Surgical Site Infection (SSI) Prevention: The Latest, Greatest and Unanswered Questions

Keith S. Kaye, MD, MPHCorporate Vice President of Quality and Patient Safety

Corporate Medical Director, Infection Prevention, Epidemiology and Antimicrobial Stewardship

Detroit Medical Center and Wayne State University

Overview• SSI Epidemiology and Outcomes• Pathogenesis and categorization• SSI and CMS• Prevention

– The basics– Special Approaches– Not recommended/unresolved

• Ongoing challenges and opportunities

SSI Epidemiology

• SSIs occur in 2%–5% of patients undergoing inpatient surgery.

• Approximately 160,000–300,000 SSIs occur each year in the United States.

• SSI is now the most common and most costly HAI.

• Most occur within 30 days of surgery; those involving prostheses might occur later (up to 90 days)

Anderson et al, infection control and hospital epidemiology june 2014, vol. 35, no. 6

Outcomes• Up to 60% of SSIs estimated to be preventable • Account for 20% of all HAIs in hospitalized patients.• Each SSI associated with ~ 7–11 additional postoperative

hospital-days.• Patients with an SSI have a 2–11-times higher risk of death • Seventy-seven percent of deaths in patients with SSI are

directly attributable to SSI.• Attributable costs of SSI vary depending on the type of

operative procedure and the type of infecting pathogen.• SSIs are account for $3.5 –$10 billion annually in healthcare

expenditures

Pathogenesis of SSI• Most SSI are caused by a patient’s

endogenous flora– Aerobic gram-positive cocci (eg staphylococci)

most common– Anaerobes, gram-negative aerobes, other

gram-positives for surgery involving colon, perineum, groin

• Exogenous sources of SSI are rare– Surgical team – OR environment– Tools, instruments

Organisms Causing SSIJanuary 2009-October 2010, N=21,100

• Staphylococcus aureus 30.4• Coagulase-negative staphylococci 11.7%• Enterococcus spp. 11.6%• Escherichia coli 9.4%• Pseudomonas aeruginosa 5.5%• Enterobacter spp 4.0%• Klebsiella pneumoniae 4.0%• Proteus spp. 3.2%• Candida spp. 1.8%• Serratia spp.1.8%

Sievert et al, Infection Control and Hospital Epidemiology, January, 2013, 34(1), 1-14

SSI classification

CMS and SSI:VBP Safety Measures, FY 2018

9

• Similar for FY 2018 except• CY 2016 included as performance period• Non-ICU CLABSI included

10

Several Outcome Measures Used in Both VBP and HAC Payment Programs

Measure Date Reporting

Began

VBP Program (1st fiscal year)

HAC Reduction Program

(1st fiscal year)

CLABSI 2011 Q1 2015 2015

CAUTI 2012 Q1 2015 2015

SSI 2012 Q1 2016 2016

MRSA 2013 Q12017

2017

C.diff 2013 Q1 2017

AHRQ Composite (“PSI 90”)

(CMS calculates)

2015 2015

Performance Periods

2015 VBP = CY 2013

2016 VBP = CY 2014

2017 VBP = CY 2015

2018 VBP = CY 2016

CMS Readmissions Reduction Program

• FY 2016 includes 30-day readmissions for– AMI– CHF– Pneumonia– COPD– Elective THA, TKA

Risk Factors

Microbial

Characteristics

Surgical

Characteristics

Patient

Characteristics

Risk

of

SSI

Risk Factors• Patient Related

– Age– Diabetes– Obesity– Smoking– Immunosuppression

• Organism– Colonization– Virulence– Drug-Resistance

• Peri-operative– Hair removal– Pre-op infections– Surgical scrub– Skin prep– Antimicrobial

prophylaxis• Agent• Timing

– Surgical skill– Operative time– OR traffic

Recommended Strategies for SSI Prevention

• Core processes that should be routinely practiced to prevent SSI

Hair Removal

• Do not remove hair unless necessary

• Remove outside of OR using clippers or depilatory

• Possible exception for shaving – urologic surgery

Antimicrobial Prophylaxis

• For indicated procedures, right agent, right time– Begin administration 1 hour prior to incision (2

hours for vancomycin, fluoroquinolones)• “Sweet spot” target – 20-30 minutes

– Stop antibiotics within 24 hours after surgery• Adjust dose for patient weight• Re-dose for procedures lasting 2 half-lives or longer

than prophylactic antibiotic• Oral and IV prophylaxis for colorectal surgery

Role of Vancomycin in Prophylaxis

• Do not routinely use vancomycin for antimicrobial prophylaxis

• Consider if methicillin-resistant Staphylococcus aureus (MRSA) SSI outbreak; of if “high” endemic MRSA SSI rates

• If used for a procedure where Staphylococci are common pathogens, administer in combination with B-lactam (eg cefazolin)– Consider combination prophylaxis for surgeries

involving prostheses

Glucose Control

• Control blood glucose during the immediate postoperative period for cardiac surgery patients (level I)– Maintain postoperative blood glucose of 180

mg/dL or lower 18–24 hours after anesthesia end time

– Avoid targeting levels of 110 mg/dl or lower

• Also recommended (level II) for other surgeries

Normothermia• �Maintain normothermia (temperature of 35.5 C or

more) during the perioperative period – Even mild degrees of hypothermia can increase

SSI rates. – Hypothermia may directly impair neutrophil

function or impair it indirectly by triggering subcutaneous vasoconstriction and subsequent tissue hypoxia.

– In addition, hypothermia may increase blood loss– Most data in colon/abdominal surgery

Supplemental Oxygen

• Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation– 80% FI02 for 2-6 hours post-op– Exclude patients with severe COPD– Data strongest in colon surgery populations– 25% reduction is SSI rates in some studies

Qadan et al, Arch Surg. 2009 Apr;144(4):359-66

Alcohol-containing Preoperative Skin Prep

• Alcohol is effective for preoperative skin antisepsis but does not have persistent activity when used alone. – Rapid, persistent, and cumulative antisepsis can be

achieved by combining with chlorhexidine gluconate (CHG) or aniodophor (povidone-iodine).

– Both CHG and povidone-iodine are acceptable.

• Alcohol is contraindicated for certain procedures– Including procedures in which the preparatory agent may

pool or not dry (eg, involving hair) due to fire risk. – Alcohol may also be contraindicated for procedures

involving mucosa, cornea, or ear.

Impervious Plastic Wound Protectors for GI and Biliary Tract Surgery

• A wound protector is a plastic sheath that lines a wound and can facilitate retraction of an incision during surgery without the need for additional mechanical retractors.

• A meta-analysis of 6 randomized clinical trials in 1,008 patients reported that use of a plastic wound protectors was associated with a 45% decrease in SSIs.

Edwards JP et al. Ann Surg 2012;256(1):53–59.

SSI Surveillance• Hallmark of SSI prevention• Many SSIs occur post discharge• Sensitivity of surveillance is poor for

superficial SSI• Deep, organ/space SSI usually require re-

admission– Sensitivity greater

• Use of automated data and alerts can improve and facilitate surveillance– Return to hospital, return to OR

Other Recommended Strategies for SSI Prevention

• WHO Checklist

• Feedback of data to surgeons– Risk-adjusted preferred– Anonymize

• Education of providers and patients

Special Approach: Screening/De-colonization of Patients for Staphylococcus

aureus• Considered a “special approach”• Consider for cardiothoracic, orthopedic surgeries

(involving prostheses)• Consider once other strategies have been trialed/are

in place• Often a 5-day pre-operative regimen of CHG bathing

(eg hibiclens) + intra-nasal mupirocoin is used• Role of intra-nasal “same day” nasal povidone-iodine

+ CHG bathing– Newer product: intra-nasal alcohol

Unresolved: Pre-Operative CHG Bathing

• Bathing night before and day of surgery

• Not currently recommended (listed as “unresolved”)– Many experts believe it works

• If done correctly, likely effective– Potential advantage of CHG wipes

Unresolved: Antimicrobial Sutures

• Use for deep suturing has been reported to reduce SSI

• No current recommendation for routine use

• Stay tuned

Challenges in SSI Prevention: Movement to Ambulatory Surgery Setting

• Progressive movement to surgery in ambulatory setting– More than ¾ of all surgeries in US performed in

outpatient setting

• Infrastructure, data systems often unique compared to those used in inpatient settings

• Infection control activities and processes frequently less established in outpatient settings

http://health.gov/hcq/resources-outpatient.asp

Surveillance Requires a LOT of Data Collection• Required data from surgical databases

– patient name, medical record number, date, type of procedure, surgeons, anesthesiologists, incision time, wound class, ASA score, closure time, and presence of an SSI

• Additional process data: – Prophylactic agent and dose and time(s) of administration

of prophylactic agent. – For patients diagnosed with SSI, necessary microbiological

data include type of SSI, infecting organism and antimicrobial susceptibilities, and date of infection.

• Additional information that may be useful for some procedures, including use of general anesthesia, emergency or trauma-related surgery, body mass index, and diagnosis of diabetes

Infection Control / Volume 35 / Issue 06 / June 2014, pp 605 – 627

SSI Surveillance is Time-Consuming• In one report, estimated time for an infection preventionist (IP)

to abstract a chart for a surgical implant case – 60 minutes (based on one-year post-op surveillance period)

• NJ hospital estimated that SSI surveillance took ~ 7 hours per work week of IP time (average daily census 192 patients)

• CDC estimates that SSI surveillance requires 540,000 IP hours annually in the US

• Automated programs can greatly reduce surveillance– Average time needed per case

• 6 minutes for manual abstraction• 2 minutes for automated abstraction

– Major limitation of automated surveillance is cost and effort for implementation

Sarvareddi et al, APIC, 2010, New Orleans, LA; Parillo, AJIC, 2015, S3-S17; CACC Meeting Report. Sacramento, CA: California APIC Coordinating Council, May5, 2011;

Increased Scrutiny on Infection Control Preventionist

• The old days: SSI surveillance was traditionally performed solely as part of quality improvement activities

• Current times: SSI rates used as a quality measure– Often publically reported – Impacts insurance reimbursement

• Surveillance definitions are not always relevant and can lead to friction between ICPs and clinicians, administrators

Additional Ongoing Challenges

• Many strategies sound simple but implementation can be complex– S. aureus screening/decolonization– Pre-operative CHG bathing– Supplemental oxygen/patient warming

What Recommendations are “New” and Might Not Yet Be Implemented at Your Site

• Supplemental oxygen– Was controversial; data now clearly support SSI

reduction– HICPAC likely to recommend in ALL surgeries, not

just colon• Glucose control

– New target is 180 mg/dL– HICPAC likely to recommend for ALL surgeries, not

just colon• Wounds protectors for GI surgery

– Make available to surgeons, share data regarding SSI reduction

What Recommendations are “New” and Might Not Yet Be Implemented (continued)

• Screening/decolonization of S. aureus– Screening and then implementing 5 day regimen

challenging• CHG bathing - difficult to get patient to perform correctly

– For targeted surgeries, might be easier to implement “same day” approaches for all patients (ie screen none, decolonize all)

• Streamlined/automated surgical data – Facilitate surveillance– Facilitate benchmarking, feedback

Summary

• SSI is common and can be deadly

• Many evidence-based approaches exist to prevent SSI

• Multi-disciplinary OR team makes SSI prevention challenging

• Implementation of preventive processes can be complex– When possible, Keep It Simple . . . (KISS)

• Don’t assume that basic strategies are being practiced at your hospital– If you look hard, you might be surprised by what you find

Questions?