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1
Surgical Site Infection
(SSI)
Y. Rongrungruang, MD
Department of Medicine
Faculty of Medicine Siriraj Hospital
Mahidol University
Comprehensive training in Infection Control
15-26 December 2014
Amari Airport Hotel
Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
Principles of SSI
• Patients undergoing surgery at risk of
SSI during pre-op, peri-op and post-
operative periods
• Acquisition of SSI organisms may be
via colonization/contamination/extra-
surgical site ID
Outcomes associated with SSI • 2–11 times higher risk of death
among patients with SSI
• 70% of deaths in patients with SSI
are directly attributable to SSI
• 60% of SSIs estimated preventable
by evidence-based guidelines
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Principles of SSI & prevention
• SSI risk more effectively reduced during
pre & peri-op > post-op periods, esp in
elective surgery
• Target to reduce SSI < 0.5% in clean, 1% in
clean contaminated, 2% in highly
contaminated wounds*
*Alexander JW, et al. Ann Surg 2011;253:1082–1093
Modifiable Non modifiable
Smoking Age
Hyperglycemia Co-morbidities
Obesity (BMI, PBF) History of radiation
Skin colonization History of SSTI
Extra SS infections
SSI risk factors & stage, Pre-operative
Alexander JW, et al. Ann Surg 2011;253:1082–93
SS = surgical site
Peri-operative
Hyperglycemia Blood transfusion
SS contamination peri-op Skin injury s/p razor
OR air contamination Hypothermia
Glove perforation Hypotension
Drain & SS colonization Oxygen desaturation
SSI risk factors & stage of operation
Alexander JW, et al. Ann Surg 2011;253:1082–93
SS = surgical site
Post-operative (immediate & late)
Hyperglycemia
Hypovolemia
Hypothermia
SS contamination post-op
Extra surgical site infections
Alexander JW, et al. Ann Surg 2011;253:1082–93
SSI risk factors & stage of operation
Types (mean) Songkla Thailand USA
Extra cost
(bahts)
43,658 5,192
(ATB
only)
120,000
Extra LOS
(days)
23.5 12.7 7.5
SSI : extra Cost & LOS
Kasatpibal N, J Med Assoc Thai 2005; 88(8): 1083-91
A 60 yr M patient presented with MSSA
bacteremia and septic arthritis Rt. Knee.
He also underwent TKR Rt. knee last 11
months.
Is this a PJI?
a. Yes, MSSA on top of prosthesis! b. Yes, this is < 1 yr post-op! c. No, this is > 90 days post-op!
Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
Site 2001 2006
LRTI 33.5 27.6
UTI 16.6 27.6
SSI 22.7 20.2
BSI 1.9 4.3
Common sites of HAI in surgical patients
Thailand 2001-2006 (%)
Danchaivijitr S, J Med Assoc Thai 2005 in 42 hospitals & national survey in 20 hospitals, 2006
Type of wound Thailand USA
Clean 1.5 2.1
Clean-contam 3.4 3.3
Contam 6.7 6.4
Dirty 7.8 7.1
SSI rates (%) by wound class
Danchaivijitr S, J Med Assoc Thai 2005 Knight R, et al. Am J Surgery 182 (2001) 682–686
Benchmarking our procedure-specific SSI
rates with those of resource-rich countries.
What ranking are we at?
a. About the same as those of them b. Variable between different SSI risk
categories c. At lower rankings
Category NNIS 0 NNIS 1 NNIS 2
CABG 0/1.0 2.2/1.7 3.7/2.5
craniotomy 0.9/0.7 1.7/1.9 2.4/3.8
hernia repair 0.8/0.2 2.1/0.2 4.5/0.0
USA vs Thailand 2004 , SSI rate (%) by
surgical procedures & risk index category
Am J Infect Control 2004;32:470-85 J Med Assoc Thai 2005; 88 (Suppl 10): S75-82
NNIS risk index category
Knight R, et al. Am J Surgery 182 (2001) 682–686
NNIS wound class / risk index & SSI
Knight R, et al. Am J Surgery 182 (2001) 682–686
Which of the followings may be the most
widely used SSI definitions?
A. NHSN
B. NICE
C. ACS
CDC, NHSN classification for surgical site infection
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Focus
• Principles & Pathogenesis
• Clinical aspects & Antimicrobial Rx
• Surveillance & Definitions
• International guidelines
• Conclusions
Which of the followings may be the latest
SSI guideline & recommendation?
A. SHEA 2008
B. NICE 2008
C. SHEA 2014
Guideline summary: Pre-op
Type SHEA 2014 NICE 2008 SHEA 2008
Glucose control I-II NA AII
Obesity I NA AII
Smoking I NA AII
Immunosuppressive III NA CII
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Guideline summary: Peri-op
Category SHEA 2014 NICE 2008 SHEA 2008
Carrier decolonization II Not routinely Unresolved
Hair removal II Recommended AI
WHO checklist I NA NA
Skin preparation I Recommended AII
Normothermia I Recommended Unresolved
Supplemental oxygen I Recommended Unresolved
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
S. aurues nasal carriage & SSI Herwaldt LA. Surgery 2003;134:S2-9
Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362:9-17
Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362: 9-17
Preoperative hair removal & SSI, Shaving vs Clipping Tanner J, Woodings D, Moncaster K. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3
Time of clipping & SSI, day before vs on the day of surgery Tanner J, Woodings D, Moncaster K. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
54
Chloroxylenol vs Iodophor/alcohol vs Chlorhexidine/alcohol
skin prep in foot & ankle surgery
Ostrander RV. J. Bone Joint Surg. Am. 2005;87:980-985
Chloroxylenol
Iodophor /alcohol
Chlorhexidine /alcohol
Category Povidone-iodine
(n=250)
CHG/Alc
(n=250)
95% CI
class II-III,
no (%)
167 (65.2) 164 (65.6) 0.91
operative
time, hr
1.43 (0.4-3) 1.45 (0.45-3) 0.93
SSI, no (%) 8 (3.2) 5 (2) 1.6 (1.4-1.8)
Peri-operative antiseptic & SSI in abd surgery
Paocharoen V, J Med Assoc Thai 2009;92:898-902
Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis
Darouiche RO, et al. N Engl J Med 2010;362:18-26.
Spanish RCT of Perioperative Low vs High Oxygen Supplement Belda FJ, et al. JAMA. 2005;294:2035-2042
Perioperative Normothermia vs hypothermia & SSI Kurz A, et al. N Engl J Med 1996;334:1209-15
Guideline summary: operative
Type SHEA 2014 NICE 2008 CDC 1999
Surgeon skill &
technique
III NA AIII
Double glovings III Recommended AIII
Aseptic technique III Recommended AIII
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Mangram AJ, et al. Infect Control Hosp Epidemiol1999;20(4):250–78.
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis
Darouiche RO, et al. N Engl J Med 2010;362:18-26.
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Guideline summary: OR characters
Type SHEA 2014 NICE 2008 SHEA 2008
Ventilation III NA CI
Traffic III NA BII
Environment cleaning III NA BIII
Sterilization of devices II NA BI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
Ventilation of Surgery & Crititcal care, Design parameter
ANSI/ASHRAE/ASHE Standard 170-2008, addendum
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
Guideline summary: Surgical prophylaxis
Type SHEA 2014 NICE 2008 SHEA 2008
Timing < 30-60 min II Recommended AI
Antimicrobial of choices II Recommended AI
Duration of prophylaxis I NA AI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
Antimicrobial prophylaxis in clean surgery
Knight R, et al. Am J Surgery 182 (2001) 682–686
Timing of Antibiotic Prophylaxis & SSI following Total Hip Arthroplasty Van Kasteren ME, et al. Clin Infect Dis 2007 : 44
1 dose vs 7 doses of perioperative antimicrobial prophylaxis
in elective gastric cancer surgery.
Mohri Y, et al. Brit J Surgery 2007; 94: 683–688
Prolonged ( > 48 h) surgical antimicrobial prophylaxis &
antimicrobial resistant organisms. Harbath S. circulation 2000;101;2916-2921
Bone5: 7%–13%
Vancomycin Penetration
Sternal Bone1: 57%
Heart Valve4:
12%
CNS: <10%
Fat4: 14%
Muscle4: 9%
Epithelial lining fluid3:
18%
Lung tissue2: 17%–24%
1. Massias L et al. Antimicrob Agents Chemother. 1992;36:2539-2541; 2. Cruciani M et al. J Antimicrob Chemother.
1996;38:865-869. 3. Lamer C et al. Antimicrob Agents Chemother. 1993;37:281-286; 4. Daschner FD et al. J
Antimicrob Chemother. 1987;19:359-362; 5. Graziani AL et al. Antimicrob Agents Chemother. 1988;32:1320-1322.
Types Vancomycin
n = 452
Cefazolin
n = 433
p value
Overall SSI
no (%)
43 (9.5) 39 (9.0) NS
MRSA 8 (1.8) 15 (3.5) NS
MSSA 17 (3.7) 6 (1.3) 0.04*
Choice of surgical prophylaxis : covering
antimicrobial resistance or sensitive? n (%)
Finkelstein R. J Thorac Cardiovasc Surg 2002;123:326-32
Bratzler DW. Surgical Infection Prevention Guidelines Writer Workgroup The American Journal of Surgery 2005:189;395–404 Clinical Infect Diseases 2004;38:1706-15
Guidelines developed jointly by the American Society
of Health-System Pharmacists (ASHP), the Infectious Diseases
Society of America (IDSA), the Surgical Infection Society (SIS),
and the Society for Healthcare Epidemiology of America (SHEA)
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
Preventing SSI : Antimicrobial & dosing
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
Surgical Antimicrobial
Therapy & Prophylaxis
• Readministration may be warranted for
prolonged or excessive bleeding,
extensive burns, cardiopulmonary bypass
• Readministration may not be warranted
in patients in whom the half-life of the
agent may be prolonged (e.g., patients
with renal insufficiency or failure)
Conclusions
• Selected SSI interventions may be
effectively implemented in selected settings
• Overuse of surgical prophylaxis may be
comparable to those of antimicrobial Rx,
but highly manageable
Establishing surgical prophylaxis ASP
• Assess the motivations
• Ensure accountability and leadership
• Set up structure and organization
• Define priorities, how to measure outcome
• Identify effective interventions
• Identify key measurements
• Educate and Train
• Communicate
Surgical Antimicrobial Prophylaxis Form
Given the evidence of ertapenem vs
comparator in preventing colorectal SSI,
general surgeons in your center considering
replace “cefoxitin” with “ertapenem” for colorectal surgical prophylaxis.
A. What’d be the evidence of erta vs cefox
against colorectal SSI?
B. Any drawback of using erta vs cefox?
C. What’d you recommend in this regard?
Itani K, et al N Engl J Med 2006;355:2640-51
Itani K, et al N Engl J Med 2006;355:2640-51
In a urology unit, there is a growing
concern of ESBL-producing
Enterobacteriaceae SSI,
“cefazolin” switched to “fosfomycin” for invasive urological surgical prophylaxis.
A. What’d be the evidence of fosfo vs cefa
against SSI?
B. Any drawback of using fosfo vs cefa?
C. What’d you recommend in this regard?
Ishisaka K, et al. J Infect Chemother (2007) 13:324–331
Ishisaka K, et al. J Infect Chemother (2007) 13:324–331
In your center with busy CVT services, the
unit staffs have been switching “cefazolin”
to “vancomycin” as a routine surgical
prophylaxis for CABG, given the concern of increasing incidence of MRSA SSI.
A. What’d be the evidence of vanco vs cefa
against MRSA SSI?
B. Any drawback of using vanco vs cefa?
C. What’d you recommend in this regard?
A diabetic pt with high risk TKR
A 75-yr-old female patient with DM
• 2005 Dec : TKR rt. knee
• 2006 June : MSSA septic arthritis rt.knee, prosthesis removal & complete antimicrobial therapy
• 2006 November : scheduled for elective TKR rt. knee
Investigation results
• Hct 36% WBC 8,000/mm3, PMN
70% L30%, plt 298,000/mm3
• ESR 24 mm/h
• FBS 120, HbA1C 6.5 %, BUN 24, Cr
1.5 mg/L, Chest X-ray & UA WNL
Your choice of surgical prophylaxis?
A. Vancomycin
B. Cefazolin
C. Fosfomycin
A diabetic pt with high risk TKR
• Nasal mupirocin & bodywash with 4%
chlorhexidine bath
• 2006 November : elective TKR rt. knee
with perioperative cefazolin x 48 hrs
• Good post-operative recovery up to 3
years of follow-up
A diabetic pt with high risk TKR
• 2006 November: elective TKR rt. knee
• 2009 December readmission :acute
monoarthritis rt. knee
• Jt. fluid : WBC & PMN elevated
• Culture + for group A streptococci
SSI
% (no/total)
Chlorhexidine 2.8 (5/185)
Povidone iodine 3.6 (7/195)
SSI reduction 23.4 (2/195)
Type of antiseptic & SSI in surgery unit
Jan – Nov 2007
Hair removal technique & SSI in surgery unit
Jan – Nov 2007
Category SSI rate
% (no/total)
Shaving 4.1 (13/320)
Non-shaving 1.8 (2/111)
Risk reduction 53.4 (11/320)
year 2550 2551 (11 mo)
total patients 7,877 6,602
SSI no. (%) 27 (3.4) 12 (1.8)
Annual SSI rate
Thai periorbital flora & antiseptics
N = 51 (no of pt)
Type coag-
Staph
Dipthe
roids
Micro
cocci
Gr-rod
no Rx 43 20 9 7
CHG Rx 40 14 4 6
PID Rx 7 1 0 0
Rongrungruang Y, et al. J Med Assoc Thai 2005
Prophylactic antibiotics prescribing practices
Prescribing Practice N (%)
Number of Antibiotic (420 patients) 1 antibiotic > 2 antibiotics
301 (71.7) 119 (28.3)
Timing of Initiation of the First Antibiotic (420 patients)
Before Operation
- at OR prior to incision 253 (60.2)
- at Ward 49 (11.7)
After Incision in OR 72 (17.1)
After Operation 46 (11.0)
Timing of Antibiotic prior to incision (253 patients)
within 30 minutes 184 (72.7)
31 to 60 minutes 59 (23.3)
31 to 120 minutes 10 (4.0)
Prophylactic antibiotics prescribing practices (cont.)
Type of Antibiotic (580 antibiotics & 420 patients)
Cefazolin 198 (47.1)
Cetriaxone 60 (14.3)
Metronidazole 48 (11.4)
Fosfomycin 47 (11.2)
Cefoxitin 36 (8.6)
Clindamycin 24 (5.7)
Ampicillin + Sulbactam 18 (4.3)
Ciprofloxacin 15 (3.6)
Cefotaxime 14 (3.3)
Cefepime 13 (3.1)
Amoxicillin + Clavulanate 12 (2.9)
Meropenem 11 (2.6)
Others 84 (20.0)
Duration of Antibiotic Prophylaxis in Before Operation Group (302 patients)
Single dose 47 (15.6)
1 day 6 (2.0)
2 days 81 (26.8)
> 2 days 168 (55.6)
Duration of Antibiotic Prophylaxis (420 patients)
Single dose 60 (14.3)
1 day 17 (4.0)
2 days 127 (30.2)
> 2 days 216 (51.4)
Department/Devision
Type of Antibiotic
within 30 minutes
31-60 minutes
61-120 minutes
Total
Cardio/CVT cefazolin 18 6 2 26
maxipime=cefepime 3 0 0 3
clindamycin 1 1 0 2
fosfomycin 1 0 0 1
gentamicin 0 0 1 1
cefepime 1 0 0 1
Total 24 7 3 34
% 70.6 20.6 8.8 100.0
Timing of Antibiotic prior to incision (253 patients)
Neuro fosfomycin 16 12 1 29
cefazolin 7 2 1 10
unasyn=ampi+sulbac 3 3
vancomycin 1 1
gentamicin 1 1
Total 26 16 2 44
% 59.1 36.4 4.5 100.0
Uro cetriaxone 11 1 12
cefoxin 1 1
cefotaxime 1 1
ciprofloxacin 1 1
Total 13 2 15
% 86.7 13.3 100.0
Vascular cefazolin 4 3 7
clindamycin 1 0 1
Total 5 3 8
% 62.5 37.5 100.0
Timing of Antibiotic prior to incision (253 patients)
Department/
Devision Type of Antibiotic
within 30
minutes
31-60
minutes
61-120
minutes Total
Timing of Antibiotic prior to incision (253 patients)
Department/ Devision
Type of Antibiotic within 30 minutes
31-60 minutes
61-120 minutes
Total
H&Neck cefazolin 5 1 6
unasyn=ampi+sulbac 2 1 3 augmentin 1 1 2 cetriaxone 1 1
clindamycin 1 1 Total 9 4 13 % 69.2 30.8 100.0
Plastic cefazolin 1 1
unasyn=ampi+sulbac 1 1 Total 2 2 % 100.0 100.0
Timing of Antibiotic prior to incision (253 patients)
Department/ Devision
Type of Antibiotic within 30 minutes
31-60 minutes 61-120 minutes
Total
Gen surg metronidazole or flagyl 15 1 2 18 cefazolin 10 3 13 cetriaxone 9 1 1 11 cefotaxime 4 1 5
unasyn=ampi+sulbac 1 2 3 ciprofloxacin 1 2 3 claforam=cefotaxime 1 1 1 3 ampicilin 1 1 gentamicin 1 1 claroxim 1 1 Total 44 11 4 59 % 74.6 18.6 6.8 100.0
Ortho cefazolin 33 13 2 48 clindamycin 3 1 4 zinnacef=cefuroxime 1 2 3 unasyn=ampi+sulbac 2 2 fosfomycin 1 1 2 cetriaxone 1 1 Total 40 18 2 60 % 66.7 30.0 3.3 100.0
Gynae cefoxin 12 12
cefoxitin 9 9 cefazolin 6 6 cetriaxone 2 2 clindamycin 1 1 metronidazole or flagyl 1 1 ampicillin 1 1 cefotaxime 1 1 Total 33 33 % 100.0 100.0
OB cefazolin 2 1 3 cefoxin 1 1 Total 3 1 4 % 75.0 25.0 100.0
ENT cefazolin 2 2 clindamycin 1 1 Total 2 1 3 % 66.7 33.3 100.0
Timing of Antibiotic prior to incision (253 patients)
Department/ Devision
Type of Antibiotic within 30 minutes
31-60 minutes
61-120 minutes
Total