Wound Infections.. Preventable or Inevitable?

A/Prof. Dale Fisher National University Hospital SLH 6th Wound Conference May 25 2012

Outline
History Pathogenesis Surgical site infection prevention strategies Burns Traumatic wounds

Infection Inevitable: Compound fractures, almost 100% mortality.amputation, miasma, no hand hygiene

Yah, but there is a slight drawback. Most patients here do NOT survive surgery. to get infected.

Robert Liston, 1794 - 1847

The fastest knife in the West End
Because blood loss was a major obstacle and modern anesthesia was unknown, the primary skill to recommend a good surgeon was speed rather than finesse.

First anaesthetic in 1840s

Ignaz Semmelweiss

Hungarian obstetrician

 Showed in 1847 that hand washing with chlorinated lime solution markedly reduced maternal mortality (strep) Died in a mental institution in 1865

Louis Pasteur, 1822 - 1895

Joseph Lister, 1827 - 1912

Lister carried out experiments to sterilise surgical instruments, wounds and dressings with carbolic acid (phenol). Surgeons had to wear clean gloves and wash their hands in carbolic acid solutions before operating. This was resisted by the medical community at the time!

Carbolic Acid

Listers cloud of carbolic spray drenched the whole area, surgeon and all. Their skin became bleached and numb, nails cracked, and lungs sore Lister described it as a necessary evil incurred to attain a greater good. Alternatives were found and mortality from amputation fell from 40% to 3% in 60 years.

Initially as a surgical antiseptic; not popular until sold as a cure for halitosis in the 1920s

Robert Koch
1843-1910 28th birthday present Anthrax, TB, cholera Cultured, purified and caused disease

Alexander Fleming, 1881 - 1955

next major drop in mortality post trauma or surgery started in 1929 with mould juice Mass production after Pearl Harbour in 1941

Outline
History Pathogenesis Surgical site infection prevention strategies Burns Traumatic wounds

The Significance of Wound Infections

Second most common adverse event in hospitalised patients SSI accounts for 40% of hospital associated infections for surgical patients In Singapore, rates for clean operations = 1.6%, contaminated operations = 4%. Extends duration of admission 60% more likely to require ICU $3000 excess costs per case (US data)
Liau KH. Surg Infect. 2010 Apr;11(2):151-9. Outcome of a strategy to reduce surgical site infection in a tertiary-care hospital.

Ukay. Preventing surgical site infections. Expert Review of Antiinfective Therapy, June 2010, Vol. 8, No. 6, 657-670

Risk Factors
Coincident remote site infection Diabetes Smoking Steroids Poor nutritional status Other immune suppression Prolonged hospital stay Colonisation with Staph. aureus

Ukay. Preventing surgical site infections. Expert Review of Antiinfective Therapy, June 2010, Vol. 8, No. 6, 657-670

Pathogen Sources
Endogenous
Patient flora
skin mucous membranes

GI tract Seeding from a distant focus of infection

Pathogen Sources
Exogenous
Health care staff
Inadequate hand hygiene Breaks in aseptic technique Soiled attire

Physical environment and ventilation Equipment and materials associated with the operative field/wound

Bacillus epidemic curve

70 60

50

40

30

20

10

Heavy contamination of linen

Towels most densely contaminated - 7403 (1054.3) spores per cm2 fabric

Other linen less affected

Patient gowns: 585 (356.4) spores/cm2

Flat cotton sheets: 80 ( 36.4) spores/cm2

Organisms
Staphylococcus aureus Coagulase-negative staphylococci Enterococcus spp. Escherichia coli Pseudomonas aeruginosa Enterobacter spp Klebsiella pneumoniae Candida spp. Klebsiella oxytoca Acinetobacter baumannii 30.0% 13.7% 11.2% 9.6% 5.6% 4.2% 3.0% 2.0% 0.7% 0.6%

Take a good swab!

- Does not have to be established infection to delay wound healing (therefore still infection prevention) - Swab technique:
- Debride, rinse with sterile saline/gauze - rotate a swab in deep bed over a 1cm2 area and with sufficient pressure to extract fluid.

- sensitivity of 90% and a specificity of 57% 2 - Want pus cells not epithelial cells
1.

2.

Gardner SE, Frantz RA, Saltzman CL, et al. Diagnostic validity of three swab techniques for identifying chronic wound infection. Wound Rep Regen 2006;14:548557. Consensus Guidelines. Int Wound J 2008; 5 (Suppl 3): 1-11

Biofilm
Bacteria create a protected colony of communicating organisms by secreting a polysaccharide extra-cellular matrix More resistant to killing by immune system or antibiotics Wounds that contain foreign materials are most likely to have biofilm firmly attached

Outline
History Pathogenesis Surgical site infection prevention strategies Burns Traumatic wounds

NHS Care bundle to prevent surgical site infection

http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Prevent-Surgical-Site-infection-FINAL.pdf

NHS Bundle

NHS Bundle

Latest innovations & the future!

Training Nursing Students as hand hygiene auditors

Evaluation Items 1.The training was clear and easy to follow (N=339) 2.I understood the "5 moments of hand hygiene" better after the training (N=339) 3.I was able to carry out the hand hygiene audit after the training (N=339) 4.The auditing experience has given me opportunities to observe how infections could be transmitted in the hospital (N=339) 5.The audit experience has enhanced my hand hygiene practice (N=339) 6.I would like to be an advocate of hand hygiene (N=339) 7.I would recommend that more nursing students be involved in hand hygiene audits (N=339) Strongly disagree Disagree Agree Strongly agree

3 (0.9%) 4 (1.2%) 3 (0.9%)

2 (0.6%) 0 1 ( 0.3%)

212 (62.5%) 149 (43.9%) 215 (63.4%)

122 (36%) 186 (54.9%) 120 (35.4%)

5 (1.5%)

1 ( 0.3%)

215 (63.4%)

118 (34.8%)

4 (1.2%)

4 ( 1.2%)

188 (55.5%)

143 (42.2%)

5 (1.5%)

15 ( 4.4%)

257 (75.8%)

62 (18.3%)

3 (0.9%)

7 ( 2.1%)

196 (57.8%)

133 (39.2%)

NUH Hand Hygiene Products Consumption January 2005 to March 2012

10000
9231

9000 8000
HH Products (Bottles)
8055

9157

7000
6555 6326

7142

6000
5673

5880

5000
4598 4339 4247 3959 3733 3349 4284

4847

4792 4568 4160 4013 3505

4883 4642

4896

4000
3657 3, 428 3381 2916 2702 2732 3480 3480 3043 2820 2914 2660 3570 3670 3585 3052 2674 2790 3666 3139 2824 3572

3762

3883 3311

3824 3577 3308 3277 2975 2470

3978 3822 3705 3234

3977

3973 3507

3970 3645

3959

4095

3274

3000 2000 1000

3231

3053

3055

2916

1940 1766 1190 723 1225 1228 870 1329 1081 1416 1520 1305 1223 1754

2012

2140

0
2 3 4 2 3 4 2 3 4 2 3 4 '09 Q 2 3 4 2 3 4 2 3 '05 '06 '07 '08 '10 '11 4 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q 1 1 1 1 1 1 1 Q Q Q Q Q Q Q Q 1 '12

Quarters Hand Foam Soap 500mls per pack* Alcohol Handrub (overall) 500mls per bottle# Chlorhexidine 4% Antiseptic skin cleanser (overall) 500mls per bottle^

Overall Hospital Wide Hand Hygiene Compliance for Inpatient Area

100% 90% 80% 70% 60%
% Compliance

69% 64% 54% 49% 45% 38% 55% 63% 65%

69%

67%

70%

69%

60% 50% 40% 30% 20% 10% 0% Baseline(Jun, Aug & Oct 08) Q1 2009 Q 2 2009

417/1088

490/1098

653/1346

906/1669

1094/2001

1187/1965

1404/2197

1602/2536

1656/2534

1541/2219

1452/2110

1622/2418

1664/2362

1542/2247

Q3 2009

Q4 2009

Q1 2010

Q2 2010

Q3 2010

Q4 2010

Q1 2011

Q2 2011

Q3 2011

Q4 2011

Q1 2012

Hand Hygiene Compliance Rate For Different Healthcare Workers

Hand Hygiene Compliance Q1 2010 - Q1 2012
100%

90%

83%
80%

73% 74%
70%

69%

73% 72% 68%

74% 68% 70% 63% 64%

% Compliance

60%

56% 50% 49% 42% 50% 47% 40% 34% 52% 48% 45%

50%

40%

30%

680 781 148 1347 1406 300

27% 3913 4100 1077 5668 5584 1446 598 876 545 743 123 170 139 204 139 200 50 68 8 19 14 30 2 4 32 95 186 225 3 11 303 586 306 89 485 138 176 437 208 436

50 110

20%

10%

0%

Doctors 2010

Nurses 2011

Patient Care Assistants Q1 2012

Therapists

Radiographers

Medical Students

Nursing Students

Others

Healthcare Professionals

Hand Hygiene Compliance RateBreakdown by hand hygiene moments

100% 90% 86% 74% 61% 53% 79%

Compliance Rate (%)

80% 70% 60% 50% 40% 30% 20% 10% 0% 1

3 Hand Hygiene Moment

Project Safe Hands

Trial in Ward 63 Pilot started in March

More on the interventions for surgical wound infection prevention..

Staph. aureus decolonisation

Nasal colonisation a risk factor for SSI 1 Decolonisation reduces risk of SSI 2
808 S.aureus (all MSSA) colonised patients undergoing surgical procedures randomised to nasal mupirocin + chlorhex body wash vs placebo RR 0.42 for all SSI RR 0.21 for deep site infection Study used PCR for screening Study did not look at MRSA
Kluytmans JA. Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery. J Infect Dis 1995; 171:216. Bode LG. Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. N Engl J Med 2010; 362:9

Hair removal
clip & probably best on the day of op!
Cochrane review:
Shaving n=575, RR=1.75 (0.93 3.28) Clipping n=130, RR=1.00 (0.06 - 15.65) Cream n=267, RR=1.02 (0.45 - 2.31) Timing
no difference for shaving Clipping on the day probably better than day before for 30 day SSI: n=457, RR=2.30 (0.98-5.41)

Skin antisepsis
Reduce burden of bacteria Bacteria remain in pores/follicles 2% Chlorhexidine-alcohol superior to povidone-iodine skin prep. RR 0.59 (0.41 0.85)1
JEJM RCT published after cochrane review

Bathing with chlorhexidine prior to surgery not beneficial: KM, et al.0.91 (0.8-1.04)2 RR Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site 1. Darouiche RO, Wall MJ Jr, Itani
2. Antisepsis. N Engl J Med 2010; 362:18. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2006; :CD004985.

Prophylactic Antibiotics
Recommended for high risk surgery
Contaminated surgery (colorectal) Foreign material implanted Where development of wound infection could be disastrous

Enzler. Antimicrobial prophylaxis in adults. Mayo Clin Proc. 2011 Jul;86(7):686-701.

Efficacy of antibiotic prophylaxis

Prophylactic Antibiotics
Antibiotics should ideally be
Bactericidal Non toxic Cheap Active against common pathogens

Frequently cephazolin used Vancomycin if true allergy or high MRSA rate

Timing of antibiotics
prospective observational study 4 Groups:
early 224 hours pre-incision preoperative 02 hours pre-incision perioperative up to 3 hours post-incision postoperative 324 hours post-incision

Classen DC. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. New England Journal of Medicine 1992;326:2816.

Timing of antibiotics
Lowest rates if given 0-2 hours pre-op If given post op, higher rates of infection with each successive hour post op
Therapeutic antibiotics should be present in the tissue throughout the period the wound is opened, top up doses may be needed Antibiotic duration: <24h except cardiac surgery 48h

Perioperative normothermia
Hypothermia causes vasoconstriction reducing tissue perfusion Warming the patient reduces the rate of SSI in colorectal surgery (16% vs 6%)1 In cardiac surgery there were no differences in outcome between hypothermic and normothermic groups 2
1. Kurz A. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209. 2. The Warm Heart Investigators.Randomised trial of normothermic versus hypothermic coronary bypass surgery. Lancet 1994; 343:559.

Surgical attire
No data looking at surgical attire and SSI risk Experimental data show that live microorganisms are shed from hair, exposed skin, and mucous membranes of operating room personnel Surgical masks, gowns and scrubs also essential to protect staff from potentially infectious materials from patient
CDC recommendations

Surgical technique
Suture material: Monofilament sutures appear to have less SSI risk Place drains through a separate incision, distant from the operative incision Closed suction drains better than open drains Avoidance of hypothermia vasoconstriction reduces perfusion of O2 and neutrophils

Supplemental Oxygen Therapy

Theoretical benefit of improved tissue oxygenation and wound healing and better immune function Meta-analysis of 5 RCTs (3000 patients) comparing perioperative Fi 80% O2 with standard care
Infection rate 9% vs 12% (RR 0.74, 0.60 0.92)

A subsequent RCT of 1400 patients concluded no difference

1. Qadan M. Perioperative supplemental oxygen therapy and surgical site infection: a meta-analysis of randomized controlled trials. Arch Surg 2009; 144:359. 2. Meyhoff CS. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA 2009; 302:1543.

Glucose control
Diabetes associated with increased SSI2
(OR 2.7)

Pre1 and post2 operative hyperglycaemia associated with increased SSI

(OR 10.2 and 2.0 respectively)

Continuous infusion insulin better than intermittent s/c insulin3

Risk of deep infection 0.8% vs 2.0% respectively
1.Trick WE. Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000; 119:108. 2. Latham R. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol 2001; 22:607. 3. Furnary AP. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 1999; 67:352.

Topical silver sulphadiazine (SSD)

Cochrane review 2010 multiple studies None of the trials indicated a beneficial effect for SSD when compared with other silvercontaining or non-silver dressings evidence that SSD may delay wound healing, may be more expensive may be more painful when applied to burns

Storm-Versloot MN. Topical silver for preventing wound infection. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD006478.

Outline
History Pathogenesis Surgical site infection prevention strategies Burns Traumatic wounds

Burns
Burns; immunosuppressive effect (Anti inflammatory response) decreased production of monocytes and macrophages; IL 12 increased IL 4 & IL 10, glucocorticoids, PGE2

75% of burns deaths are from infection

Church. Burn Wound Infections. Clin microbio rev. http://cmr.asm.org/content/19/2/403

Burns
A burn is initially sterile, then over next 24-48h becomes colonised with bacteria
Endogenous: patients own skin flora Exogenous bacteria transmitted from the environment or from healthcare workers

Initially colonised with gram positive Then antibiotic susceptible gram negatives After antibiotic treatment they are replaced by yeasts, moulds and antibiotic resistant organisms Colonisation with pseudomonas before 30 days incurs 7x higher mortality compared to colonisation after 30 days

Rowley-Conwy (2010) Infection prevention and treatment in patients with major burn injuries. Nursing Standard. 25, 7, 51-60. Rafla. Burns. 2011 Feb;37(1):5-15. Infection control in the burn unit.

Infection Control in Burns

Burn can be colonised by contact, droplet or airborne spread
Mode of transmission
Common treatment rooms Contaminated equipment (eg. BP cuffs) Hydrotherapy Hand hygiene failure by staff and visitors
Rafla K, Infection control in the burn unit. Burns. 2011 Feb;37(1):5-15. Epub 2010 Jun 18.

Prevention of Burn Infection

Daily wound assessment Aseptic technique when handling wound Minimise wound exposure time Debriding dressing for necrotic wounds Surgical debridement of invasive infection Avoid IV catheters through burned tissue if possible Private rooms to prevent cross contamination Avoid plants in unit (pseudomonas and fungi) Antibiotic prophylaxis only in perioperative period

Bali; October 12, 2002

Silla RC Infection in acute burn wounds following the Bali bombings: a comparative prospective audit. Burns. 2006 Mar;32(2):139-44

The incidence of primary BWI in the Bali-tourist group (68.2%) compared with the standard WA group (18.2%) was significant (p=0.001).

Outline
History Pathogenesis Surgical site infection prevention strategies Burns Traumatic wounds

Wound Debridement
Bacteria thrive in necrotic tissue that is poorly penetrated by immune cells or antibiotics. Surgical debridement for heavily necrotic wounds VACC dressing
Negative pressure removes wound pus and promotes granulation tissue

Maggots (popular in Europe)

Secretions dissolve dead tissue More rapid debridement than conventional dressings
Venturi. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) device; a review. Am J Clin Dermatol 2005; 6:185194 Opletalov. Maggot therapy for wound debridement: a randomized multicenter trial. Arch Dermatol. 2012 Apr;148(4):432-8.

Mammalian Bites
Tetanus shot Rabies post exposure prophylaxis Antibiotics?
Effective post human bite OR 0.02 (0.00 - 0.33) Insufficient evidence for animal bites Dog bite OR 0.74 (0.30 - 1.85) Cat bite n=11, infection rate 67% control group vs 0% antibiotic group
Cochrane 2008 - Antibiotic prophylaxis for mammalian bites (Review)

Outline
History Pathogenesis Surgical site infection prevention strategies Burns Traumatic wounds

The future of infection prevention

RNA III inhibiting peptide to disrupt quorum signaling between bacteria in biofilms
promising in animal studies

Doing what we know better

Giacometti A. RNA III inhibiting peptide inhibits in vivo biofilm formation by drug-resistant Staphylococcus aureus. Antimicrob Agents Chemother 2003; 47:19791983.

Conclusions
Concept of a continuum between sterile, critical colonisation and infection While infection will always be a risk, interventions over the last 200 years have reduced rates from 50% to single digits Strict adherence to infection control protocols & bundles together with new innovations can reduce this further

Thank You!