Postoperative breast infections at Touro Infirmary: increase in cases and response thus far Jay Hawkshead, DrPH, CPH, CIC Infection Control Manager Touro Infirmary

Overview From January 2012 through June 2013, there were 61 individually documented mastectomy and breast reconstruction procedures performed in the Touro ORs by staff surgeon in question. For this period, a total of 11 infections meeting NHSN criteria for surgical site infection have been confirmed in his patients, for an overall rate of 18.0% in these procedures. Overall rate of postoperative infection in OR class 1 and 2 procedures over the same period, which was 0.7% (45 infections out of 6572 procedures). 61 procedures through June 2013 represent nearly a doubling of the surgeon’s case volume over the previous 18 month period, from July 2010 through December 2011 (34 cases).

Overview cont.’d

Case characteristics Cases in 2012-13 are the only such infections recorded by Infection Control since 2008. The majority of patients who developed infection in were those upon whom the surgeon in question performed the reconstruction (9 patients), typically with a DIEP flap, while the minority (3) were mastectomies. ASA score typically 3 (serious systemic disease that is not a constant threat to life). Organisms isolated from the patients’ wounds were typically gram negatives, e.g., Pseudomonas, Klebsiella, and Proteus species, along with 2 isolates of Staphylococcus aureus; 2 cases culture negative. Polymicrobial cases were common.

Case characteristics cont.’d Infections typically appeared 2-4 weeks post-procedure. Cases and controls in 2012 cases analyzed did not differ significantly based on age (p = 0.754) or BMI (p = 0.250). A total of 7 other staff surgeons altogether either performed procedures on the patient the same day as the surgeon in question, or assisted during his procedures  there was no significant difference in the rate of participation of these other surgeons among the patients who developed infection (p = 0.54).

Initial response by hospital By May 2012, the first 3 SSIs in the surgeon’s patients had been confirmed. Initially, each case was reviewed with the OR team trying to identify any specific issues with the specific cases. No flash sterilization had been done and no particular OR related issues were identified. In July there was a another case; again practices were reviewed. The surgeon was consulted to identify if there were any specific issues that he could identify to explain the increase; none were reported. In October 2012, there were 3 additional SSIs in breast surgery patients.

Initial response by hospital cont.’d The OR team and the surgeon came up with the following actions: Sterilize the Mayo stand (consider getting sterile disposable Mayo trays) Identified and provided new Neoprobe cover Minimized staff relief and traffic in these cases (note: these issues have been noted by Orthopaedic service as well) Requested capital purchase of Bluetooth Neoprobe (approved) Focused use of the IRiS UV light room decontamination system Discussed hair removal strategies

Case control study begun As further cases continued to be discovered, Infection Control undertook a case control study to determine significant risk factors for postoperative infections in this patient population. But what risk factors were we looking for exactly?  MANY known risk factors for SSI have been described, but which ones are most important in these cases? We reviewed the literature, and found a 2012 meta- analysis that identified significant risk factors in such surgeries.

Xue et al., EJSO 38

Data collection Based on Xue et al.’s findings of significant risk factors, we reviewed charts of patients operated on in 2012 to collect data on certain risk factors, including but not limited to: Age HTN, diabetes, smoking status BMI ASA Surgical, chemo, radiation therapy history Amount of intraoperative bleeding Drainage tubes Corticosteroid exposure

Results Univariate analyses revealed the following statistically significant (p ≤ 0.05) or borderline significant (0.05 ≤ p ≤ 0.10) associations between risk factors and outcome of SSI: HTN (p = 0.03), diabetes (p = 0.06) Use of 15FF Blake drain (p = 0.06)  use of other drain types was not significant, nor were the total number of drains used Amount of intraoperative bleeding in cc (p = 0.09) Bilateral procedure (p = 0.09)  these tended to be much longer in duration (?diminution of preop antibiotic effectiveness, need to reprep before second procedure) ?BMI (p = 0.11) In multivariate logistic regression model, bilateral procedure (p = 0.10) and presence of diabetes/hypertension (p = 0.09) retained borderline significant association with an outcome of postoperative infection.

Surgeon’s take The surgeon contends that inherent risk factors in his patient population are leading to infections: HTN/diabetes, weight, cancer diagnoses, etc. Significant associations between presence of these risk factors and the outcome suggest he may have a point. But questions still to be answered include: How well controlled are the patients’ diabetes and HTN? And how well are incisions being cared for at home? Could intraop bleeding have been better controlled? Were patients redosed with prophylactic antibiotics at the appropriate time, particularly in longer (esp. bilateral) procedures?

Next steps Results of analysis were recently presented to infection control committee and hospital administration. Recommendation was made to share results with the chief of surgery, who could then discuss the situation with the surgeon in question  this has not happened yet (but hopefully will soon) In the meantime, further research will be done to add 2013 patients, both infected and noninfected, to the database, with goal of increasing statistical power. We also intend to gather better data pertaining to the questions of preoperative antibiotic timing, redosing, etc.; these have been identified as issues in other surgical procedures in the hospital.

Questions? Observations? Suggestions? Thank you!