FRESH FROM THE PRESS: UPDATED BEST PRACTICES IN SURGICAL

SITE INFECTION PREVENTION

DR. CLAUDE LAFLAMME, SUSAN FRYTERS, DANIEL THIRION

SEPT. 18, 2014

Today… Slides for today’s presentation SSI GSK; in both official languages Certificate of Attendance Another day… Data Collection Form SSCL National Call; Oct 8th

Before We Get Started

SSI Faculty

Our Speakers: Dr. Claude LaFlamme Susan Fryters Daniel Thirion

Objectives

Learn about the current status of SSI prevention in Canada Review the updated SSI-GSK Compare CPSI SSI-GSK to

national and international literature

Introduction

Sept-Oct (2013)

Nov-Dec (2013)

Jan-April (2014)

May-Aug (2014)

Literature Search (2005-2013)

Data Collection Data Analysis New topics

Updating the previous topics based on new evidence

Writing up additional topics

SSI faculty review First English draft

CPSI Edits Translation Formatting

Draft CDC guideline, 2014 SHEA/IDSA practice recommendation Infection control and hospital epidemiology June 2014, vol. 35, no. 6

SSI Bundle Four Original Components

• Prophylactic Antimicrobial coverage

• Appropriate hair removal

• Peri-Operative glucose control

• Peri-Operative normothermia

Coated Surgical Sutures

SSI Decolonization

Canadian Pediatric SSI Journey – B.C. Children’s Hospital

SSI Health Economics

SSI Individual Risks Factors

SSI Impact on Patient’s Perspective and Quality of Life

OR Environment and SSI

Additional Evidence-Based Recommendations

CPSI SSI Measurement 2006-2014

APPROPRIATE USE OF PROPHYLACTIC ANTIBIOTICS

Daniel Thirion Susan Fryters

Indication

Patients at high risk of infection – Clean-contaminated and contaminated

Insertion of implants or prosthetic material Patients in whom an infection would have

catastrophic consequences – High risk co-morbidities – Immunosuppressed patients

Should provide coverage for the majority of organisms – does not need to eradicate every potential

pathogen to be effective Local epidemiological/antibiogram data Consider patient’s colonization or

infection with multi-drug resistant organisms, e.g. MRSA

Choice of antibiotic for prophylaxis

Important to determine true allergy status to avoid unnecessary use of alternatives such as clindamycin or vancomycin True penicillin or cephalosporin allergy:

• respiratory difficulty, hypotension, or hives; or • a severe non-IgE-mediated reaction, e.g.

interstitial nephritis, hepatitis, hemolytic anemia, serum sickness, or severe cutaneous reaction

Choice of antibiotic - Allergy

Goal: To achieve serum and tissue antibiotic

concentrations that exceed the MICs of the majority of organisms likely to be encountered at the time of the incision, and for the duration of the procedure

Appropriate Dosing

2 g IV recommended for all adult patients – simpler, nontoxic drug, high number of obese patients For pts ≥120 kg, 3 g IV is recommended

by ASHP/IDSA/SIS/SHEA guidelines but is based on expert opinion Available evidence* suggests 3 g is not

necessary regardless of BMI

Weight based Dosing - Cefazolin

* Ho VP, et al. Cefazolin dosing for surgical prophylaxis in morbidly obese patients. Surg Infect 2012;13:33-7.

1.5 mg/kg standard dose Use 5 mg/kg as a single pre-op dose if:

– post-op doses are indicated, to provide ~24 hours of antimicrobial prophylaxis, or

– anticipated duration of surgery is > 5 hours. Dose should be based on IBW, or

DW if ABW > 20% above IBW. Round dose to nearest 20mg

Weight based Dosing - Gentamicin

15 mg/kg standard dose Dose should be based on total/actual

body weight, to maximum of 2 g/dose Round dose to nearest 250mg

Weight based Dosing - Vancomycin

Surgical site infection risk based on timing of perioperative antibiotic dose, omitting vancomycin and fluoroquinolones.

Timing

Steinberg JP, et al. Ann Surg 2009

Prophylaxis recommended for all patients undergoing cesarean delivery Administration of antibiotics should be

completed prior to incision (as opposed to cord clamping) Cefazolin 2g IV once prior to incision Alternatives if allergy: clindamycin +

gentamicin

Antibiotic Px – Caesarean Section

Antibiotic administration should be completed prior to tourniquet inflation Evidence remains controversial

Antibiotic Px – Tourniquet Application

Soriano A, et al. Clin Infect Dis 2008

Repeat antibiotic dose intraoperatively if: – prolonged surgery (more than 2 half-lives of

the antibiotic used) or – procedures in which there is significant

blood loss (more than 1.5 L) in order to maintain therapeutic levels

perioperatively Time intraoperative dose from time of

pre-op dose

Re-dosing

Table 1. Antibiotic Administration & Re-dosing

A single dose of antibiotic is sufficient for most non-complex and uncomplicated surgeries

Prophylaxis up to 24 hours includes specific categories of open heart, thoracic, gastrointestinal and orthopeadic surgeries.

No data to support continuation of prophylaxis after wound closure or until all indwelling drains and intravascular catheters have been removed

Duration

Risk of super-infections with Clostridium difficile – Risk increases with duration of exposure – Risk according to local epidemiological

patterns Risk of emerging antibiotic resistance

within the patient population of your institution

Antibiotic Resistance

Example of reporting conformity to involved surgical teams

Reporting optimal antibiotic use

0

10

20

30

40

50

60

70

80

90

100

GCS Agent Dose Timing Duration Redosing

Mean AllServices(n=403)Mean Generalsurgery (n=50)

GCS: Global conformity score

• Soap or Chlorhexidine solution • At least once

Pre-Operative Shower/Bath

• Should contain Alcohol • 2%CHG/70%IPA • FDA 2012: Use with care in infants under 2 month of age • Follow manufacturer recommendations in regard to

flammability and contraindications • Do not wash off

Intra-Operative Skin Prep

Antiseptic Prophylaxis

Antiseptic Use (Cont’d)

NEUROSURGERY

Caution should be exercised to avoid CGH contact with the eyes, the inside of

the ears, the meninges, or other mucous membranes for all patients, especially

neuro patients (AORN 2010)

TRAUMA

If there is not enough time for chlorhexidine/alcohol to dry before the

operation, then it should not be used

Decolonization

Staphylococcus aureus is the most common cause of SSI

Mupirocin nasal ointment has the ability to nearly eradicate S. aureus from the nasal sites

There was a 56% reduction in the rate of infection in the mupirocin-chlorhexidine group compared to the placebo group (Bode et al, 2010)

Rao et al. also demonstrates that 26% of the patients that tested positive for S. aureus completed the decolonization protocol and had no post-op infections at 1-year follow up (2008)

SHEA: For orthopedic and cardiac surgery

Photodynamic Therapy

Photodynamic Therapy has been known to be an effective decolonization method

In preliminary human testing, PDT eradicated MRSA completely from the nose with total treatment times <10 minutes (Street et al, 2009)

An advantage of photodynamic therapy stems from its mechanism involving singlet oxygen generation that makes it impossible to induce effective resistance mechanisms (Wilson, 2004)

The issue in PDT for SSIs is how to eliminate the pathogens without damaging the host tissue and without compromising the local protective mechanism initiated by the very existence of the pathogens (Moghissi, 2010)

Photodynamic Therapy (Cont’d)

Patients who received decolonization therapy were much less likely to have a SSI (51/3398) compared to those who were not decolonized (n=24/443). (p<0.0001; OR = 3.759) (Bryce et al, 2013)

The risk of a S.aureus infection was much higher if patients were not decolonized; 67% (16 S.aureus/24 cases) compared to 31% (16 S.aureus/51 cases) in the decolonized group. (p=0.0052; OR =4.375) (Bryce et al 2013)

No recommendations possible at this point

Antiseptic Coated Sutures

CDC draft • Antiseptic Coated Sutures do not reduce SSI (2011-4 RCTs)

SHEA • Ann Surg 2012;255(5):854–859. 7 RCTs • Do not systematically use Antiseptic Coated Sutures

Edmiston • Surgery. 2013 Jul;154(1):89-100 13 RCTs • Antiseptic Coated Sutures are efficacious. Level 1 evidence

Wang • Br J Surg. 2013 Mar;100(4):465-73. 17 RCTs • Antiseptic Coated Sutures are associated with a significant SSI reduction

Wang 2013: 3720 patients, variety of surgery Triclosan Antiseptic Coated Sutures reduced SSI by 30% “consistent results in favor of TCS in adult patients,

abdominal procedures, and clean or clean-contaminated surgical wounds”

Unanswered questions: Risk of bacterial resistance? What is the cost/effectiveness ratio?

SHEA: Utilization should be based on specific indications

Antiseptic Coated Sutures

Best • None

Acceptable

• Clippers (Within 2 hrs, outside OR) • Depilatories (Test)

Never • Razor

Appropriate Hair Removal

Goal

Evidence

Time

Never

• Pre, Intra and Post BG below 10.0-11.1 mmol/L

• SHEA: Less than 10 mmol/L • CDC (draft): Less than 11.1 mmol/L • 24-48 hrs pre-op • Intra-op • 48-72 hrs post-op

• Aim for 4-6 mmol/L

Peri-Operative Glucose Control

Peri-Operative Normothermia

Goal

• Central Core T° • 36-38°C

Incidence • 50-90% • GA or Neuraxial anesthesia

Culprits

• Heat Redistribution • Impaired Thermoregulation • Heat Loss

SSI rate increases by 50-60% Blood Loss increase by16% all surgeries

combined, but increase by 50% in cardiac surgery Increase Mechanical ventilation time Increase LOS in PACU Increase cardiac morbidity

Complications associated with Peri-Operative Hypothermia

Strategy to minimize the risk of Hypothermia

Pre-warming should be initiated between 30 minutes to 2

hours prior to major surgery Increase the ambient temperature in the operating room to

20-23⁰C Warmed forced-air blankets when surgery is expected to last

>30 minutes Warmed Intravenous fluids for abdominal surgeries of >1

hour duration Warmed lavage liquids for colorectal surgery

Normothermia

CDC (draft) “Maintain perioperative normothermia”(Category 1A) SHEA Maintain normothermia: Core temperature ≥ 35.5°C

• Common practice in Canada to rewarm patients to 37° C before weaning from Cardio-Pulmonary Bypass • Underbody skin-warming surface technology (Forced-

Air warming system being the most commonly used and studied) for all cardiac surgery cases with or without the assistance of CPB

• Normothermia reduces blood loss by 40-60%, myocardial damage, extubation time and improves Cardiac Index

Normothermia in Cardiac Surgery

Thermal Management Cardiac Surgery

OR Environment

Recommendations to Control SSI in the OR: Reduce the number of times the door opens

The number of OR staff should be limited

The doors should close properly

Practice of appropriate hand hygiene

Appropriate sterilization of the equipment

Use of laminar flow ventilation*

Relative OR environment humidity of 30%-60% * Also evidence not showing benefits

• Supplemental Oxygen • SHEA: Decrease SSI by 25%, Most effective in colorectal Sx,

Combine with glucose control, normothermia and normovolemia

• CDC draft: Higher FiO2 intra and post-op for patients under GA, ETT, normal lung function

• Gentamicin-Collagen Sponges (SHEA) • No benefit in Colorectal surgery • Beneficial in Cardiothoracic surgery (heterogeneous data)

• Incisive drapes +/- Iodophor coated • No Benefit (CDC, SHEA)

Not included in GSK

SSI and Additional Hospital LOS

Post-Discharge SSI Surveillance

National Healthcare Safety Network (NHSN) (2014) recommends that an SSI surveillance period should be at least 30 days for all superficial incisional SSIs and many of the deep incisional and organ/space SSIs

The National Surgical Quality Improvement Project (NSQIP) also employs a 30 days surveillance period to generate SSI outcomes

There are some surgeries like cardiac and hip/knee prosthesis that require a 90 days post-op surveillance period. This list of surgical procedures can be found at: http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf

In agreement with SHEA and CDC

No measurement = No Improvement Important to have a national data set AMP Re-dosing AMP C/S BG Control Normothermia including Cardiac Surgery

Measurement

1. Appropriate intra-op skin cleansing on intact skin

2. Timely Prophylactic Antibiotic Administration

3. Receiving 2 gms of Cefazolin as Prophylactic Antibiotic 4. Receiving appropriate Prophylactic Antibiotic redosing. 5. Appropriate Prophylactic Antibiotic Discontinuation 6. Appropriate Hair Removal 7. All Diabetic or Surgical Patients at risk of high blood glucose with controlled post-operative serum glucose POD 0, 1, and 2

SSI Measures Percent of patients with or receiving:

8. Normothermia at time of arrival in PACU

9. Skin-warming surface technology used

10. Surgical Infection at time of discharge 11. Surgical Infection identified through post discharge surveillance (<= 30 days or 31 -90 days post procedure)

SSI Measures (continued) Percent of patients with or receiving:

Improvement for SSI Compliance

Decrease in SSI rate in colorectal surgery from 25.6% to 15.9% due to a significant increase in compliance of the guidelines (Hedrick, 2007)

Increase in compliance to the guidelines from 38% to 92% decreased SSI rates by almost 40% (Berenguer et al, 2010)

Unfortunately, these strategies have not been adhered my many institutions through out the country

A study based in the U of T teaching hospitals, less than 50% stated that these strategies were practiced consistently at their organizations

Pre-Operative

• Decolonization: PDT, Mupirocin

• Glucose Control < 10-11mmol/L

• Shower Chlorhexidine or Soap

• No hair removal • Standardized

Chlorhexidine-Alcohol skin prep

Intra-Operative

• AMP: On Time, Proper Dose, Re-dose, C/S, Tourniquet Discontinuation

• Glucose Contro < 10-11mmol/L

• Normothermia (Includes Cardiac)

• Antibiotic coated sutures

• DO NOT wash off the skin prep

• Limit OR traffic

Post-Operative

• Glucose Control 48-72 hrs

• < 10-11mmol/L

Conclusion Surgical Site Infection Prevention

Questions?