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Surgical Infection
Within one linear centimeter of your lower colon, there lives and works more bacteria than all humans who have ever been born. Yet many people continue to assert that it is we who are in charge of the world. Neil deGrasse Tyson
Surgical infection has been around as long as surgical procedures have been performed. Advances in our understanding of infections began to expand exponentially in the 19th century from discoveries by physicians and scientists, such as Ignaz Semmelweis, who discovered that puerperal fever rates in obstetric patients could be reduced by hand washing, Joseph Lister, with his principles of antisepsis and use of carbolic acid to prevent infection, Charles McBurney, who pioneered “source control” with development of the appendectomy, or William Altemeier and his Manual of Control of Infection in Surgical Patients.
I
Background and Scope of Problem
- 1.
In 1991 the New England Journal of Medicine published “The Nature of Adverse Events in Hospitalized Patients,” which reported a 3.7% rate of disabling injuries caused by medical treatment (wound infections made up 14%).
- 2.
In 1999 the Institute of Medicine published, “To Err Is Human: Building a Safer Health System.”
- a.
Cited studies that claimed number of deaths in the United States from medical errors may be higher than deaths from automobile accidents. This accelerated the development of health care quality improvement initiatives.
- b.
Subsequently, the Healthcare Research and Quality Act of 1999 was passed and the Agency for Healthcare Research and Quality was branded. Progress was made in reducing morbidity due to medication errors but was slow in reducing infections.
- a.
- 3.
In 2005 the National Nosocomial Infections Surveillance was renamed National Healthcare Safety Network (NHSN).
- a.
It serves as the most widely used health care–associated infection (HAI) tracking system.
- b.
Centers for Medicaid and Medicare Services (CMS) imposes financial penalties on hospitals that do not participate in NHSN reporting.
- a.
- 4.
In 2007 research was published estimating the number of HAIs and resulting deaths in US hospitals.
- a.
Rate of 4.5 infections per 100 hospital admissions was reported.
- b.
Of deaths from patients with HAIs, 63% were attributed to the infection.
- a.
- 5.
In 2008 the US Department of Health and Human Services established the Federal Steering Committee for the Prevention of HAI with the ultimate goal of eliminating HAIs.
- 6.
In 2009 they released the National Action Plan to Prevent HAIs: Road Map to Elimination with 5-year target goals, which included:
- a.
50% reduction in central line–associated bloodstream infections (CLABSIs)—successful,
- b.
30% reduction in Clostridium difficile hospitalizations—unsuccessful,
- c.
25% reduction in catheter-associated urinary tract infections (CAUTIs)—unsuccessful,
- d.
25% reduction in surgical site infections (SSIs)—unsuccessful,
- e.
95% adherence to Surgical Care Improvement Project (SCIP) measures—successful and subsequently retired.
- a.
- 7.
Cost analysis published in 2012 estimated costs per case for the following:
- a.
CLABSIs—$45,814
- b.
Ventilator-associated pneumonia (VAP)—$40,144
- c.
SSIs—$20,785
- d.
C. difficile infections—$11,285
- e.
CAUTIs—$896
- a.
- 8.
In 2012 the final rule implementing a hospital inpatient value-based purchasing program went into effect that rewards hospitals for performance in quality measures instead of rewarding the act of reporting on them.
- 9.
Road Map to Eliminate HAI: 2013 Action Plan Conference was held with proposed 2020 targets, which included:
- a.
50% reduction in CLABSIs from 2015 baseline,
- b.
25% reduction of CAUTIs from 2015 baseline,
- c.
30% reduction in facility-onset C. difficile from 2015 baseline,
- d.
30% reduction in SSI admission and readmission from 2015 baseline.
- a.
- 10.
In 2014 updated multistate prevalence statistics from surveys taken from 2009 to 2011 to assess for HAIs were reported in the New England Journal of Medicine.
- a.
Four percent of patients were diagnosed with at least one HAI.
- (1)
Pneumonia accounted for 22%.
- (2)
SSIs accounted for 22%.
- (3)
Gastrointestinal infections (primarily C. difficile ) accounted for 17%.
- (4)
Device-related infections accounted for 25%.
- (1)
- a.
- 11.
In 2016 the Centers for Disease Control and Prevention (CDC) released the National and State Healthcare Associated Infections Progress Report. It reported the following statistics for acute care hospitals:
- a.
Fifty percent reduction in CLABSIs compared with the national baseline
- b.
No reduction in CAUTIs compared with the national baseline
- c.
Seventeen percent reduction in SSIs compared with the national baseline
- d.
Eight percent reduction in C. difficile infections compared with the national baseline
- a.
II
Most Common Infections Affecting Surgical Patients
A
Central Line–Associated Bloodstream Infection
- 1.
Definition: CLABSI is a laboratory-confirmed bloodstream infection in which a central line was in place for greater than 2 calendar days on day of diagnosis. It also includes bloodstream infections in which the line was removed the day before diagnosis if the line was previously in place for greater than 2 calendar days.
- 2.
Epidemiology and pathogenesis
- a.
Four percent of short-term, noncuffed central venous catheters lead to bloodstream infections, compared with 0.1% of peripheral intravenous (IV) lines, 0.8% of arterial lines, and 2.4% of peripherally inserted central catheters (PICCs).
- b.
Intensive care unit (ICU) length of stay is increased approximately 10 days secondary to nosocomial bloodstream infection.
- c.
Top five causative agents include
- (1)
Staphylococcus aureus
- (2)
Coagulase-negative staphylococcus
- (3)
Candida spp.
- (1)
- d.
Most CLABSIs from short-term central venous catheters are extraluminally acquired and result from skin flora
- a.
- 3.
Prevention of CLABSI
- a.
Healthcare Infection Control Practices Advisory Committee (HICPAC) (part of the CDC) published guidelines in 2011. Highlights as they pertain to surgical residents are as follows:
- (1)
Perform hand hygiene before procedure.
- (2)
Use maximal sterile barrier precautions (sterile gloves, cap, gown, mask, drapes, etc.) for placement of central venous catheters.
- (3)
Wear new sterile gloves when handling new catheter in guidewire exchange.
- (4)
Prep skin with greater than 0.5% chlorhexidine for central venous catheter placement.
- (5)
Subclavian placement is recommended instead of internal jugular or femoral venous placement for nontunneled central venous catheter insertion to minimize infectious risk.
- (a)
Risk of infection is 4.5% with subclavian placement versus 20% associated with femoral venous placement or 8.6% with internal jugular placement.
- (b)
Infectious risk must be weighed against risk of pneumothorax or perforation of great vessels (<1% but often fatal).
- (c)
Subclavian placement should be avoided in patients on hemodialysis or with advanced kidney disease.
- (a)
- (6)
Ultrasound guidance used by trained personnel is recommended in placement of internal jugular catheters.
- (7)
Chlorhexidine-impregnated dressing sponge may be indicated for your facility.
- (8)
Promptly remove catheter that is no longer essential.
- (9)
Replace catheters placed without aseptic technique (emergent) within 48 hours.
- (10)
Routine central catheter replacement is not recommended.
- (11)
Replacement of central venous catheter for infectious cause should not be performed over a guidewire.
- (1)
- a.
- 4.
Treatment
- a.
Catheter removal and appropriate IV antimicrobial therapy
- b.
Not recommended—routine tip culture and subsequent treatment for a positive result
- a.
B
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