A few weeks ago my old Podiatric College roommate sent me a link to a fascinating YouTube video.  I then sent it to a few friends who, in turn, posted it on a few other blogs so it has become a minor viral (or should I say “bacterial”) success.  This lecture, by Professor Eshal Ben-Jacob of Tel Aviv University, covers aspects of bacterial communication and their “social interactions” as regulated by various stimuli.  It is an utterly fascinating subject presented in a clear, understandable manner with incredible videos and photographs.  This work has major implications in the way bacteria become pathogenic, are currently treated and some future directions that could be considered.  Just as a “heads-up” it will take a commitment of time from you, the viewer, as the lecture is an hour long but please don’t let that keep you from viewing it in its entirety.  It is absolutely worth it.  http://www.youtube.com/watch?v=yJpi8SnFXHs

One of the most frequent questions I am used to be asked is about when antibiotic prophylaxis should be used in performing foot and ankle surgery.  I have an entire lecture on this topic where I go through the data, or lack thereof, on the subject and suggest the clinical situations where prophy has traditionally been utilized (i.e. surgery longer than 2 hours, trauma surgery, immunocompromised hosts, etc).  More and more the question posed to me has become: “Warren, my hospital requires me to use prophylactic antibiotics even when I don’t feel they are necessary.  They have actually threatened to take away my surgical privileges if I don’t use them.  What can I do about that?”  Unfortunately, the answer is…not much.

Why is this happening?  What has changed?  In my opinion there are two main reasons we have come to be in this situation. 1) The Surgical Care Improvement Project (SCIP) 2) Changes in CMS guidelines that will not reimburse a hospital for a re-admission for a nosocomial infection. 

Point #2 is fairly self explanatory.  Hospitals don’t get paid if a patient is readmitted with a diagnosis of a nosocomial post operative infection.  Therefore, they need to try everything in their power to prove that any infection that does occur is not their fault and they did everything possible to prevent that infection.  Chief amongst these is demanding prophylactic antibiotics be given to everyone undergoing surgery.  Then, when the patient gets infected they can always claim that the infection was community acquired and not nosocomial.   

Point #1, SCIP, may not be as well known by the average lower extremity surgeon and is a bit more complicated.  Back in 2005 a national initiative was developed to attempt to reduce post operative complication rates by 25% in a 5 year period.  A set if 20 measures were developed, 9 are publicly reportable, 6 of which focused specifically on postoperative infection prevention.  4 of these are directly relatable to lower extremity work.  These include:

1.  INF-1:  Patients need to receive prophylactic antibiotics within one hour prior to surgical incision or 2 hours if using vancomycin.

2.  INF-2: Patients receive prophylactic antibiotics recommended for their specific surgical procedure

3.  INF-3: Patients prophylactic antibiotics are discontinued within 24 hours after surgical end time

4.  INF-6: Surgery patients should have appropriate hair removal with a clippers or depilatory, if at all (no razors)

I think that all readers would agree that this is a lofty and worthy goal.  The program is “voluntary” although CMS reduces hospital reimbursement by 2% if they fail to report performance on the various measures.  Probably, for this reason, the participation rate is around 95% of all hospitals.  Now the bad news…IT MAY NOT BE WORKING! 

In the June 23, 2010 issue of the Journal of the American Medical Association, Stulberg and colleagues published a retrospective cohort analysis of over 400,000 patient discharges between 2006 and 2008 (PubMed Link: http://www.ncbi.nlm.nih.gov/pubmed?term=Stulberg%20JJ%20AND%20SCIP ).  They found that when the measures were taken all together in an “all or none” infection prevention score, there was a lower probability of developing a post operative infection.  However, adherence to any individual measure (such as the use of prophylactic antibiotics) was NOT associated with a significantly lower probability of infection.

There are some other interesting tidbits to take away from this study.  The category of “Neck, Back or Extremity Surgery” presented with the overall lowest rate of post operative infection at only 0.19%.  Also, in fairness, although not reaching a level of statistical significance, the use of prophy did decrease the overall risk of infection from 21.0 to 7.5 per 1000 discharges (unfortunately, this was not broken out by procedure type).  I would also point out that the SCIP protocols do not demand all patients receive antibiotics, just that the “recommended” antibiotic, according to nationally accepted guidelines, is given.  Somehow this seems to have been morphed into a requirement to administer them.

So what does this all mean to the lower extremity surgeon?  The risk of infection for our surgery remains very low, somewhere probably well below 1.0%.  In the largest study of its type, published in JFAS in 2004, Zgonis retrospectively looked at charts from 555 patients undergoing elective foot and ankle surgery and found no statistically significant difference in infection rate in the group that received prophy vs. those who did not (PubMed link: http://www.ncbi.nlm.nih.gov/pubmed/15057856 ).  The bottom line is that prophylactic antibiotic use is probably not medically necessary in these patients.  Unfortunately, unless you are ready to really “battle City Hall”, from a practical standpoint you are going to continue to be coerced into using antibiotics you suspect are not beneficial. 

I find this all rather ironic.  In an environment where hospitals are being required (at the risk of the same possible decrease in reimbursement) to have Antimicrobial Stewardship programs to effectively decrease antibiotic usage, physicians are being told by those same administrations that they need to use antibiotics that are probably not necessary.

Post operative infection

This week I will be giving a talk to the Podiatric Assistants at the APMA National Meeting in Boston on the topic of office infection control.  I believe that this is an area which does not receive enough attention since it is far from “sexy” or cutting edge but is still important.  Last year I sat in on discussions by the Clinical Practices Committee of The American Podiatric Medical Association in an attempt to come up with some Guidelines for disinfection and sterilization of instruments for the podiatric physician.  This document, available online for members of APMA by searching the term “disinfection” in the Members Section at www.apma.org, incorporates information from the CDC document “Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008” also available online at http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf.  Much of the CDC document is not directly applicable to daily office practice, thus the need for the specialized Guidelines. 

In the APMA document we approached podiatric instrumentation much the same way as the dentist classify their instruments.  They are broken down into 3 categories:

Critical Instruments: These are any object that enters sterile tissue or the vascular system and therefore must be sterile because any contamination could transmit disease.  These would include any instrument used in a surgical procedure.  These instruments should be sterilized.

Semi-critical Instruments: These instruments contact non intact skin.  Examples would include tissue nippers or curettes used in debridement of an ulceration or incision and drainage of an abscess.  These devices require high level disinfection.

Noncritical Instruments: These come in contact with intact skin or nails. Virtually no risk has been documented for transmission of infection through noncritical instruments.  Examples would include nail nipper and burrs or handles used for debridement of keratotic lesions.  Low level disinfection can be used by intermediate level disinfection is recommended. 

Sterilization is the complete elimination of all vegetative bacteria, fungi and viruses along with any bacterial spores.  It can be achieved through a number of methods including the most commonly used steam/autoclave with a recommended minimum exposure of 30 minutes at 121° C.  Other techniques such as gas sterilization with ethylene oxide for moisture or pressure sensitive devices can also be used.  In the current document, based on FDA findings in dental offices, glass bead sterilization is not recommended. 

Disinfection has been broken down into 3 “levels”:

High level disinfection:  This is the complete elimination of all microorganisms on an instrument except for a small number of spores.  It is usually accomplished with a chemical such as glutaraldehyde.

Intermediate level disinfection: Destroys all vegetative bacteria, viruses and fungi but not bacterial spores.  This can be accomplished with phenolic compounds, iodophor, alcohol or chlorine.

Low level disinfection: Destroys all vegetative bacteria (except tuburcule bacilli) viruses and fungi but no spores. 

Finally, the APMA Guidelines discuss the need for various levels of disinfection with debridement procedures.  Debridement is broken down into manual, mechanical and dust extraction:

Manual: Instruments used in the manual debridement of nails such as nipper and curettes should be cleaned with intermediate level disinfectants.  Scalpel blades should not be reused and their handles can be treated as non-critical instruments.

Mechanical: Burrs should be thoroughly cleaned of any nail debris/dust and then treated with intermediate level disinfectants as noncritical instruments. 

Dust Exposure Precautions: The APMA recommends a dust extraction system or other safeguards to avoid exposure.  This may fall more under an OSHA recommendation than an infection control practice but I feel it is a critically overlooked precaution in many podiatric offices (as evidenced by the response I receive when I talk to Podiatric Assistants about this issue!).

This was just a superficial review of a complex topic but it is one of importance to all practices. These Guidelines are practical and quite “do-able”.  I remember sitting in on a lecture on office infection control at a Washington State Pod Med Assoc meeting a few years ago.  This talk, given by an infection control nurse working with a local county’s health department, basically required every single surface of the treatment room to be covered in disposable plastic drapes before each and every patient and thoroughly wiped down between patients.  It was far from practical and would have bankrupted the practice!  If we don’t follow basic infection control procedures as outlined in this APMA document who knows what agency will be telling us what to do next.