healthcare associated infections: preventing surgical site infections edward l. goodman, md...

Healthcare Associated Infections: Preventing Surgical Site

InfectionsEdward L. Goodman, MD

September 27, 2004

Outline

• Definition

• Magnitude of the problem

• Pathophysiology

• Non pharmacologic methods

• Perioperative antimicrobials

• Conclusions

• Bibliography

Definitions

Criteria

Criteria

Criteria

Magnitude of the ProblemBurke. N Eng J Med 2003;348:651-6

MagnitudeBurke

Pathophysiology

• Surgical Factors– Wound classification

• Clean

• Clean contaminated

• Dirty

– Emergency vs. Elective– Surgical technique– Perioperative environment

Pathophysiology

• Host factors– NNIS Stratification System

• Time of surgery

• ASA score– Rating system to predict mortality

– Colonization with potential pathogens

Microbiology of SSI

Microbiology by Surgery Site

Microbiology by Surgery Site

Is the Microbiology of SSI Predestined?

• Are the organisms already present on the patient?– Classically, it was taught that SSI are caused by

flora entering the wound during the procedure– Studies on Staph aureus bacteremia support that

mechanism

Endogenous Source of Staph Aureus Bacteremia

Do Postoperative Factors Play a Role?MRSA SSI vs. other SSI

Manian et al. CID 2003:36

MRSA SSI vs. MSSA SSI

Non Pharmacologic Operative Interventions

• Supplemental oxygen during surgery

• Maintenance of normothermia

• Maintenance of normoglycemia

Supplemental Oxygen

• Greif 2000:– Double blind, controlled multicenter study of

500 patients undergoing colorectal resections

– Intervention: 80% vs 30% FiO2 during and 2 hours after surgery

– Reduction in SSI rate from 11.2% to 5.2% (p=0.01)

Supplemental OxygenGreif et al. NEJM 2000

Not so fast

• Pryor 2004– Double blind, randomized, controlled study in

one hospital of patients undergoing a variety of abdominal surgeries

– Intervention: 80% vs 35% FiO2 during and two hours after

– Increase in SSI rate from 11.3% to 25% (p=0.03)

Oxygen TherapyPryor JAMA 2004

Maintenance of Normothermia

• Anesthesia influences thermoregulatory control

• Mild hypothermia associated with– Adverse myocardial events/vasoconstriction– Coagulopathy– Inhibits oxidative killing by PMN’s– Reduces metabolism of many drugs– Thermal discomfort

Anesthetic Effects on Thermoregulation

Sessler CID 2002;35:1397-1404

Kurz, A. et al. N Engl J Med 1996;334:1209-1216

Core Temperatures during and after Colorectal Surgery in the Study Patients

Kurz, A. et al. N Engl J Med 1996;334:1209-1216

Postoperative Findings in the Two Study Groups

Maintenance of Normoglycemia

• Cardiothoracic surgery– In diabetic patients, maintenance of sugar <200

associated with lower risk of deep SSI (2.4% vs 1.5%, p<0.02)

– Continuous intravenous insulin superior to sliding scale (2% vs 0.8%, p=0.01)

• Zerr et al. Ann Thor Surg 1997;63:356-61• Furnary et al. Ann Thor Surg 1999;67:352-60

Perioperative Antimicrobials

• Topical

• Systemic

Topical Mupirocin

• Nasal Source of Staph Aureus for subsequent SSI

• Preoperative topical use in nares– Only on those patients known to be carriers

• Resistance is becoming an issue– Prolonged use CONTRAINDICATED– No evidence of any benefit beyond five days

Perl, T. M. et al. N Engl J Med 2002;346:1871-1877

Overall and Staphylococcus aureus-Specific Rates of Nosocomial Infection among Patients Who Received Mupirocin and Those Who Received Placebo

Pre Operative Antibiotics

• Type of surgery– Clean contaminated

• Transect mucosal surfaces

– Clean with high risk of infection• Insertion of prosthesis

• Cardiac/neurosurgery

• Choice of drug• Timing of drug• Duration of drug

Timing of AntibioticsClassen et al. N Eng J Med 1992; 326:281-6

Conclusions

• Not possible to prevent all SSI• Preoperative and intraoperative processes

can reduce the rate• Antibiotics alone are not the answer• Prolonging prophylactic antibiotics are

contraindicated• Screening for MRSA colonization may

become mandatory

Bibliography• Bratzler DW, Houck PM. Antimicrobial Prophylaxis for Surgery. Clin

Infect Dis 2004;38:1706-15.• Burke JP. Infection Control – a problem for patient safety. N Engl J

Med 2003; 348:651-6.• Classen DC, Evans RS et al. The Timing of Prophylactic

Administration of Antibiotics and the Risk of Surgical Wound Infections. N Eng J Med 1992;326:281-6.

• Furnary AP, Kerr KJ et al. Continuous Intravenous Insulin Infusion Reduces the Risk of Wound Infection in Diabetics after Open Heart Operations. Ann Thor Surg 1999;67:352-60

• Gottrup F. Prevention of surgical wound infections. N Eng J Med 2000; 342:202-204.

• Grief R el al. Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infections. N Eng J Med 2000; 342:161-167.

Bibliography

• Kurz A, Sessler DI et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. N Eng J Med 1996; 334:1209-1215.

• Mangram AJ, Horan TC, Pearson ML, Silver, LC, Jarvis WR, the Hospital Infection Control Practices Advisory Committee, Guideline for the prevention of surgical site infection 1999. Infection Control Hosp Epidemiol 1999;20: 247-280.

• Manian, FA, Meyer PL et al. Surgical Site Infections Associated with Methicillin-Resistant Staphylococcus aureus: Do Postoperative Factors Play a Role? Clin Infect Dis 2003; 36:863-868.

• Perl TM, Cullen JJ et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infection. N Eng J Med 2002; 346: 1871-77.

Bibliography

• Pryor KO, Fahey TJ et al. Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population. JAMA 2004;291:79-87.

• Sessler DI, Akca O. Nonpharmacological Prevention of Surgical Wound Infections. Clin Infect Dis 2002;35:1397-1404.

• Von Eiff C, Becker K et al. Nasal Carriage as a source Staphylococcus Aureus Bacteremia. N Engl J Med 2001; 344: 11-16.

• Zerr KJ, Furnary AP et al. Gluconse Control Lowers the Risk of Wound Infection in Diabetics After Open Heart Surgery. Ann Thorac Surg 1997;63:356-361