¤ Skin  disinfec/on     200  Pa#ents   SSI  rate  (%)       Pa/ents  with   Normothermia   6  %   colorectal   opera/ons     sample     p=0.009   Hypothermia     19  %   Kurz  et  al.  NEJM  1996;  334:1209-­‐15    Andreas  Voss,  MD,  PhD   5  
  6. 6. Surgical  Site  Infec/ons   November  2012   SSI-­‐rate   ¤ S.  aureus  coloniza/on     ¤ An/microbial  prophylaxis   Local                    Systemic   5  (4%)                      8  (6%)     ¤ Surveillance   Control     ¤ Normothermia   19  (14%)   *  p  <  0.01   ¤ Hyperoxia   ¤ Glucose  levels   ¤ Hair-­‐removal   ¤ Skin  disinfec/on   Melling. Lancet. 2001; 358:876. JAMA 2004; 291:79-87 ¤ S.  aureus  coloniza/on   ¤ An/microbial  prophylaxis   ¤ Surveillance   ¤ Normothermia   JAMA 2005; 294:2035-42 ¤ Hyperoxia   •   High  FiO2  (0.80)          during  and  aqer     ¤ Glucose  levels        surgery   •   Colorectal  !   •   General  surgery?   ¤ Hair-­‐removal   ¤ Skin  disinfec/on   ¤ Postopera/ve  hyperglycemia  is  an  important   ¤ S.  aureus  coloniza/on   independent  risk  factor  for  SSI  in  general   ¤ An/microbial  prophylaxis   surgery  pa/ents.   ¤ Surveillance   ¤ Normothermia   ¤ Hyperoxia   ¤ Glucose  levels   ¤ Hair-­‐removal   ¤ Skin  disinfec/on   Archives of Surgery 2010;145:858-864]Andreas  Voss,  MD,  PhD   6  
  7. 7. Surgical  Site  Infec/ons   November  2012    No  Hair       Group  Removal  Depilatory  Shaved   ¤ Number  155  153  246   ¤ Infec/on  rate  0.6%  0.6%  5.6%   Seropian.  Am  J  Surg.  1971;  121:  251.   ¤ Inappropriate:     ² Shaving   Rasors vs. OR = 2.02 „Clipping“ (CI95 1.21-3.36) ¤ Appropriate:   Rasors vs. OR = 1.54 ² No  hair  removal  at  all   Depilatory cream (CI95 1.05-2.24) ² Clipping     ² Depilatory  use     Tanner  et  al.  Cochrane  Database  Syst  Rev  2006  Jul  19   ¤ S.  aureus  coloniza/on   ¤ An/microbial  prophylaxis   ¤ Surveillance   ¤ Normothermia   ¤ Hyperoxia   ¤ Glucose  levels   ¤ Hair-­‐removal   ¤ Skin  disinfec#on  Andreas  Voss,  MD,  PhD   7  
  8. 8. Surgical  Site  Infec/ons   November  2012   lt s ! resu New NEJM             Darouiche  et  al    NEJM      2010;362:18-­‐26   ¤ The  overall  rate  SSI  was  significantly  lower  in   ¤ Alcoholic  solu/ons  standard  of  care  in  NL  en   the  chlorhexidine–alcohol  group  than  in  the   other  EU   povidone–iodine  group    (9.5%  vs.  16.1%;  P=0.004)     ² I  miss  the  comparison  with  povidone–iodine-­‐ alcohol!   ¤ Chlorhexidine–alcohol  was  significantly  more   protec/ve  against   ¤ What  part  of  chlorhexidine–alcohol  works?   ¤ How  important  is  the  CHG  concentra/on   ² superficial  incisional  infec/ons  (4.2%  vs.  8.6%,  P=0.008)     ¤  Landmark  study  that  shows  that  the  choice  of   ² deep  incisional  infec/ons  (1%  vs.  3%,  P=0.05)     skin-­‐prep  counts  !   Darouiche  et  al    NEJM      2010;362:18-­‐26   Darouiche  et  al    NEJM      2010;362:18-­‐26   Reasons  why  implementa/on  of  effec/ve   IC  measures  in  the  OR  is  complicated   J  Am  Coll  Surg  2008;  207:810-­‐20  Andreas  Voss,  MD,  PhD   8  
  9. 9. Surgical  Site  Infec/ons   November  2012   What  do  we  need  to  effec/vly  implement   IC  measures  in  the  OR   ¤  People,  /me  and  money   ¤  Strong  leadership     ² To  handle  the  mul/-­‐disciplinary  environment   ² To  ensure  responsibili/es  are  known  to  individual  HCWs     ¤  Pa/ent  safety  culture   ² Survey  and  act  on  process  &  outcome  data   ¤  “Conformity”  of  all  HCWs  ‘opera/ng”  in  and  around   the  OR   ² To  increase  compliance  with  basic  IC  measures  in  OR  Andreas  Voss,  MD,  PhD   9  

×