Reducing Cesarean Surgical Site Infections No Disclosures Marya G. Zlatnik, MD, MMS Maternal Fetal Medicine UC UC SF SF 1 2 Objectives Surgical Site Infections � 3 rd most frequent nosocomial infxn � Significance of SSIs in OB � Pathogenesis of SSI � 15% of nosocomial infxns � Patient factors, procedural factors � Increased hospital stay & costs � CDC recommendations for prevention � 7-10 extra hospital days � Cost >$3000 each � UCSF experience � C/S: Most common surgery in US � CDC recommendations � Antibiotic timing � SSIs common: endometritis, wound infxn � Rate of C/S SSI at UCSF as high as 12% in past � Other/broader strategies 3 4 Births: Preliminary data for 2006. National vital statistics report; Vol 56, no 7 10/23/2014 1
Pathogenesis of SSI Patient Factors Contributing to SSI • Multi-factorial event driven by Dose of bacteria x Virulence � Coincident infxns � Loss of intact skin � Procedure variables Host Resistance � Patient risk factors � Obesity � Blood transfusions � Diabetes � Poor Nutritional • Main pathogens = pt’s own flora Status − from skin & vagina � Indwelling invasive devices � Steroid Therapy • Exogenous sources of SSI pathogens (less common) � Tobacco use � Extremes of Age − OR environment − Surgical personnel � Severity of illness − Instruments 6 7 What can we do to prevent SSI? National Recommendations: Reducing SSIs � SHEA/ISDA/AHA/TJC 2014 � National recommendations 2014 � Atbx prophylaxis � Pre-op � Appropriate timing, drug, dosing, re-dosing � In OR � Don’t shave � Post-op � Preoperative skin prep: alcohol + (CHG) � These are general recommendations, not OB � Control blood sugars perioperatively (<180mg/dl) specific (but most apply to OB) � Normothermia � Adequate ventilation/oxygenation � Surveillance for SSI Anderson 2014 Strategies to Prevent Surgical Site Infections in Acute Care Hospitals 8 9 Infxn Contr Hosp Epi http://www.jstor.org/stable/10.1086/676022 10/23/2014 2
A hairy tale: Preoperative: Hair Removal successful patient education strategies � Use clippers, not razors for hair removal to reduce prehospital � Micro-breaks in skin barrier hair removal by � Clipping immediately before associated w/ patients undergoing elective caesarean lower SSI risk than shaving or clipping night section before � Don’t remove hair unless interferes w/ operation Seropian, 1971, others 10 Ng J Hosp Infec 2013 http://dx.doi.org/10.1016/j.jhin.2012.09.013 A hairy tale: education strategies to Preoperative: Antiseptic Shower/Bath reduce prehospital hair removal by patients undergoing C/S � Decreases skin microbial colony counts � Fewer pts shaved (1 wk): 83% � 53% in 2011 � Require pts to shower w/ antiseptic agent the night before OR (elective cases) � SSI rate decreased: 7.6% � 3.7% after patient Cat IB education interventions (P < 0.001) � Pre-clean skin using soap/CHG � Overall reduction in SSI rate primarily d/t to � Remove any gross contamination Cat IB reduction in superficial infections � Waiting on C/S data Ng, J Hosp Infec 2013 12 13 http://dx.doi.org/10.1016/j.jhin.2012.09.013 10/23/2014 3
Surgeon Hand/Forearm Prep Preoperative: Skin Preparation in OR � Objectives � Skin Prep—2 elements: � Remove dirt, debris & transient flora � Physical separation of bugs � Reduce microbial counts as much as possible –friction & soap � Leave antimicrobial residual on the skin � Chemical activity on bugs by antimicrobial � Optimum duration unknown soln � 2- 5 min scrub as effective as 10 min � Use fast-acting, broad spectrum antimicrobial � Chlorhexidine gluconate (CHG) � CHG/alcohol better than iodine � Persistent effect, broad spectrum � Allow to air dry Amer-Alshiek 2013 CDC/HICPAC/APIC/SHEA/IDSA hand hygiene guidelines 2002 14 15 Antimicrobial Prophylaxis: Agents, Preoperative Hand Prep Timing � Artificial Nails � 1 st & 2 nd gen cephalosporins most common � Increased bacterial & � As effective as 3 rd gen for C/S fungal colonization (Cochrane 1999) � Long nails increase � Giving ≤ 2 hrs before incision reduces SSI tears in gloves (0.59% vs ≥ 3.3%) � Increased nosocomial infxns � General consensus: 30-60 min before incision � Nail polish & hand jewelry � Except C/S, after cord clamping CAT 1A � SSI risk unknown � No artificial nails or polish, nail beds CDC “Guideline for Prevention of Surgical Site free of infxn Infection, 1999” available online at www.cdc.gov/ncidod/hip CDC Hand Hygiene, Mayo 16 17 10/23/2014 4
Antibiotic Prophylaxis Surgical Attire: Recommendations � Cefazolin 2g Anderson 2014 � Sterile gowns/gloves during case � 3g if > 80kg � Masks/eye protection to protect staff � Repeat Dosing � Theoretically filters aerosols from staff to patient - � Cochrane re: C/S prophylaxis—1 dose as good as not proven multiple doses � When sneezing or coughing w/ mask on, face sterile � Repeat for long (>3-4 hr) cases or excess blood field directly loss (>1500cc) � Scrub clothes—Change if soiled or moist � Maintain therapeutic levels during case &, at � Hair covering in OR most, few hours after closure Cat IA • Cat IB/OSHA 18 19 Surgical Techniques Believed to SSI Surveillance Reduce SSI Risk � Good hemostasis � Surveillance of SSI w/ feedback to � Handle tissues gently surgeons reduces SSI risk � Eradicate dead space � Successful surveillance program � Avoid inadvertent entry into hollow viscus includes: � Remove devitalized tissues � effective surveillance methods � data feedback Cat IB � Use drains & suture material appropriately � Starbucks cards & emails! � Prevent hypothermia � Use EHR Cat IB Barwolff J Hosp Infect 2006 20 21 10/23/2014 5
Other C/S-related Methods C/S SSI Reduction—UC Irvine � Avoid chorioamnionitis � Multi-disciplinary team: � Spontaneous Delivery of Placenta � Atbx timing, reducing op time, double gloving, � 5.7% vs 15.2% endometritis w/ manual 1- layer uterine closure, tincture of iodine extraction @ C/S prep, no shaving • Baksu Acta Obst Gyn Scand 2005 � C/S endometritis reduced from 4.1% to 1.6% � ? Uterine exteriorization � Cost savings of $35,653 per year � Quicker, less febrile morbidity • Jakobs-Jokhan Cochrane 2004 W Gornick, UCI Med Ctr, Irvine CA (APIC 97) 22 23 SSI after C/S: Implementing 3 changes to Pre-Op Checklist improve the quality of patient care • Clippers to remove hair � ACOG abstract 2014—NY • 2% CHG instead of 0.5% � After institution: SSI 6.2% � 3% • Sew skin with non-absorbable suture � Electric clipper to remove hair at surgical site (instead of absorbable) � Cleaning skin with chlorohexidine solution � Broad spectrum atbx prophylaxis before incision � Cefazolin 1 gm IV bolus (30-60 min before surgery) plus azithromycin 500 mg IV (1 hour before surgery) � Removal of placenta by cord traction � Closure of deep subcutaneous layer >2cm � Skin closure with subcuticular suture 5% SSI 16% SSI Caban 2014 Corcoran, Am J Infec Control, 2013 24 10/23/2014 6
Reducing SSI in L&D at UCSF: Feb 2005 Scope & Magnitude of SSI at UCSF O 2 Post-op Patient warming � 2003: 217 C/S in 6 months at UCSF Reduce Retrain RNs in � 9% rate SSI (13 incisional, 6 endometritis) nonessential aseptic personnel in technique � NNIS benchmark 3% OR REDUCE C/S � Analysis of risk factors: only diabetes & BG >200 SSIs were significantly associated � Identified as an area for improvement in our L&D New surgical Improve scrub prep technique � Task force (Duraprep) � MDs, RNs, Administrators, Hospital infection control Blood Sugars 26 27 Reducing Surgical Site Infection UCSF SSI before & after Protocol Changes 2006 Administer atbx prior to O 2 Postop incision Patient warming p= 0.68 Retrain RNs in aseptic Reduce p= 0.08 technique nonessential REDUCE personnel in SURGICAL SITE p= 0.22 OR INFECTIONS New surgical Improve scrub prep technique Blood Sugars 28 29 Kaimal AJOG 2008 10/23/2014 7
Methods All Cesareans March 2005 June 2006 June 2007 p= 0.002 Retrain RNs in aseptic technique Antibiotics Study p= 0.014 New surgical prep administered completed prior to Reduce nonessential personnel incision Supplemental O2 p= 0.020 Patient warming Improve scrub technique Improve BG control Historical Controls Intervention Group 30 31 Kaimal SMFM 2008 Multivariable Regression Results at UCSF � Change in policy to administer prophylactic aOR 95% CI atbx prior to incision � significant decrease in 0.33 Overall SSI 0.14-0.77 C/S SSI � Demonstrate the integration of research 0.34 Endometritis 0.13-0.92 findings into real-life clinical practice � Our protocol is now to ask anesthesia to 0.22 Cellulitis 0.49-0.96 routinely administer cephalosporin prior to incision (cefazolin 2-3g) Controlling for labor, parity, prior cesarean delivery, maternal age, BMI, DM 32 33 10/23/2014 8
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