Infection Control for the OB/GYN Surgeon

Gonzalo Bearman, MD, MPHAssistant Professor of Internal Medicine &

EpidemiologyAssociate Hospital Epidemiologist

Outline• Nosocomial Infections are a significant cause of morbidity and

mortality• There has been increased public interest in nosocomial

infections• Shifting paradigm

– Many infections are preventable

• SSI and OB/GYN– Surveillance data– Risk factors– Modifiable risk factors- modifiable interventions

• BSI and OB/GYN– Surveillane– Risk reduction strategies

• Proliferation of drug resistant nosocomial pathogens– Hand Hygeiene and Contact precautions

Hospital-acquired infections reported by Pennsylvania hospitals in 2004:

Infection Number

Urinary tract 6,139

Bloodstream 1,932

Pneumonia 1,335

Surgical site 1,317

Multiple infections 945

Total 11,668

Source: Pennsylvania Health Care Cost Containment Council

“11,600 patients got infections in Pa. hospitals “

7/13/2005

"The consequences clearly are huge," says Marc Volavka, executive director of the Pennsylvania Health Care Cost Containment Council, an independent state agency that published the data. "Everyone is paying the bill."

U.S. News and World Report, July 18, 2005.

Shifting Vantage Points on Nosocomial Infections

Gerberding JL. Ann Intern Med 2002;137:665-670.

Many infections are inevitable, although

some can be prevented

Each infection is potentially

preventable unless proven otherwise

Nosocomial Infections• 5-10% of patients admitted to acute care hospitals

acquire infections– 2 million patients/year– ¼ of nosocomial infections occur in ICUs– 90,000 deaths/year– Attributable annual cost: $4.5 – $5.7 billion

• Cost is largely borne by the healthcare facility not 3rd party payors

Weinstein RA. Emerg Infect Dis 1998;4:416-420.Jarvis WR. Emerg Infect Dis 2001;7:170-173.

Nosocomial Infections

• 70% are due to antibiotic-resistant organisms

• Invasive devices are more important than underlying diseases in determining susceptibility to nosocomial infection

Burke JP. New Engl J Med 2003;348:651-656.Safdar N et al. Current Infect Dis Reports 2001;3:487-495.

Attributable Costs of Nosocomial Infections

Cost per Infection

Wound infections $3,000 - $27,000

Sternal wound infection $20,000 - $80,000

Catheter-associated BSI

$5,000 - $34,000

Pneumonia $10,000 - $29,000

Urinary tract infection $700

Nettleman M. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. 2003:36.

Major Sites of Nosocomial Infections

• Urinary tract infection

• Bloodstream infection

• Pneumonia (ventilator-associated)

• Surgical site infection

Surgical Site Infections in Obstetrics and Gynecology

National Nosocomial Infections

Surveillance System (NNIS) • NNIS is the only national system for tracking

HAIs• Voluntary reporting system has approximately

300 hospitals• The NNIS database uses standardized

definitions of HAI’s to:– Describe the epidemiology of HAIs – Describe antimicrobial resistance associated with

HAIs – Produce aggregated HAI rates suitable for

interhospital comparison

http://www.cdc.gov/ncidod/hip/SURVEILL/NNIS.HTM

National Nosocomial Infections Surveillance System (NNIS)

Classification Wound Class SSI Risk

Clean 0Lower

Higher

Clean-contaminated:GI/GU tracts entered in a controlled manner

1

Contaminated: open, fresh, traumatic wounds

infected urine, bile

gross spillage from GI tract

2

Dirty-infected:3

NNIS- SSI Surveillance 1992-2004

Abdominal Hysterectomy

Risk Index Number of hospitals

Pooled mean ratePer 100 operations

Median- 50% percentile

0 107 1.36 0.91

1 100 2.32 1.96

2,3 53 5.17 4.21

Am J Infect Control 2004;32:470-85

NNIS- SSI Surveillance 1992-2004

Am J Infect Control 2004;32:470-85

Vaginal Hysterectomy

Risk Index Number of hospitals

Pooled mean ratePer 100 operations

Median- 50% percentile

0,1,2,3 71 1.31 0.91

NNIS- SSI Surveillance 1992-2004

Cesarean Section

Risk Index Number of hospitals

Pooled mean ratePer 100 operations

Median- 50% percentile

0 130 2.71 2.17

1 117 4.14 3.19

2,3 51 7.53 5.38

Am J Infect Control 2004;32:470-85

Hospital Morbidity Due to Post-operative

Infections in Obstetrics and Gynecology • Post operative infections prospectively

surveyed from 1997-1998 in tertiary care medical center, Bahrain– Definition of postoperative infection:

• Fever• Purulent discharge from wound

– With or without a positive microbiologic culture

• Re-admissions for wound infections were not included in the study

Saudi Medical Journal 2000: Vol 21 (3) 270-273

Type of operation

(%)

No. of Operations

(%)

Wound Infection alone (%)

Fever alone (%)

Both wound Infection and Fever (%)

Cesarean section

2193 35 (2) 30 (1) 7 (0.3)

Major Gynecologic Surgery

1839 9 (0.4) 5 (0.3) 4 (0.2)

Total 4032 35 (0.9) 35 (0.9) 11(0.3)

Saudi Medical Journal 2000: Vol 21 (3) 270-273

Hospital Morbidity Due to Post-operative

Infections in Obstetrics and Gynecology

Organism Number of Isolates

Gram Positive•S.aureus•S.epidermidis•Streptococci•Enterococci

3 (3)

13 (14)

6(6)

19 (20)

Gram Negative•Enterbacter •Klebsiella •E.coli•Proteus•P.aeruginosa•Acinetobacter•Gram negative bacilli

4(4)

14(15)

11(12)

9(10)

8(8.5)

1(1)

1(1)

Candida 5(5)

Total 94

Saudi Medical Journal 2000: Vol 21 (3) 270-273

Hospital Morbidity Due to Post-operative Infections in Obstetrics and Gynecology

Genitourinary flora is a significant source of contamination during surgery

Risk Factors for Surgical Site Infections Following Cesarean Section

• OBJECTIVE: To identify risk factors associated with surgical-site infections (SSIs) following cesarean sections.

• DESIGN: Prospective cohort study. • SETTING: High-risk obstetrics and neonatal tertiary-care

center in upstate New York.• METHODS:

• Prospective surgical-site surveillance was conducted using methodology of the National Nosocomial Infections Surveillance System.

• Infections were identified on admission, within 30 days following the cesarean section, by readmission to the hospital or by a postdischarge survey.

• Multiple logistic-regression analysis used for risk factor identification

Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7

Multiple logistic-regression analysisRisk Factor Odds Ratio/ 95% CI/ P value

Absence of antibiotic prophylaxis

2.63; 1.50-4.6; P=.008

Length surgery 1.01; 1.00-1.02; P=.04

<7 prenatal visits 3.99; 1.74-9.15; P=.001

Duration of ruptured membranes

1.02; 1.01-1.03; P=.04

Risk Factors for Surgical Site Infections Following Cesarean Section

Infect Control Hosp Epidemiol. 2001 Oct;22(10):613-7

Summary: SSI’s in OB/GYN

• NNIS- SSIs are reported to occur in 1%-7% of OB/GYN surgeries

• SSI are typically caused by maternal cutaneous or endometrial/vaginal flora

• When an exogenous source is the cause of SSI in the obstetrical patient, S.aureus is frequently implicated

Preventing Surgical Site Infections

Focus on modifiable risk factors

Sources of SSIs

• Endogenous: patient’s skin or mucosal flora– Increased risk with devitalized tissue, fluid

collection, edema, larger inocula• Exogenous

– Includes OR environment/instruments, OR air, personnel

• Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection– May occur days to weeks following the procedure

• Most infections occur due to organisms implanted during the procedure

Downloaded from: Principles and Practice of Infectious Diseases

© 2004 Elsevier

Up to 20% of skin-associated bacteria in skin appendages (hair follicles, sebaceous glands) & are not eliminated by topical antisepsis. Transection of these skin structures by surgical incision may carry the patient's resident bacteria deep into the wound and set the stage for subsequent infection.

Risk Factors for SSI• Duration of pre-op hospitalization * increase in endogenous reservoir• Pre-op hair removal * esp if time before surgery > 12 hours * shaving>>clipping>depilatories• Duration of operation *increased bacterial contamination * tissue damage * suppression of host defenses * personnel fatigue

SCIP

• A national partnership of organizations to improve the safety of surgical care by reducing post-operative complications through a national campaign

• Goal: reduce the incidence of surgical complications by 25 percent by the year 2010

• Initiated in 2003 by the Centers for Medicare & Medicaid Services (CMS) & the Centers for Disease Control & Prevention (CDC)– Steering committee of 10 national organizations– More than 20 additional organizations provide technical

expertise

Putting risk reduction guidelines into practice

SCIP Steering Committee Organizations

• Agency for Healthcare Research and Quality • American College of Surgeons • American Hospital Association • American Society of Anesthesiologists • Association of periOperative Registered Nurses • Centers for Disease Control and Prevention • Centers for Medicare & Medicaid Services • Department of Veterans Affairs • Institute for Healthcare Improvement • Joint Commission on Accreditation of Healthcare

Organizations

SCIP Performance Measures

Surgical infection prevention

• SSI rates• Appropriate prophylactic antibiotic chosen• Antibiotic given within 1 hour before incision• Discontinuation of antibiotic within 24 hours of surgery

• Glucose control• Proper hair removal• Normothermia in colorectal surgery patients

Monetary incentives for promoting quality and compliance with SSI risk reduction guidelines:

March 12, 2005

In recent years, the healthcare industry has placed a stronger emphasis on reducing medical errors, monitoring everything from how long doctors sleep to whether or not their handwriting is legible.Now one organization is not only recognizing the hospitals that follow patient safety and clinical guidelines, but rewarding them for doing so. Anthem Blue Cross and Blue Shield recently gave a total of $6 million to 16 Virginia hospitals as part of the company's new Quality-In-Sights Hospital Incentive Program (Q-HIP).

http://www.richmond.comID=15

Downloaded from: Principles and Practice of Infectious Diseases

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Procedure Approved Antibiotics Approved for β-lactam allergy

Hysterectomy•Cefazolin•Cefoxitin

•Clindamycin + gentamicin•Clindamycin + levofloxacin•Metronidazole + gentamicin•Metronidazole + levofloxacin •Clindamycin

Process Indicators:

Appropriate Antibiotic Prophylaxis

Process Indicators:

Duration of Antimicrobial Prophylaxis

Prophylactic antimicrobials should be discontinued within 24 hrs after the end of surgery

Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

Process Indicators:

Timing of First Antibiotic Dose

Infusion should begin within 60 minutes of the incision

Bratzler DW et al. Clin Infect Dis 2004;38:1706-15.

Nosocomial Bloodstream Infections

Nosocomial Bloodstream Infections, 1995-2002

Rank Pathogen Percent

1 Coagulase-negative Staph 31.3%

2 S. aureus 20.2%

3 Enterococci 9.4%

4 Candida spp 9.0%

5 E. coli 5.6%

6 Klebsiella spp 4.8%

7 Pseudomonas aeruginosa 4.3%

8 Enterobacter spp 3.9%

9 Serratia spp 1.7%

10 Acinetobacter spp 1.3%

N= 24,84752 BSI/10,000 admissions

Edmond M. SCOPE Project.

Nosocomial Bloodstream Infections, 1995-2002

Edmond M. SCOPE Project.

•Proportion of all BSI 0.9% (n=209)

•E.coli (33%)

•S.aureus (11.7%)

•Enterococci (11.7)

Obstetrics and Gynecology

In obstetrics, BSIs are uncommon. However, the principal pathogen is E.coli and not coagulase negative staphylococci.

The source is typically genitourinary

N= 24,84752 BSI/10,000 admissions

Nosocomial Bloodstream Infections

• 12-25% attributable mortality

• Risk for bloodstream infection:BSI per 1,000 catheter/days

Subclavian or internal jugular CVC 5-7

Hickman/Broviac (cuffed, tunneled) 1

PICC 0.2 - 2.2

Risk Factors for Nosocomial BSIs

• Heavy skin colonization at the insertion site

• Internal jugular or femoral vein sites

• Duration of placement

• Contamination of the catheter hub

Prevention of Nosocomial BSIs

• Coated catheters– In meta-analysis C/SS catheter decreases BSI

(OR 0.56, CI95 0.37-0.84)– M/R catheter may be more effective than C/SS– Disadvantages: potential for development of

resistance; cost (M/R > C/SS > uncoated)

• Use of heparin– Flushes or SC injections decreases catheter

thrombosis, catheter colonization & may decrease BSI

Prevention of Nosocomial BSIs

• Limit duration of use of intravascular catheters– No advantage to changing catheters routinely

• Change CVCs to PICCs when possible• Maximal barrier precautions for insertion

– Sterile gloves, gown, mask, cap, full-size drape– Moderately strong supporting evidence

• Chlorhexidine prep for catheter insertion

30%-40% of all Nosocomial Infections are Attributed to Cross Transmission- Implication For The Spread Drug Resistant Pathogens

Fig 1. Selected antimicrobial-resistant pathogens associated with nosocomial infections in ICU patients, comparison of resistance rates from January through December 2003 with 1998 through 2002, NNIS System.

Am J Infect Control 2004;32:470-85

NNIS: Selected antimicrobial resistant pathogens associated with HAIs

Antimicrobial Resistant Pathogens of Ongoing Concern

• Vancomycin resistant enterocci– 12% increase in 2003 when compared to 1998-2002

• MRSA– 12% increase in 2003 when compared to 1998-2002– Increased reports of Community-Acquired MRSA

• Cephalosporin and Imipenem resistant gram negative rods– Klebsiella pneumonia– Pseudomonas aeruginosa

Am J Infect Control 2004;32:470-85

Transfer of VRE via HCW Hands

Duckro et al. Archive of Int Med. Vol.165,2005

16 transfers (10.6%) occurred in 151 opportunities.

•13 transfers occurred in rooms of unconscious patients who were unable to spontaneously touch their immediate environment

The inanimate environment is a reservoir of pathogens

~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents a positive Enterococcus culture

The pathogens are ubiquitous

Community-associated methicillin-resistant Staphylococcus aureus in

hospital nursery and maternity units.

• Outbreak of 7 cases of skin and soft tissue infections due to a strain of CA-MRSA. – All patients were admitted to the labor and

delivery, nursery, or maternity units during a 3-week period.

– Genetic fingerprinting showed that the outbreak strain was closely related to the USA 400 strain that includes the midwestern strain MW2

Emerg Infect Dis. 2005 Jun;11(6):808-13.

Table 1. Clinical information for patients with methicillin-resistant Staphylococcus aureus infection during the outbreak period

PatientAge at onset Sex Strain Infection type Initial therapy Definitive therapy

P1, newborn

8 d F USA 400 Preseptal cellulitis Nafcillin, cefotaxime Topical gentamicin

P2, newborn

13 d F USA 400 Omphalitis, otitis externa

Ampicillin, cefotaxime

Topical mupirocin

P3, mother 33 y F USA 400 Breast abscess Cefazolin Surgical drainage, vancomycin, topical mupirocin

P4, newborn

2 d M USA 400 Omphalitis, pustulosis Nafcillin Gentamicin Gentamicin, topical mupirocin

P5, newborn

4 d M USA 400 Pustulosis Cephalexin Topical bacitracin

P6, newborn

2 d M USA 400 Pustulosis None Local wound care

P7, newborn

1 d F USA 400 Pustulosis, mastitis Topical mupirocin Vancomycin

P8, mother 24 y F Unique Peripheral IV catheter site

Cefazolin Trimethoprim-sulfamethoxazole, catheter removal

Emerg Infect Dis. 2005 Jun;11(6):808-13.

Epidemic of Staphylococcus aureus nosocomial infections resistant to

methicillin in a maternity ward • Seventeen cases were recorded over a nine-

week period (two cases per week).– All were skin and soft tissue infections

• Pulsed field gradient gel electrophoresis confirmed the clonal character of the strain.

• No definite risk factors were determined by a case-control study.

• Environmental factors were considered key in the persistence of this MRSA outbreak.

Pathol Biol (Paris). 2001 Feb;49(1):16-22.

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, C.diff CNS and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

The inanimate environment is a reservoir of pathogens

Recovery of MRSA, VRE, CNS. C.diff and GNR

Devine et al. Journal of Hospital Infection. 2001;43;72-75

Lemmen et al Journal of Hospital Infection. 2004; 56:191-197

Trick et al. Arch Phy Med Rehabil Vol 83, July 2002

Walther et al. Biol Review, 2004:849-869

Alcohol based hand hygiene solutionsQuick Easy to use

Very effective antisepsis due to bactericidal properties of alcohol

Hand Hygiene

• Single most important method to limit cross transmission of nosocomial pathogens

• Multiple opportunities exist for HCW hand contamination– Direct patient care

– Inanimate environment

• Alcohol based hand sanitizers are ubiquitous– USE THEM BEFORE AND AFTER PATIENT

CARE ACTIVITIES

Contact Precautions for drug resistant pathogens.

Gowns and gloves must be worn upon entry into the patient’s room

Conclusion• Nosocomial Infections are a significant causes of morbidity and

mortality• There has been increased public interest in nosocomial

infections- this will likely result in greater compliance with IC guidelines

• Shifting paradigm– Many infections are preventable

• SSI and OB/GYN– 1-7 % of all OB/GYN procedures (NNIS)– Increased scrutiny of compliance with risk reduction intervention

– Preoperative antibiotics: choice, timing, discontinuation;

• BSI and OB/GYN– BSI is less common than in Medicine/Surgical services– Risk reduction strategies should include appropriate use and

prompt removal of invasive devices

• Proliferation of drug resistant nosocomial pathogens– Importance of Hand Hygiene and Contact precautions