Paestum 20 maggio 2006

Significato, fattori di rischio e costi delleinfezioni post-operatorie

Nicola PetrosilloIstituto Nazionale per le Malattie Infettive

“Lazzaro Spallanzani” - Roma

Infezioni post-operatorie

SSI UTI CVC-r VAP

incontin

ritenz acuta

diuresi 24h

vescica neur.

n.s.

- Le infezioni del sito chirurgico (SSI) contribuiscono in maniera significativa alla morbosità e letalità associate alle procedure chirurgiche .

- Pazienti con SSI presentano prolungata degenza, incremento dei costi in termini di degenza, attività mediche, infermieristiche, diagnostiche e prescrizione di farmaci

(Kirkland KB et al. Infect Control Hosp Epidemiol 1999; 20-725-30. Coello R et al.J Hosp Infect 1993; 25: 239-50. Rioss J et al. Gac Sanit 2003; 17:218:25).

Surgical site infections

In modern surgery, the rate of infections increases because of:

1) Longer and more complicated operations2) Older patients3) Use of prosthetic devices4) Spread of immunosuppressive treatment (transplants)

5) Increase of immunodepressed patients6) More invasive diagnostic procedures7) Use (and overuse) of antimicrobials8) Asepsis?

• Le infezioni della ferita

chirurgica

rappresentano una

complicanza frequente

Milioni di $/anno

Infezione ferita chirurgica 140

Eventi avversi da Warfarin

102

Cadute 44

Embolie polmonari 40

Trombosi venose profonde

38

Emorragie app. dig. da FANS

32

Int. chirurgici non necessari

29

Ulcere da decubito 27

Fratture mal ridotte 12

Inf. vie urinarie da catetere

10

Pneumotorace iatrogeno 4,5

Vomito postoperatorio 2

Eventi avversi nel sistema sanitario australiano.

J QUAL CLIN PRACTICE 1999;19:7-12.

• Hanno un rilevante impatto clinico ed economico

Site

Rate

x 100 admissions

%

Surgical Site Infection 1.39 24

Lower Respiratory Tract Infection

0.60 11

Urinary Tract Infection 2.39 42

Bloodstream Infection 0.27 5

Other 1.07 18

All 5.72 100

Haley RW, 1985

Fattori dell’ospite Età avanzata Comorbidità Obesità Malnutrizione Diabete mellito Immunodepressione Altre infezioni Malattie cutanee

Fattori preoperatori Degenza prolungata Tricotomia Profilassi antibiotica non

adeguata

Fattori chirurgici Antisepsi cutanea inadeguata Intervento d’urgenza Impianto di protesi Durata prolungata di intervento Drenaggi chirurgici Scarsa tecnica chirurgica Contaminazione non prevista

Fattori ambientali Portatore di Staph. o Strep. Vestizione equipe Attività eccessiva Antisettici contaminati Ventilazione non adeguata Disinf./sterilizzazione non

adeguata

Infezioni della ferita chirurgica Infezioni della ferita chirurgica – Fattori di rischio– Fattori di rischio

Incidence of SSI in Italian Surgical Settings

Petrosillo N, et al. ECCMID 2004

108 SSI (58.7%) were detected during the hospital stay, and 104 (41.3%) after discharge.

Incidence of SSI in Italian Surgical Settings

Petrosillo N, et al. ECCMID 2004

Antisepsis–Crowding–Disinfection-Sterilization

The operating theatre

Astagneau P, J Hosp Infect 2001

Risk factors for surgical site infections in older people.

Kaye KS, et al. J Am Geriatr Soc 2006;54:391-6

• Case-control study

• Duke University

•Elderly patients (> or =65) who underwent surgery between 1991 and 2002 at the study hospitals.

• 569 cases (SSI) and controls

Risk factors for surgical site infections in older people.

Kaye KS, et al. J Am Geriatr Soc 2006;54:391-6

In multivariate analysis, independent predictors of SSI included: •obesity (OR 1.77 95%CI=1.34-2.32),•chronic obstructive pulmonary disease (COPD) (OR=1.66, 95% CI=1.17-2.34), •and a wound class classified as contaminated or dirty (OR=1.65, 95% CI=1.01-2.72).

•Having private insurance was associated with lower risk (OR=0.29, 95%CI=0.12-0.68).

Predictors of wound infection in ventral hernia repair

Finan KR et al. Am J Surg 2005; 190:678-81

•A total of 1505 VHR cases were used for analysis; wound infection occurred in 5% (n = 74).

Best-fit logistic regression models demonstrated that•steroid use, •smoking, •prolonged operative time, •and use of absorbable mesh

were significant independent predictors of wound infection.

Staphylococcus aureus BloodstreamInfection After Cardiac Surgery:

Risk Factors and Outcome

Olsson C, et al. Infect Control Hosp Epidemiol 2006; 27:83-5

Staphylococcus aureus BloodstreamInfection After Cardiac Surgery:

Risk Factors and Outcome

Olsson C, et al. Infect Control Hosp Epidemiol 2006; 27:83-5

Deep wound infection after proximal femoral fracture: consequences and

costs.

Pollard TC et al. J Hosp Infect 2006; 63: 133-9.

•61 cases (SSI) vs 122 controls

•Infected cases had greatly increased hospital stay (P<0.001), •were 4.5 times less likely to survive to discharge (P=0.002), •and if they survived, were three times less likely to return to their original residence (P=0.05).

Deep wound infection after proximal femoral fracture: consequences and

costs.

Pollard TC et al. J Hosp Infect 2006; 63: 133-9.

•The total cost of treatment per infected case was pound 24 410 compared with pound 7210 for controls (P<0.001).

•Meticillin-resistant Staphylococcus aureus (MRSA) infection increased admission length and cost compared with non-MRSA infection (P=0.02).

Impatto economico delle infezioni Impatto economico delle infezioni ospedaliereospedaliere

Costi per il Costi per il singolo singolo paziente paziente (morbosità, (morbosità, mortalità, mortalità, extra-extra-degenza)degenza)

Costi Costi addizionali per addizionali per

il il sistemasistema sanitariosanitario e e per l’intera per l’intera

societàsocietà

Jarvis, 1996Jarvis, 1996

Responsabilità medico-legali per gli operatoriResponsabilità medico-legali per gli operatori

Costi delle infezioni ospedaliere

Diretti:- giorni addizionali di degenza- risorse impegnate per la diagnosi - costo del trattamento- monitoraggio del decorso clinico

Indiretti:- letalita'- perdità di produttività

- danni funzionali- danni psicologici- peggioramento delle condizioni di base

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

- Review of European studies published after 1988

- Incidence, prevalence, prospective cohort surveillance

- Overview of the costs associated with SSI in Europe

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

- 48 studies selected prevalenceincidence

10 of them prospective cohort studies (7 case-matched or case-controlled)

• Hospitals ranged from 1-214• Units ranged from 1 to 132• Study patients ranged from 43 to 236,334

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

SSI rate covered a range between 2-5 percent

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. 2004

SSI – a European perspective of incidence and economic

burden

Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. 2004

Source Country Cost per day

Cost for mean of 9.8 days

Netten & Curtis

UK 409 4,008

Oostrenbrink Netherlands 230 2,254

DKG Germany 317 3,107

Pena Spain 170 1,666

PMSI France 412 4,038

Orsi Italy 413 4,047

Costs of additional hospitalization days associated with SSI

Excess cost associated with Staphylococcus aureus

poststernotomy mediastinitis.

Upton A et al. N Z Med J 2005;118:U1316.

• Retrospective case-control study

•S. aureus PSM was associated with longer average length of hospital stay, 42.6+/-18.7 vs 10.4+/-4.0 days(p=0.005).

•The mean cost per patient in New Zealand $was 30,527 dollars+/-10,489 dollars for controls and 76,104 dollars +/- 31,460 dollars for cases,and the mean excess cost associated with S. aureus PSM was 45,677 dollars per patient.

1 NZ $ = 0,5 euro

Extra charge and extra length of postoperative stay attributable to surgical site infection in six

selected operations.

Kasatpibal N et al. J Med Assoc Thai 2005;88:1083-91.

• Appendectomy, herniorrhaphy, mastectomy, cholecystectomy, colectomy,and craniotomy.

•Mean of extra hospital chargeattributable to SSI was 43,658 (95% C.I; 30,228-57,088) baht and mean of excess postoperative stay was 21.3 (95% C.I; 16.6-26.0) days.

1 baht = 0,02 euro

Le SSI: anche un problema di costi

• 30 milioni/anno di procedure chirurgiche in Europa

• Numero casi SSI: 450.000-6.000.000.

• Costo giornaliero letto/degenza: 325 Euro

• Degenza prolungata media: 10 gg

• Costo europeo complessivo: 1.47- 19.1 miliardi Euro.

… ma non solo costi