DS 30 - An Investigation of Surgical Site Infections with Serratia Marcescens

Background: The Healthcare-Associated Infections and Antimicrobial Resistance (HAI/AR) program with the Tennessee Department of Health (TDH) was contacted in early-2023 regarding a series of surgical site infections (SSIs) testing positive for Serratia marcescens within a small community hospital. HAI/AR houses a 16-member Infection Prevention (IP) team which consultatively assists Tennessee facilities to investigate breaches of infection prevention/control and clusters of unexpected infections.

Methods: To assist the facility with its investigation, HAI/AR provided epidemiologic support and an onsite IP assessment focused on the facility’s perioperative area. The investigation involved complete case ascertainment for January to June 2023 with full medical record abstraction utilizing a HAI/AR created tool. The IP assessment was conducted using the Centers for Disease Control and Prevention (CDC) Infection Control Assessment and Response (ICAR) tool.

Results: The investigation discovered 9 SSIs during the period. Surgical types included orthopedic (lumbar, hip, knee), and general surgery (hernia, small bowel). Three different surgeons were associated with this cluster. The ICAR assessment revealed gaps in environmental cleaning and disinfection. Observations of importance included: (1) lack of written procedures for environmental services (EVS) or surgical staff for room turnover cleaning, (2) inappropriate contact times for disinfectants, (3) poor compliance with hand hygiene instructions and opportunities, and (4) contamination of the sterile field during skin antiseptic application. HAI/AR provided a comprehensive report with the facility agreeing to implement all major recommendations. No additional Serratia marcescens cases have been identified since June 2023.

Conclusions: This investigation demonstrates the importance of following a defined process for environmental cleaning and disinfection in the perioperative area. External assessments can assist facility-led investigations by providing additional, and targeted, expertise and overcoming person power limitations. There are tools freely available, including through CDC and the Association for Professionals in Infection Control and Epidemiology (APIC), that can assist with the gaps identified during investigations.