Surgical site infections March 6 2015 Surgical Infection

Surgical site infections March 6, 2015 Surgical Infection Society – Turkey, March 6, 2015

Surgical Site Infections – Compliance to guidelines. A protocol is not enough! Roland Andersson, MD, Ph. D President, Surgical Infection Society-Europe Professor of Surgery Vice Dean, Faculty of Medicine, Lund University, Sweden

Lessons learned from compliance from other guidelines – Acute pancreatitis Key recommendations Compliance Stratification of severity Variable CECT scanning Variable Prophylactic antibiotics Mostly Endoscopic sphincterotomy (biliary AP) Variable Timing of cholecystectomy (biliary) Variable, increasing Surgery (sterile necrosis) Mostly FNA (infected pancreatic necrosis) Not applicable Enteral nutrition Mostly Efficacy of antiproteases Not applicable Speciality centers for severe AP Variable Awareness high (German surgeons), compliance intermediate Lankisch PG. Pancreatology 2005; 5: 591 -593 Foitzik T. Pancreatology 2007; 7: 80 -85 Adherence to best practice guidelines in the treatment of severe pancreatitis poor Vlada AC. HPB 2013; 15: 822 -27 Implementation more difficult the more interventional and dependent on factors not controlled by the physician. Simplified audit goals after implementation. Andersson R. Scand J Gastroenterol 2008; 43: 515 -517 Surgical Infection Society – Turkey, March 6, 2015

Compliance on guidelines frequently lacking Examples from recommendations on timing of cholecystectomy in acute gallstone pancreatitis • Compliance (cholecystectomy ES recommended during initial admission or within three weeks) in a Dutch study (308 patients with mild biliary pancreatitis) only performed in 53 %. • The delay carry a substantial risk of recurrent biliary events Bakker OJ et al. BJS 2011; 98: 1446 -54 Sun E et al. JOP 2013; 14: 221 -27 • Lack of early severity classification, differences in standard care in a Swedish national survey Andersson B et al. Scand J Gastroenterol 2012; 47: 1064 -70 Surgical Infection Society – Turkey, March 6, 2015

Non-compliance to guidelines on surgical site infection prevention • Unnumerous articles on surgical site infections (SSI) including guidelines, focusing on different aspects of SSI • SSI - health economy – limited information • SSI – guidelines and compliance – few papers • SSI – compliance and audit – few papers • SSI – compliance, audit and government – lacking Surgical Infection Society – Turkey, March 6, 2015

Surgical site infection prevention • Web-based survey. Checklist, standardized orders, protocols, forms for surveillance programs most highly rated, but the strategies were not in place at the surgeons’ institutions Eskicoglu et al. Can J Surg 2012; 55: 233 -38 Surgical Infection Society – Turkey, March 6, 2015

Updated recommendations for control of surgical site infections • Costs of SSI considerable, approximately twice that of a patient without an SSI • Uniform adherence to proposed guidelines would be of extreme benefit also as comes reduction in postoperative readmissions Alexander JW et al. Ann Surg 2011; 253: 1082 -93 Lawson EH et al. Ann Surg 2013; 258: 10 -18 Surgical Infection Society – Turkey, March 6, 2015

Prevention of surgical site infections – compliance with guidelines • Poor compliance with infection prevention guidelines; intervention must be multifaceted, hospital and service specific. Good safety and teamwork climate is not enough Meeks DW et al. Am J Surg 2011; 201: 76 -83 Durando P et al. Amm J Infect Control 2012; 40: 969 -72 Surgical Infection Society – Turkey, March 6, 2015

Continued non-compliance with the American College of Surgeons recommendations to decrease infectious exposure in the operating room – why? • Respondents familiar with recommendations in general. • Reasons for non-compliance included decreased practical things like decreased tactile sensation with double gloving, lack of training with hands-free zone and lack of availability of blunt-tip suture needles. • Room for improvement of compliance by increasing awareness and benefits associated Welc CM et al. Surg Infect 2013; 14: 288 -92 Surgical Infection Society – Turkey, March 6, 2015

Improving awareness of best practices to reduce SSI: a multistakeholder approach Poor compliance with infection prevention guidelines; intervention must be multifaceted, hospital and service specific. Good safety and teamwork climate is not enough Create a patienteducational initiative involving an active partnership of all stakeholders (Skoufalos A et al. Am J Med Qual 2012; 27: 297 -304) Surgical Infection Society – Turkey, March 6, 2015

Poor compliance with SSI guidelines and care bundles • Need of continuous updating, comprehensive surveillance, checklists and care bundles and effective communication strategies for all healthcare providers and service commissioners as well as patients Leaper et al. Int Wound J 2014; 25 mar [Online] doi: 10. 1111/iwj. 12243 Surgical Infection Society – Turkey, March 6, 2015

Any success stories in SSI prevention? • By using the surgical care improvement project (SCIP), a meaningful relationship between SCIP adherence and SSI rates have been reported Cataife G et al. Med Care 2014; 52: (2 Suppl 1): S 66 -73 Surgical Infection Society – Turkey, March 6, 2015

Key components in bundles preventing SSIs • Normothermia preventing SSIs (following gastrointestinal surgery) – limited value • Lehtinen et al. Ann Surg 2010; 252: 696 -704 • Wound dressings and preparation Limited evidence for the effect of wound covering with different dressings • Walter et al. BJS 2012; 99: 1185 -94 • Wound-edge protection devices reduce SSI following open abdominal surgery (poor quality, small sample sizes) • Gheorghe et al. Ann Surg 2012; 255: 1017 -29 Surgical Infection Society – Turkey, March 6, 2015

Key components in bundles preventing SSIs • Preoperative skin antisepsis with clorhexidine more effective than with iodine preventing SSIs and cost saving • Lee et al. Infect Control Hosp Epidemiol 2010; 31: doi: 10. 1086/654134 • Kalish et al. J Vasc Surg 2014; 60: 1238 -46 • Skin antisepsis – is the role of alcohol in clorhexidine skin preparation the overlooked component? • Maiwald et al. PLOS One 2012; 7: 1 -12 • Oxygen is a cost-effective and safe drug against SSIs • Bitterman. Crit Care 2009; 13: 205 (doi: 10. 1186/cc 7151) • Antibiotic prophylaxis (too short) considered the most important malpractice associated with an increased risk of SSIs • Miliani et al. J Antimicrobiol Chemother 2009; 64: 1307 -15 Surgical Infection Society – Turkey, March 6, 2015

Key components in bundles preventing SSIs • The use of local anesthesia is associated with lower incidence of SSIs • Lee et al. World J Surg 2011; 35: 2596 -2602 • The anesthesiologist is a key player – timely administration of preoperative antibiotics, maintenance of perioperative normothermia and perioperative hyperoxia • Forbes et al. Can J Anesth 2013; 60: 176 -83 Surgical Infection Society – Turkey, March 6, 2015

Reduction of SSI in HPB surgery • Introduction of ACS-National Surgical Quality Improvement Program decreased SSI in complex HPB surgery over a two-year period. Surgeon-specific feedback on SSI rate considered the most important factor for improvement Ceppa EP et al. HPB 2013; 15: 384 -91 Surgical Infection Society – Turkey, March 6, 2015

Any impact of hospital volume on SSI? • High volume centers associated with a decreased mortality, less overall infections, sepsis, length of stay (abdominal aortic surgery) Vogel TR et al. Vasc Endovascular Surg 2011; 45: 317 -24 • Increased hospital volumes may be associated with a decrease in SSI Boas R et al. Am J Med Qual 2014; 1 -4. Early online Surgical Infection Society – Turkey, March 6, 2015

Enhanced recovery after surgery/Fast-track surgery concept – of any benefit in reducing SSI? Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183: 630 -641 Surgical Infection Society – Turkey, March 6, 2015

Enhanced Recovery After Surgery/Fast-track surgery – Is evidence-based care influencing the rate of surgical site infections and outcome? Ansari D, Andersson R. Langenbecks Arch Surg 2013; 398: 29 -37. Surgical Infection Society – Turkey, March 6, 2015

Ansari D, Andersson R. Langenbecks Arch Surg 2013; 398: 29 -37. Surgical Infection Society – Turkey, March 6, 2015

Surgical Infection Society – Turkey, March 6, 2015

Compliance to guidelines on Surgical Site Infections – A protocol is not enough • Surgical site infections is associated with substantial morbidity and mortality, increased length of hospital stay and a huge health economical burden • Numerous guidelines and recommendations on parts or all defined risk factors have repeatedly been published in order to prevent SSIs. Compliance with these evidence-based guidelines vary and has not resulted in any major decrease in the SSI rate • All parts of both identified variables and all stakeholders involved have to be addressed in a structured way, including checklists, audits; monitoring and measure. Define cost effectiveness and highest acceptable SSI rate • If not healthcare providers and physicians address this issue, someone else will Surgical Infection Society – Turkey, March 6, 2015

Surgical Infection Society – Turkey, March 6, 2015