1. Preventing Surgical Site Infections Donald E. Fry, M.D. Professor Emeritus of Surgery University of New Mexico

2. Prevention of SSIs Objectives Reduce the inoculum of bacteria at the surgical site Reduce the inoculum of bacteria at the surgical site Surgical Site Preparation Surgical Site Preparation Antibiotic Strategies Antibiotic Strategies Optimize the microenvironment of the surgical site Optimize the microenvironment of the surgical site Enhance the physiology of the host Enhance the physiology of the host

3. Hair Removal of the Surgical Site Razor vs. Clipper Percent SSI Infection Percent SSI Infection Discharge 30-day Follow up Discharge 30-day Follow up PM Razor 5.2%8.8% AM Razor6.4%10% PM Clipper4.0%7.5% AM Clipper1.8%3.2% Alexander JW et al: Arch Surg 1983; 118:347-52.

4. Antiseptic Preparation of the Surgical Site Isopropyl alcohol, povidone iodine, and chlorhexidine are all recommended. * Isopropyl alcohol, povidone iodine, and chlorhexidine are all recommended. * ChoiceCommentary Isopropyl alcoholFlammable Povidone IodineMust dry for maximum antibacterial effect ChlorhexidineColorless; even distribution at surgical site is an issue * Mangram AJ at al: Am J Infect Control 1999; 27:97-132.

5. Immunocompromised Surgical Host Microenvironment of the Surgical Site VariableCausationEffect Hemoglobin/Poor HemostasisIron, microbial Hematoma proliferation Hematoma proliferation Dead TissueElectrocauteryIneffective phagocytosis Foreign BodiesBraided SutureIneffective phagocytosis Dead SpaceObesity; Lack of No Drainage phagocytosis “The Germ is nothing, the terrain is everything” L. Pasteur (1895)

6. Joseph Lister A Surgeon from Edinburgh Introduced the practice of using Antiseptics during surgical procedures. Even introduced the aerosolization of antiseptics to prevent SSI.

7. Surgical Site Infection History of Preventive Strategies AntisepsisAsepsisAntibiotics

8. Preventive Systemic Antibiotics Experimental Evidence Cutaneous injection of bacteria Cutaneous injection of bacteria Inflammation at 24- 48 hrs is proportional to the logarithm of the bacterial inoculum. Inflammation at 24- 48 hrs is proportional to the logarithm of the bacterial inoculum.

10. Prevention of Surgical Site Infection Use of Preventive Antibiotics: GI Surgery Cephaloridine Placebo Cephaloridine Placebo Patients 101 98 Infections 6 29 (Polk and Lopez-Mayor, Surgery 1969; 66:97) (Polk and Lopez-Mayor, Surgery 1969; 66:97)

11. Preventive Systemic Antibiotics: Importance of Timing(Cefazolin) 8-12Hrs Preop 1Hr Preop 1-4Hrs Postop None 8-12Hrs Preop 1Hr Preop 1-4Hrs Postop None Gastric 5% 4% 17% 22% Biliary 3% 0% 9% 11% Colon 6% 6% 15% 16% Total 4% 3% 14% 15% ( Stone, Ann Surg 1976; 184:443) ( Stone, Ann Surg 1976; 184:443)

12. Preventive Systemic Antibiotics Postoperative Administration(Cefamandole) Preop Drug Preop Drug Preop Drug Preop Drug + 5 Days of Drug + 5 Days of Placebo + 5 Days of Drug + 5 Days of Placebo Gastric 0% 0% Biliary 0% 6% Colon 11% 9% Total 5% 6% (Stone, Ann Surg 1979; 189:691) (Stone, Ann Surg 1979; 189:691)

13. Systemic Preventive Antibiotics Penetrating Abdominal Trauma Timing # of Patients Timing # of Patients Infection Rate Preoperative 116 7% Intraoperative 98 33% Postoperative 81 30% ( Fullen et al: J Trauma 1972; 12:282)

14. Systemic Preventive Antibiotics Aortobifemoral Bypass SSIs/Patients Infection Rate SSIs/Patients Infection Rate Cefazolin 2/225 0.9% Placebo 16/237 6.8% ( Kaiser et al: Ann Surg 1978; 188:283) ( Kaiser et al: Ann Surg 1978; 188:283)

15. Systemic Preventive Antibiotics Hip Fracture Surgery SSIs/Patients Infection Rate SSIs/Patients Infection Rate Nafcillin 1/135 1% Placebo 7/145 5%(P<.04) (Boyd et al: JBJS 1973; 55:1251) (Boyd et al: JBJS 1973; 55:1251)

16. Systemic Preventive Antibiotics Open Fractures #Patients #Infections #Patients #Infections Cefonicid(One Day) 79 10(13%) Cefonicid(Five Day) 85 10(12%) Cefamandole(5 Day) 84 11(13%) (Dellinger et al:Arch Surg 1988; 123:333) (Dellinger et al:Arch Surg 1988; 123:333)

17. Antibiotic Prophylaxis Demonstrated Benefit G.I. Procedures (including appendicitis) G.I. Procedures (including appendicitis) Oropharyngeal procedures Oropharyngeal procedures Vascular (abd & leg) procedures Vascular (abd & leg) procedures Open heart procedures Open heart procedures Obstetrical and Gynecological procedures Obstetrical and Gynecological procedures Orthopaedic hardware placement Orthopaedic hardware placement Craniotomy Craniotomy Some “clean” procedures Some “clean” procedures

18. Systemic Preventive Antibiotics Contraindications Ventilator Patients to Prevent Pneumonia Ventilator Patients to Prevent Pneumonia Foley Catheters to Prevent UTI Foley Catheters to Prevent UTI IV Lines to Prevent Catheter Sepsis IV Lines to Prevent Catheter Sepsis Chest Tubes to Prevent Empyema Chest Tubes to Prevent Empyema Open Wounds(Including Fractures) Open Wounds(Including Fractures)

19. Song and Glenny: Brit J Surg 1998; 85:1232

20. Single vs Multiple Dose Surgical Prophylaxis: Systematic Review McDonald M: Aust NZ J Surg 1998;68:388 All studies, fixed All studies, random Multi > 24hMulti < 24h Favors single dose Favors multiple dose

21. Systemic Preventive Antibiotics Why Postoperative Administration Fails Systemically Administered Antibiotic does not penetrate the Established Fibrin Matrix in the Wound. 1 Systemically Administered Antibiotic does not penetrate the Established Fibrin Matrix in the Wound. 1 The Closed Surgical Wound has continued Inflammation and Edema, which creates a “Halo” of Ischemia. 2 The Closed Surgical Wound has continued Inflammation and Edema, which creates a “Halo” of Ischemia. 2 Dunn D, Simmons DL: Surgery 1982; 92:513-9. Lee JT: Surgical Infections, Fry DE(Ed), Little-Brown, Boston. Pp. 145-59, 1995.

22. Systemic Preventive Antibiotics Consequences of Prolonged Postoperative Use Excessive Antibiotic and Drug Delivery Costs. Excessive Antibiotic and Drug Delivery Costs. Increased Patterns of Antibiotic Resistance. Increased Patterns of Antibiotic Resistance. Increased Antibiotic-Associated Complications. Increased Antibiotic-Associated Complications. Bratzler et al Arch Surg 2005, 140:174-82.

23. Preventive Systemic Antibiotics Antibiotic-Associated Complications Hypersensitivity Hypersensitivity Nephrotoxicity Nephrotoxicity Hepatic Toxicity Hepatic Toxicity Coagulation/Platelet Aggregation Complications Coagulation/Platelet Aggregation Complications Fungal Super-infections Fungal Super-infections Clostridium difficile Enterocolitis Clostridium difficile Enterocolitis Cunha BA: Med Clin N Am 2001; 85:149-85.

24. Systemic Preventive Antibiotics Elimination Half-life Counts Cephalothin is gone from the wound in 90 min from time of administration. Cephalothin is gone from the wound in 90 min from time of administration. Cefazolin in therapeutic concentrations beyond 2½ hours. Cefazolin in therapeutic concentrations beyond 2½ hours. Fry and Pitcher: Arch Surg 1990; 125:1490

25. Prevention of SSIs Surgical Infection Prevention Project Administration of antibiotic within 60 min of skin incision. Administration of antibiotic within 60 min of skin incision. Antibiotic consistent with recommended choices. Antibiotic consistent with recommended choices. Antibiotic should not be continued beyond 24 hours after completion of the procedure. Antibiotic should not be continued beyond 24 hours after completion of the procedure. Bratzler et al Arch Surg 2005, 140:174-82.

26. Surgical Infection Prevention Performance Stratified by Surgery 40.792.947.6 All Surgeries (34,133) 79.190.852.4 Hysterectomy (2,756) 41.075.940.6 Colon (5,279) 36.397.452.0 Hip/knee (15,030) 44.891.940.0 Vascular (3,207) 34.395.845.3 Cardiac (7,861) Antibiotic Stopped within 24 hours % Correct Antibiotic % Antibiotic within 1 hour % Surgery (N)

27. Discontinuation of Antibiotics Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery. Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

28. Public Law 109-171 Deficit Reduction Act of 2005 Procedures of reporting Procedures of reporting Each hospital must: Each hospital must: For the FY 2007 update, hospitals are required to complete and return a written form on which they pledge to submit data 21 clinical quality measures beginning with discharges that occur in July 2006 For the FY 2007 update, hospitals are required to complete and return a written form on which they pledge to submit data 21 clinical quality measures beginning with discharges that occur in July 2006 Failure to report results in loss of 2% of the hospital’s annual payment update Failure to report results in loss of 2% of the hospital’s annual payment update Final Inpatient Prospective Payment System Rule published August 18, 2006 in Federal Register

29. Public Law 109-171 Deficit Reduction Act of 2005 Surgical Infection Prevention/SCIP Surgical Infection Prevention/SCIP Antibiotic within 60 minutes incision Antibiotic within 60 minutes incision Antibiotic choice consistent with SIP/SCIP Recommendations Antibiotic choice consistent with SIP/SCIP Recommendations Antibiotic DCed within 24 hours surgery end time (48 hours cardiac surgery) Antibiotic DCed within 24 hours surgery end time (48 hours cardiac surgery)

30. Prevention of SSIs Something New Potential Strategies to Augment the Host!  Oxygen Supplementation  Intraoperative Temperature Control  Glucose Control

31. Prevention of SSIs Enhanced Oxygenation 0.30 FiO 2 0.80 FiO 2 0.30 FiO 2 0.80 FiO 2 No. Patients 250 250 SSIs 28 13 Infection Rate 11% 5% (Grief et al: NEJM 2000; 342:161) (Grief et al: NEJM 2000; 342:161)

32. Prevention of SSIs Temperature Control T o >36.5 T o >34.5 T o >36.5 T o >34.5 No. Patients 104 96 Transfused Pts. 23(22%) 34(35%)[P<.054] SSIs 6 18 Infection Rate 5.8% 18.8%(P<.009) ( Kurz et al: NEJM 1996; 334:1209) ( Kurz et al: NEJM 1996; 334:1209)

33. Prevention of SSIs Glucose Control Intermittent Continuous Intermittent Continuous Insulin Infusion Insulin Infusion No. Patients 968 1499 Deep Sternal SSI 19 12(P<0.01) Infection Rate 2.0% 0.8% (Furnary et al: Ann Thorac Surg 1999; 67:352) (Furnary et al: Ann Thorac Surg 1999; 67:352)

35. Surgical Care Improvement Project: Why? Medicare could prevent* up to: 13,027 perioperative deaths 271,055 surgical complications * Major surgical cases

36. Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010 To reduce preventable surgical morbidity and mortality by 25% by 2010

37. Surgical Care Improvement Project (SCIP) Preventable Complication Modules Preventable Complication Modules Surgical infection prevention Surgical infection prevention Cardiovascular complication prevention Cardiovascular complication prevention Venous thromboembolism prevention Venous thromboembolism prevention Respiratory complication prevention Respiratory complication prevention

38. Surgical Care Improvement Project Performance measures - Process Surgical infection prevention Surgical infection prevention Antibiotics Antibiotics Administration within one hour before incision Administration within one hour before incision Use of antimicrobial recommended in guideline Use of antimicrobial recommended in guideline Discontinuation within 24 hours of surgery end Discontinuation within 24 hours of surgery end Glucose control in cardiac surgery patients Glucose control in cardiac surgery patients Proper hair removal Proper hair removal Normothermia in colorectal surgery patients Normothermia in colorectal surgery patients Reporting of SSI rates by Hospital is expected to be the first surgical outcome measure for reporting. Reporting of SSI rates by Hospital is expected to be the first surgical outcome measure for reporting.

39. Preventive Antibiotics in Colorectal Surgery Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190(1):9-15. One year demonstration project of 56 hospitals. Employed systems changes, education, and monitoring of process measures. Marked improvement in all procedures seen compared to national data. 27% improvement in SSI rates.

40. Preventing Surgical Site Infection Summary Appropriate Preparation of the Surgical Site Appropriate Preparation of the Surgical Site Appropriate Hair Removal Appropriate Hair Removal Antiseptic Preparation of the Site Antiseptic Preparation of the Site Appropriate Use of Systemic Preventive Antibiotics Appropriate Use of Systemic Preventive Antibiotics Administer within 60 min window before incision Administer within 60 min window before incision Appropriate drug choice Appropriate drug choice Discontinue with 24 hours of the procedure Discontinue with 24 hours of the procedure Optimization of the Physiology of the Host Optimization of the Physiology of the Host Supplemental Oxygenation Supplemental Oxygenation Core Temperature Control Core Temperature Control Glucose Control Glucose Control