1. Preventing Surgical Site Infections in the OR
Kerri A. Thom, MD, MS
Assistant Professor, UM School of Medicine

2. Nothing to Disclose

3. Key Point
Up to 60% of surgical site infections may be preventable and there are multiple strategies aims at reducing infection

4. Key Points – SSI Prevention
Up to 60% of SSI are preventable
Antibiotic prophylaxis is very important
Be aware of your own bioburden
Be aware of impact of traffic/door openings

5. Key Points
Surgical antimicrobial prophylaxis is the most important intervention in the prevention of SSI
Essential elements include:
Selection of appropriate agent
Timing (within 1 hour of incision)
Dose (weight-based, re-dosing)
Minimizing adverse events

6. Objectives
Recognize modifiable risk factors for surgical site infection
Provide safe care by applying key measures to preventing infections in the OR
Optimize antibiotic prophylaxis by selecting the most appropriate agent and giving the optimal dose at the optimal time

7. Overview Background Antibiotic Prophylaxis, What Matters
Modifiable risks for SSI
Antibiotic Prophylaxis, What Matters
Agent, dose, time
Other important measures
Optimizing modifiable risk factors
Use of the surgical checklist
Hand hygiene
Limiting traffic and door openings

8. Surgical Site Infections (SSI)
Most Common Healthcare infection1
21% of all HAIs
11%, BSI
HAP
14%
20%, SSI
36%, UTI
CLABSI
14%
22%, Other
11%, PNA
Magill S et al. N Engl J Med, 2014

9. Surgical Site Infections (SSI)
Most Common Healthcare infection1
21% of all HAIs
11%, BSI
15 million inpatient surgeries per year
HAP
14%
20%, SSI
36%, UTI
CLABSI
14%
22%, Other
11%, PNA
Magill S et al. N Engl J Med, 2014

10. Surgical Site Infections (SSI)
Most Common Healthcare infection1
21% of all HAIs
11%, BSI
15 million inpatient surgeries per year
2-5% ( K) develop SSI
HAP
14%
20%, SSI
36%, UTI
CLABSI
14%
22%, Other
11%, PNA
Magill S et al. N Engl J Med, 2014

11. Surgical Site Infections (SSI)
Most Common Healthcare infection1
21% of all HAIs
Up to 55% of SSIs are preventable!
11%, BSI
HAP
14%
20%, SSI
36%, UTI
CLABSI
14%
22%, Other
11%, PNA
1Magill S et al. N Engl J Med, Umscheid et al. Infect Control Hosp Epidemiol, 2011

12. Surgical Site Infections (SSI)
Prolong hospital stay (7-10 days)
Increased Mortality
Risk of death, 2-11 times greater
77% of deaths are attributable to SSI
More expensive than other complications (e.g., sternal wound infections most expensive complication of CABG)
1/3 of these are deep/organ space
Kirckland et al, Infect Control Hosp Epi, 1999 Managram et al, Infect Control Hosp Epi, 1999 Hollenbeak et al, Chest, 2000 Wenzel et al, Clin Infect Dis, 2007

13. Pathogenesis SSI Microbial Characteristics Host Characteristics
e.g. Virulence, Dose
SSI
Complex relationship between microbial contamination and patient/surgical characteristics
Host Characteristics
Surgical Characteristics
e.g. Duration, Implant
e.g. Host Defense, Immunity
Anderson. Infect Dis Clinics North Am 2011

14. Microbial Characteristics
Pathogenesis
Microbial Characteristics
e.g. Virulence, Dose
SSI
Microbial contamination of the wound is a necessary step!
The risk is greatest when the wound is open (e.g. commonly at the time of surgery)
Host Characteristics
Surgical Characteristics
e.g. Duration, Implant
e.g. Host Defense, Immunity
Anderson. Infect Dis Clinics North Am 2011

15. Sources of Microbial Contamination
Endogenous
Exogenous
ADD PICTURES HERE ENDOGENOUS – PATIENT
EXOGENOUS – SURIGCAL HAND HOLDING INTRUMENT
Altemeier, Surg Clin North Am 1968 Berkelman, JAMA 1982 Bassett, Lancet 1970 Clegg, J Infect Dis 1983 Gartenberg, N Engl J Med 1978
Most Common
Gram-positive (Skin Flora)
Air, Instruments, etc…
Post-operative Dressing

16. Organisms Causing SSI
Staphylococcus aureus 30.0% Coag-negative Staphylococci 13.7% Enterococcus spp. 11.2% Escherichia coli 9.6% Pseudomonas aeruginosa 5.6% Rest: Other gram negative bacteria, Candida
Point out that the most important thing to remember is that they causative organisms typically reflect the normal flora and common colonizing organisms of the surgical site
Hidron, Infect Control Hosp Epidemiol 2008

17. SSI Patient Post-Operative Surgery Patient Age Undernutrition
Infection at Remote Site
Prolonged Pre-op Stay
Prior Operations
Immunesuppression
Cancer
Diabetes
Obesity
Smoking
Surgical
Wound Class
Prophylactic Antibiotics
Pre-op Cleansing
Pre-op Screening
Pre-op Hair Removal
Surgical Technique Surgical Duration
OR environment
Hypothermia
SSI
Post-Op
Glucose Control
Wound Care

18. Prophylactic Antibiotics
Use for surgeries that require:
entering a hollow viscus, insertion of prosthesis, or if development of SSI would pose catastrophic risk
Point out that the most important thing to remember is that they causative organisms typically reflect the normal flora and common colonizing organisms of the surgical site
One of the most important interventions to prevent SSI

19. The Ideal Agent?

20. No impact on Microbiome
The Ideal Agent?
Safe
Effective
No impact on Microbiome

21. Antibiotic Selection Activity against expected pathogens
Favorable safety profile (toxicities, allergies)
Favorable cost profile
Point out that the most important thing to remember is that they causative organisms typically reflect the normal flora and common colonizing organisms of the surgical site

22. Dose Weight-based Cefazolin 2 gm for all RCT of 1 versus 2 gm
1 gm decreased serum/tissue concentrations, below necessary MICs
Point out that the most important thing to remember is that they causative organisms typically reflect the normal flora and common colonizing organisms of the surgical site
Forse, Surg, 1989

23. Timing Successful prophylaxis relies on drug availability
at the operative site during time of contamination
Begin administration within 1 hour of cut time
2 hr for Vanc/FQ
Complete administration by incision
Re-dose at 3 hour intervals (and/or blood loss)
Stop antibiotics after procedure
Point out that the most important thing to remember is that they causative organisms typically reflect the normal flora and common colonizing organisms of the surgical site

24. Timing
SSI rates corresponding to the temporal association between administration of antibiotics and the start of surgery
2847 pts elective clean or clean/contaminated surgeries
Classen NEJM, 1992

25. Timing
Association between the timing of prophylaxis and incidence of SSI following Cardiac Surgery, THA/TKA, Hysterectomy
4472 patients
Steinberg JP, Ann Surg, 2009

26. Timing Successful prophylaxis relies on drug availability
at the operative site during time of contamination
Begin administration within 1 hour of cut time
2 hr for Vanc/FQ
Complete administration by incision
Re-dose at 3 hour intervals (and/or blood loss)
Stop antibiotics after procedure
Point out that the most important thing to remember is that they causative organisms typically reflect the normal flora and common colonizing organisms of the surgical site

27. National QI Initiatives
SCIP (Surgical Care Improvement Project)
Appropriate selection
Within 1 hour
Stopped within 24 hours
CMS Reporting
SSI after CABG, THA, TKA
Soon…SSI after Colorectal and Hysterectomy

29. Other Infection Prevention Measures

30. (based on WHO Surgical Checklist)
Use an OR Checklist
(based on WHO Surgical Checklist)

31. Surgical Checklist

33. Results of Starting Checklist
Variable % Decrease p value
Total disruptions/case 47 <0.01
Miscommunications/case
Time circulator gone
Henrickson. J Amer Coll Surgeons 2009; 208:

34. Does the Checklist Impact Mortality?
22 item checklist modeled on WHO
25,513 patients followed
Record of checklist completion:
Not done
Partial - at least 1 of 22 done
Completed - all done
van Klei. Ann Surg 2012; 255: 44-9

35. Checklist Completion and Mortality
Adjusted Odds Ratio Mortality All patients 0.85 ( )
van Klei. Ann Surg 2012; 255: 44-9

36. Checklist Completion and Mortality
Adjusted Odds Ratio Mortality All patients 0.85 ( ) Completed 0.44 ( ) Partial 1.09 ( ) Not done 1.16 (
van Klei. Ann Surg 2012; 255: 44-9

39. Reducing our own bioburden
Hand hygiene (and/or surgical scrub)
Appropriate attire
Including covering hair
Monitor for skin lesions

40. Hand Hygiene
In/Out of Room
Multiple opportunities during case

41. Healthcare worker attire is not sterile and is commonly contaminated with potentially pathogenic bacteria both in the course of duties at work and in care, maintenance and wearing of attire outside the hospital setting. Studies consistently show that 25 to 50% of hospital ‘scrubs’ are contaminated with potentially pathogenic bacteria such as MRSA and Acinetobacter baumannii. At the University of Maryland Medical Center 30% of scrubs of ICU nurses are contaminated with these bacteria (unpublished data not shown below). Additional data from UMMC has shown that after caring for patients with a multidrug-resistant organism, healthcare workers acquire these bacteria on their clothing between 20 to 40% of the time. Researchers at VCU have shown in a simulated setting that bacteria contaminating healthcare worker white coats can easily transfer to pig skin. Further, researchers at U Miami have shown that contamination of healthcare hands, which are known to be the primary vector of transmission of bacteria to patients, is correlated with contamination of attire (scrubs and white coats). These and other studies suggest that attire, and in particular contaminated attire, do play a role in transmission of bacteria to patients in the hospital setting.
In the OR setting, several studies below are worth noting demonstrating that the bacteria that contaminate OR scrubs worn under sterile gowns can penetrate through these gowns and be cultured, which in turn can then be spread via surgeon hands to the patient. Further, bacteria on the scrubs can be found in air samples in the OR. In a very interesting report of an outbreak of Gordonia bronchialis sternal wound infections, investigators identified a single nurse whose clothing and washing machine were contaminated with G. bronchialis. Removal of potential pathogenic microorganisms during the laundering process has been shown to be reliant on several factors including water temperature, appropriate use of detergent and ironing. Healthcare worker clothing laundered at home is more likely to be contaminated with potential bacteria than attire laundered by a healthcare facility (or third party). In one study, investigators found that scrubs were contaminated 39% of the time at the beginning (compared to 50% of the time at the end of a shift) even when considered “clean” by the healthcare worker. At a study done at UMMC, white coats of surgeons and internists were contaminated with S. aureus 22.8% of the time, and there was a higher portion of coats contaminated if the scrubs were cleaned at home (59%) compared to cleaning in the hospital laundry facility (29%). Another study showed that hospital laundered scrubs had significantly fewer bacterial counts than home laundered scrubs (p < 0.01). And a separate study demonstrated that ‘clean’ re-useable scrubs laundered at home had higher bacterial colony count than scrubs laundered by third party facility or hospital and these ‘clean’ scrubs were more similar to ‘worn” scrubs with respect to bacterial counts.

42. Managing Air Flow

43. Microbial Air Counts and OR Traffic
68% of the variance in total CFU/m3 (p = 0.001) explained by
Traffic flow (door openings)
Number of persons (clutter) in the OR
Procedure duration
In addition, the data showed a strongly positive correlation between the
A weaker, yet still positive correlation between
AE Andersson et al. AJIC 2012, Jan 28 epublished

46. Door Openings 284 operations 22 pts had SSI: Risk factors for SSI:
Mastectomy (n = 5; 2.8%)
Colon resection (n = 16; 21.6%)
Aorta reconstruction (n = 1; 2.8%)
Risk factors for SSI:
Wound class: p < 0.001
Emergency procedure: p = 0.001
Door openings/hour 0-6 vs > 6: p = 0.02
prospective surveillance of SSI and implementation of bundle elements: timing of perioperative prophy abx, hygiene disicipline = door openings, appropriate hair removal, periop normothermia
FJ Prakken, et al. NED TIJDSCHR GENEESKD. 2011;155:A3269

47. Reasons for Door Openings
177 (33.5%) = necessary
40 = expert consultations
137 = supplies & equipment
184 (35.7%) = semi-necessary
76 = surgical team members entering or leaving
134 = breaks
168 (31.8%) = unnecessary
30 = logistics, like planning other operations
45 = social
93 = no detectable reason
AE Andersson et al. AJIC 2012, Jan 28 epublished

48. Door Openings Number of door openings varied by specialty
19-50 door openings/hour
OR doors open:
~20 seconds/opening
15-20 min/hour
Requests for information > breaks (~25%) > supplies (~20%)
RJ Lynch, et al. Am J Med Qual 2009;24;45-52

49. Strategies to Reduce Door Opening

50. Key Point
Up to 60% of surgical site infections may be preventable and there are multiple strategies aims at reducing infection

51. Key Points – SSI Prevention
Up to 60% of SSI are preventable
Antibiotic prophylaxis is very important
Be aware of your own bioburden
Be aware of impact of traffic/door openings

52. Key Points
Surgical antimicrobial prophylaxis is the most important intervention in the prevention of SSI
Essential elements include:
Selection of appropriate agent
Timing (within 1 hour of incision)
Dose (weight-based, re-dosing)
Minimizing adverse events

53. WASH YOUR HANDS!
ANY QUESTIONS?