Significato, fattori di rischio e costi delle Paestum 20 maggio 2006 Significato, fattori di rischio e costi delle infezioni post-operatorie Nicola Petrosillo Istituto Nazionale per le Malattie Infettive “Lazzaro Spallanzani” - Roma

Infezioni post-operatorie SSI UTI CVC-r VAP

- 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 operations 2) Older patients 3) Use of prosthetic devices 4) Spread of immunosuppressive treatment (transplants) 5) Increase of immunodepressed patients 6) More invasive diagnostic procedures 7) Use (and overuse) of antimicrobials 8) Asepsis?

Eventi avversi nel sistema sanitario australiano. Hanno un rilevante impatto clinico ed economico 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. Haley RW, 1985 Le infezioni postoperatorie della ferita chirurgica rappresentano una complicanza frequente: si collocano, infatti, al 2° posto tra tutte le infezioni ospedaliere. Oltre a ciò comportano costi rilevanti per la struttura sanitaria: secondo un sistema australiano di rilevazione degli eventi avversi, le infezioni della ferita chirurgica si collocano al primo posto tra tutti gli eventi avversi ordinati in ragione del costo per il sistema sanitario.

Infezioni della ferita chirurgica – Fattori di rischio 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

Incidence of SSI in Italian Surgical Settings were detected during the hospital stay, and 104 (41.3%) after discharge. Petrosillo N, et al. ECCMID 2004

Incidence of SSI in Italian Surgical Settings Petrosillo N, et al. ECCMID 2004

The operating theatre Antisepsis–Crowding–Disinfection-Sterilization

Astagneau P, J Hosp Infect 2001

Risk factors for surgical site infections in older people. 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 Kaye KS, et al. J Am Geriatr Soc 2006;54:391-6

Risk factors for surgical site infections in older people. 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). Kaye KS, et al. J Am Geriatr Soc 2006;54:391-6

Predictors of wound infection in ventral hernia repair 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. Finan KR et al. Am J Surg 2005; 190:678-81

Staphylococcus aureus Bloodstream Infection After Cardiac Surgery: Risk Factors and Outcome Olsson C, et al. Infect Control Hosp Epidemiol 2006; 27:83-5

Staphylococcus aureus Bloodstream Infection 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. 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). Pollard TC et al. J Hosp Infect 2006; 63: 133-9.

Deep wound infection after proximal femoral fracture: consequences and costs. 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). Pollard TC et al. J Hosp Infect 2006; 63: 133-9.

Impatto economico delle infezioni ospedaliere Costi addizionali per il sistema sanitario e per l’intera società Costi per il singolo paziente (morbosità, mortalità, extra-degenza) Jarvis, 1996 Responsabilità 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 Review of European studies published after 1988 Incidence, prevalence, prospective cohort surveillance Overview of the costs associated with SSI in Europe Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

SSI – a European perspective of incidence and economic burden 48 studies selected 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 Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. Int Wound J 2004

SSI – a European perspective of incidence and economic burden SSI rate covered a range between 2-5 percent 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. 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 Costs of additional hospitalization days associated with SSI 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 Leaper DJ, van Goor H, Reilly J, Petrosillo N, et al. 2004

Excess cost associated with Staphylococcus aureus poststernotomy mediastinitis. 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 Upton A et al. N Z Med J 2005;118:U1316.

Appendectomy, herniorrhaphy, mastectomy, Extra charge and extra length of postoperative stay attributable to surgical site infection in six selected operations. 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 Kasatpibal N et al. J Med Assoc Thai 2005;88:1083-91.

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