Prevenzione dellee infezioni del sito chirurgico

Transcription

1 Prevenzione dellee infezioni del sito chirurgico Nicola Petrosillo Istituto Nazionale per le Malattie Infettive Lazzaro Spallanzani, Roma, Italy

2 Post-operative infections in Italy Prospective national multicenter surveillance study was conducted ingeneral and Gynecological units of 48 Italian hospitals 4665 intervention in 48 surgical units SSI occurred in: -61.4%) during inhospital, -38.6% during postdischarge 316 infections ( 6.8 per 100 interventions) 0,9% 0,7% 5,2% SSI BSI LRTI Petrosillo N et al. BMC Infect Dis 2008; 8: 34

3 Epidemiology of SSI

4 Mortality risk is high among patients with SSIs A patient with an SSI is: 5x more likely to be readmitted after discharge 1 2x more likely to spend time in intensive care 1 2x more likely to die after surgery 1 The mortality risk is due to MRSA higher when SSI is A patient with MRSA is 12x more likely to die after surgery 2 1. WHO Guidelines for Safe Surgery Engemann JJ et al. Clin Infect Dis. 2003;36:

5 Current SSI Burden Burden-US ~300,000 SSIs/yr (17% of all HAI; second to UTI) 2%-5% of patients undergoing inpatient surgery Mortality 3% mortality 75% of deaths among SSI patients are directly attributable to SSI Morbidity- long-term disabilities Length of Hospital Stay ~7-10 additional postoperative hospital days Cost $3000-$29,000/SSI depending on procedure & pathogen Up to $10 billion annually Anderson DJ, et..al., Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29:S51-S61 for individual references

6 HAI Est Annual % Est Direct Cost Surgical Site Infection (SSI) 33.7% $ MRSA SSI $ Central Line Associated Bloodstream Infection (CLABSI) MRSA CLABSI Ventilator Associated Pneumonia (VAP) Catheter Associated Urinary Tract Infection (CAUTI) Clostridium difficile Infection (CDI) 18.9% $ % $ <1% $ % $ Avg Length of Stay Attributable Mortality ~11.days ~4% ~23 days ~10 days ~26% ~16 days ~13 days ~24% < 1 day <1% ~ 3 days ~4% Zimlichman E et al. JAMA Intern Med 2013

7 Multistate Point-Prevalence Care Associated Infections Survey of Health Prevalence survey in 10 geographically diverse states (183 hospitals) to determine the prevalence of health care-associated infections in acute care hospitals 504 (~4%) infections in 11,282 patients Most common infections: Pneumonia (21.8%), SSI (21.8%) Gastrointestinal infections (17.1%) Magill SS, et al. N Engl J Med 2014;370:

8 Estimates of Healthcare-Associated Infections Occurring in Acute Care Hospitals in the United States, 2011 Major Site of Infection Pneumonia Gastrointestinal Illness Urinary Tract Infections Primary Bloodstream Infections Surgical site infections from any inpatient surgery Other types of infections Estimated total number of infections in hospitals Estimated No. 157, ,100 93,300 71, , , ,800 Magill SS, et al. N Engl J Med 2014;370:

9 In , 29 EU/EEA Member States and Croatia participated in the first EU-wide, ECDC-coordinated point prevalence survey (PPS) of healthcare-associated infections (HAIs) and antimicrobial use in acute care hospitals patients from 947 hospitals were included in the final European sample for analysis.

10 The prevalence of patients with at least one HAI in acute care hospitals in the PPS sample was 6.0% (country range 2.3% 10.8%). Of a total of reported HAIs, the most frequently reported HAI types were -respiratory tract infections (pneumonia 19.4% and lower respiratory tract 4.1%), -surgical site infections (19.6%), -urinary tract infections (19.0%), -bloodstream infections (10.7%) and -gastro-intestinal infections (7.7%), with Clostridium difficile infections accounting for 48% of the latter.

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13 At Uni- and Multivariate analysis risk for of SSI : longer intervention duration ASA score of at least three Duration of pre-surgery hospital stay of at least two days Videoscopic procedures were associated with reduced SSI rates Operations performed in hospitals with at least two years of surveillance behind them showed a 29% lower risk of SSI

14 Proportion of surgical site infections identified through post-discharge surveillance, Italy, (n=1,628) Over 60%, identifiedd through PDS

15 Tanner J et al. Surgery 2015;158:66-77

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17 PREOPERATIVE BATHING AND SKIN PREPARATION Ensuring personal hygiene of the operative team and surgical patient on the day of surgery is not controversial but the role of preoperative bathing and skin preparation with antiseptics to prevent SSIs is unproven. A Cochrane review of seven randomized controlled trials (RCTs; n= patients) found that preoperative showering or bathing with chlorhexidine was found to be no more effective than placebo, soap or no washing. Most of the studies included were over 20 years old. Webster J et al. Cochrane Database Syst Rev 2012; (9):CD004985

18 PREOPERATIVE BATHING AND SKIN PREPARATION A further systematic review of 10 studies (n=7351) examined the effects of the number of antiseptic showers and type of antiseptics. No definitive conclusions could be made about the optimal number of preoperative showers, but in eight of the studies, chlorhexidine led to a reduction in skin surface bioburden. There were many methodological flaws in the trials, many being underpowered. In addition, skin bacteria did not seem to necessarily correlate with SSI risk. Jakobsson J et al. Worldviews Evidence-Based Nursing 2011; 8:

19 PREOPERATIVE BATHING AND SKIN PREPARATION - Another systematic review of 20 randomized and nonrandomized studies (n=9520) evaluated three types of skin antiseptic (povidone iodine, alcohol or chlorhexidine) for patient skin preparation, operative team hand scrub procedure, preoperative showering or the use of antiseptic-impregnated incise drapes, prior to thoracic, cardiac, plastic, orthopaedic, neurological, abdominal or pelvic surgery. Kamel C et al. Infect Control Hosp Epidemiol 2012; 33:

20 PREOPERATIVE BATHING AND SKIN PREPARATION Significant heterogeneity precluded meta-analysis but preoperative showering appeared to reduce skin surface bioburden; however, the effect on SSIs was inconclusive. Again there were multiple flaws in the studies including inconsistencies in the formulation, strength and application of antiseptics, with mixed quality and randomization and the inclusion of a wide range of procedures. Kamel C et al. Infect Control Hosp Epidemiol 2012; 33:

21 Edmiston CE et al.

22 Edmiston CE et al.

23 Edmiston CE et al. 4% shower, a minimum of 2 sequential showers and 1- minute pause before rinsing maximal skin surface concentrations of chlorexidine gluconate that are sufficient to inhibit or kill gram-positive or gram negative surgical wound pathogens.

24 PATIENT ANTISEPTIC SKIN PREPARATION It is conventional practice to prepare patients skin at the surgical site immediately before incision using an antiseptic (such as povidone iodine or chlorhexidine; aqueous or alcohol based).

25 PATIENT ANTISEPTIC SKIN PREPARATION A Cochrane review compared different preoperative skin preparations for preventing SSI after caesarean section in five randomized, quasi-randomizedd and cluster randomized trials (n=1462). In women who received skin preparation preoperatively the use of incisional drapes made no significant difference to SSI rates [relative risk (RR)=1.29, 95% CI , P=0.084]. One trial (n=79) comparing alcohol scrub along with a povidone iodine incise drape vs. povidone iodine scrub without drape reported no infections in either group. No conclusions can be confidently drawn because of heterogeneity and low numbers of patients studied, Hadiati DR et al. Cochrane Database Syst Rev 2014; CD

26 PATIENT ANTISEPTIC SKIN PREPARATION An RCT (n=849) compared alcoholic 2% chlorhexidine, administered from a disposable device, with a conventional aqueous povidone iodine skin preparation. The chlorhexidine group significantly reduced SSIs but the comparison with an aqueous based antiseptic was flawed; nevertheless, this device has had a wide uptake in surgery in general. Darouiche RO et al. N Engl J Med 2010; 362:18 26

27 PATIENT ANTISEPTIC SKIN PREPARATION The most effective antiseptic for skin preparation before surgical incision is uncertain, but alcohol based antiseptics are likely to be more effective than aqueous solutions. Darouiche RO et al. N Engl J Med 2010; 362:18 26

28 Optimal oxigenation during surgery is part of best practice to ensure a haemoglobin saturation of more than 95%. A systematic review and meta-analysis of 7 RCTs (n=2728) examined the role of perioperative oxygen supplementation (fraction of inspired oxygen, FiO 2 = 0.8) for 2h postoperatively in the recovery room to reduce SSIs. No significant difference between the study and control groups Benefit for colorectal surgery. Togioka B et al. Anesth Analg 2012; 114:

29 It is conventional to cover incisions with a dressing at the end of an operation. Wheter a dressing is necessary at all, or wheter it should be a transparent polyurethane or absorptive island dressing, is unclear.

30 A cochrane review of 16 RCTs (n= 2578) investigated the value of wound dressings for the prevention of SSIs and found that there was no evidence that covering wounds reduced SSIs. Caveat: there were many methodological flaws in these trials, including heterogeneity, small size and poor scientific quality; many were old studies

31 The concept of a wound barrier, used during surgery to protect the wound edges from contamination, is attractive, but wound guards, based on semirigid plastic rings inserted into the incisionn with drapes attached to the circumference, have not been part of routine surgical practice

32 Pinkney TD et al.

33 A systematic review and meta-analysis found 10 RCTs and 2 controlled trials (n=1933) on the use of wound guards to prevent SSIs after open abdominal, mostly colorectal, surgery. Most studies were old and of poor quality, with variable definitions and risk of bias, but an exploratory meta-analysis using a random effects model suggested a potential benefit (RR= 0.60, 95% CI , p=0.005). Gheorghe A et al. Ann Surg 2012; 255:

34 Pinkney TD et al.

35 There are 3 independently undertaken systematic reviews and metanalysess which found level 1 evidence for their use. Subanalysis suggested that the effect was only significant after abdominal surgery but not after breast or cardiac surgery. Wang ZH et al. Br J Surg 2013; 100:465-73

36 Edmiston CE et al. Surgery 2013; 154:89-100

37 Daoud FC et al. Surg Infect (Larchment) 2014; 15:165-81

38 Early versus delayed post-operative bathing or showering to prevent wound complications There is currently no guidance about when the wound can be made wet by post-operative bathing or showering. Early bathing (i.e. within 48 hours after surgery) may encourage early mobilisation of the patient, which is good after most types of operation. Avoiding post-operative bathing or showering for two to three days may result in accumulation of sweat and dirt on the body. Conversely, early washing of the surgical wound may have an adverse effect on healing, for example by irritating or macerating the wound, and disturbing the healing environment. Toon CD et al. Cochrane Database Syst Rev Jul 23;7:CD010075

39 Early versus delayed post-operative bathing or showering to prevent wound complications CONCLUSIONS There is currently no conclusive evidence available from randomised trials regarding the benefits or harms of early versus delayed post-operative showering or bathing for the prevention of wound complications, as the confidence intervals around the point estimate are wide, and, therefore, a clinically significant increase or decrease in SSI by early post- be ruled operative bathing cannot out. Toon CD et al. Cochrane Database Syst Rev Jul 23;7:CD010075

40 Pada S et al. Curr Opin Infect Dis 2015; 28:369-74

41 Evidence of the detrimental effects of operating theater door opening was demonstrated in an observation quality improvement project. Bundle of care perioperative antibiotics, hair removal before surgery, perioperativee normothermia, and discipline in the operating room; or limiting the number of operating room door openings (a surrogate marker for operating room discipline) effect on SSI rates after colorectal surgery. The biggest effect was observed once compliance with operating theater door openings reached 80%. Crolla RMPH et al. PLoS One 2012; 7: e44599

42 LAF, based on the principle of unidirectional high velocity airflow, is thought to reduce the risk of SSI by directing pathogens away from the surgical site as well as providing a constant stream of «ultraclean air» over the operative field.

43 There have been numerous studies demonstrating a reduction in air contamination mostly using microbial air sampling. Some have shown significant reduction in CFU that suggests LAF systems are effective in reducing microbiological loads, and others have found no significant difference. Of note, no correlation has been established between airborne bacteria counts and SSIs. Pada S et al. Curr Opin Infect Dis 2015; 28:369-74

44 An old study RCT effect of LAF on SSI after total hip or knee replacement. Statistically significant reduction in SSI in the LAF group (0.6%) compared with the control group (1.5%) (p<0.001). The design of the study did not include a strictly controlled test of the effect of prophylactic antibiotics resulting in difficulty distinguishing the effects of perioperative prophylaxis and ultraclean air.

45 When the effect of operating room ventilation was assessed after strictly controlling for antibiotic prophylaxis in 22,170 total primary hip replacements in a more recent study, no significant difference in SSI rates was observed between LAF and conventional theaters.

46 More worrying is the evidence for harm with LAF systems. Data from German National Nosocomial Infections Surveillance System 99,,230 procedures from 63 surgical departments 1901 (1.9%) SSIs. At univariate analysis higher SSI rates in departments with LAF The risk for severe SSI after hip prosthesis implantation was significantly higher using LAF operating room ventilationn (OR= %CI ) as compared with conventional ventilation. Brandt C et al. Ann Surg 2008; 248:

47 Possible explanations Local wound hypothermia due to the speed of ventilation (hypothermia is a risk for SSI) Improper positioning of operating room personnel resulting in turbulent airflow over the operative field.

48 Gastmeier P et al. J Hosp Infect 2012; 81:73-8

49 One area that has received more attention recently is the impact that noise may have in the operating theater and its role in surgical complications

50 Noise may have an impact on the amount of sedation needed by the patient during an operation, with larger amounts of sedation required (and the consequent increased risk) by patients who undergo operations in noisy (whether music or background noise) when compared with quietere operating theater Kang JG et al. J Clin Anesth 2008; 20: 12-6

51 Noise also affects the performance of staff in the theater.

52 Increased noise in the operating theater also leds to miscommunications; one of the most frequently blamed factors resulting in medical errors Way TJ et al. J Am Coll Surg 2013; 216: Kawase T et al. Neuroscience 2005; 382:e254-e258 Stringer B et al. J Perioper Pract 2008; 18: 384

53 Kurmann A et al. Br J Surg 2011; 98: Anderson DJ et al. Infect Control Hosp Epidemiol 2014; 35: Diab-Elschahawi M et al. Am J Infect Control 2011; 39:e25-e29

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55 Lefebvre A et al. J Hosp Infect 2015; 91: 100-8

56 No significant difference was observed between the absence of depilation and chemical depilation or clipping (1.05, ; 0.97, , respectively) or between chemical depilation and clipping (1.09, ). This metanalysis of 19 RCTs confirmed the absence of any benefit of depilaton to prevent SSI, and the higher risk of SSI when shaving is used for depilation. Chemical depilation and clipping were compared for the first time. The risk of SSI seems to be similar with both methods. Lefebvre A et al. J Hosp Infect 2015; 91: 100-8