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
incontin
ritenz acuta
diuresi 24h
vescica neur.
n.s.
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; 20725-30. 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?
• Hanno un rilevante impatto
clinico ed economico
• Le infezioni della ferita
Eventi avversi nel sistema sanitario
australiano.
Milioni di
chirurgica
rappresentano una
Infezione ferita chirurgica
complicanza frequente
Rate
Site
$/anno
140
Eventi avversi da Warfarin
102
Cadute
44
Embolie polmonari
40
Trombosi venose profonde
38
x 100
admissions
%
Surgical Site Infection
1.39
24
Emorragie app. dig. da FANS
32
Lower Respiratory
Tract Infection
0.60
11
Int. chirurgici non necessari
29
Urinary Tract Infection
2.39
42
Ulcere da decubito
27
Bloodstream Infection
0.27
5
Fratture mal ridotte
12
Other
1.07
18
Inf. vie urinarie da catetere
10
All
5.72
100
Pneumotorace iatrogeno
4,5
Haley RW, 1985
Vomito postoperatorio
2
J QUAL CLIN PRACTICE 1999;19:7-12.
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
108 SSI (58.7%)
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=1.012.72).
•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 per il
singolo
paziente
(morbosità,
mortalità,
extradegenza)
Costi addizionali
per il sistema
sanitario e per
l’intera società
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
prevalence
incidence
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).
1 NZ $ = 0,5 euro
•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.
Upton A et al. N Z Med J 2005;118:U1316.
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