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Post Operative Infections: Risk Factors and Prevention Strategies

Post Operative Infections: Risk Factors and Prevention Strategies. Yasir Gashi MBBS,MD,FSSUM. Agenda. Introduction Pathophysiology Patient related risk factors and its modification Pre-operative aspects Intar -operative aspects Operating room Use of antibiotics Conclusions.

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Post Operative Infections: Risk Factors and Prevention Strategies

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  1. Post Operative Infections:Risk Factors and Prevention Strategies Yasir Gashi MBBS,MD,FSSUM

  2. Agenda • Introduction • Pathophysiology • Patient related risk factors and its modification • Pre-operative aspects • Intar-operative aspects • Operating room • Use of antibiotics • Conclusions

  3. Search principles

  4. Search principles

  5. Search principles

  6. Filtering • Most recent • Direct conclusion for prevention • Guidelines • Evidence higher classes

  7. Level I (evidence from large, well-conducted, randomized, controlled clinical trials or a meta-analysis), • Level II (evidence from small, well-conducted, randomized, controlled clinical trials), • Level III (evidence from well-conducted cohort studies), • Level IV (evidence from well-conducted case-control studies), • Level V (evidence from uncontrolled studies that were not well conducted), • Level VI (conflicting evidence that tends to favor the recommendation), or • Level VII (expert opinion or data extrapolated from evidence for general principles and other procedures).

  8. Level I (evidence from large, well-conducted, randomized, controlled clinical trials or a meta-analysis), • Level II (evidence from small, well-conducted, randomized, controlled clinical trials), • Level III (evidence from well-conducted cohort studies), • Level IV (evidence from well-conducted case-control studies), • Level V (evidence from uncontrolled studies that were not well conducted), • Level VI (conflicting evidence that tends to favor the recommendation), or • Level VII (expert opinion or data extrapolated from evidence for general principles and other procedures).

  9. Definition • POIs or SSIs The United States Centers for Disease Control and Prevention “Infections occurring at or near the site of surgery within 30 days after operation or within 1 year if implant is in place” Mangram AJ et al (1999) .Quidelines for prevention of SSIs. Epidemio;. 20:250-278

  10. Epidemiology • Occurs in 1.5- 2 % of all Orthopedics procedures • Associated with 9% mortality Astagneau P et al (2001). Mortality and Morbidity associated with SSIs: J Hosp infect 48:267-274

  11. Pathophysiology • Most of the infections acquired peri-operatively • Source: • Patients • Theater staff • 40% is Staph A • MRSA is increasing • Poly microbial pathogens found in 1 third • 5% of them include MRSA Weigelt et al (2010). SSIs causative pathogens and associated outcomes Am J of Infect control, 38: 112-120

  12. Risk factors

  13. Risk factors

  14. Risk factors

  15. Risk factors

  16. Risk factors related to patient • Non modifiable • Modifiable

  17. Risk factors related to patient • Non modifiable: age and severity of the illness • Modifiable

  18. Risk factors related to patient • Non modifiable • Modifiable Diabetes Mellitus : “Those with HBA1C less than 7 have twofold lower infection rate than those with HBA1C more than 7” Dronge et al 2006 long term diabetic control and post operative infectious complication Arch surgery 141: 375-380

  19. Risk factors related to patient • Non modifiable • Modifiable Obesity :

  20. Risk factors related to patient • Non modifiable • Modifiable Obesity : Incidence is increasing / one third in USA / 8 million are morbidly obese > 300,000 death per yr 100 million $ per yr Finkelstien EA et al (2003) national medical spending attributable to overweight and obesity , how much and who’s paying ?

  21. Risk factors related to patient Obesity • Obese Pt has a higher rate of nosocomial SSIs • Those with BMI > 30 have almost double the risk for SSIs . 0.05 % FOR NORMAL Pts BMI < 27 2.8 % FOR OBESE Pts 4% FOR MORBIDLY OBESE Pts Canturk Z et al Nosocomial infections and obesity in surgical Pts . Obes Res 2003

  22. Risk factors related to patient Obesity : Why at higher risk ?? 1. Hypoperfusion: ischaemia / necrosis / suboptimal neutrophil oxadative killing 2. Tissue mass : capillaries ratio is high 3. Larger wound surface / high dose of bacteria/ larger dead space

  23. Risk factors related to patient Obesity : Why at higher risk ?? 4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 % BMI 50-60: 28% BMI > 60 : 10%

  24. Risk factors related to patient Obesity : Why at higher risk ?? 4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 % BMI 50-60: 28% BMI > 60 : 10%

  25. Risk factors related to patient Obesity : Why at higher risk ?? 4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 % BMI 50-60: 28% BMI > 60 : 10%

  26. Risk factors related to patient Obesity : What to do ? 5 strategies • Tight peri-operative glucose control • Increase peri-operative O2 tension • Larger dose of antibiotics – hit for the maximum • Go for MIS whenever feasible • Delay the operation if elective and wt reduction is possible

  27. Risk factors related to patientSmoking • Pulmonary and cardiovascular complications, as well as wound infections are significantly more prevalent in smokers than in non-smokers (1,2) 1. Moller, A., Villebro, N., Pedersen, T. & Tonnensen, H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. The Lancet 2002; 359:114-117. 2. Ngaage, D., Martins, E., Orkell, E., Griffin, S., Cale, A., Cowen, M. & Guvenkik, L. The impact of the duration of mechanical ventilation on the respiratory outcome in smokers undergoing cardiac surgery. Cardiovasc Surg 2002; 10(4);345-350.

  28. Smoking • Cigarette smoking interferes with primary wound healing, possibly secondary to constriction of peripheral blood vessels, leading to tissue hypovolemia and hypoxia. • HoogendoornJm et al . Adverse effects of smoking on healing of bones and soft tissues. Unfallchirurg. 2002;105:76–81. [PubMed] • 19. BeldaFj et al Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005;294:2035–2042. [PubMed]

  29. Smoking • RCT in 2003 demonstrated abstinence from smoking for as little as 4 weeks significantly reduces incisional wound infections. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003;238:1–5.

  30. Alcohol

  31. Risk factors related to patientMalnutrition • Serum albumin < 3 is ae higher risk of SSIs • No enough evidence in the literiture

  32. Risk factors related to patientImmunosuppressive drugs • Unfortunately, no data are available from randomized, double-blind, controlled clinical trials.

  33. Risk factors related to surgery • Almost all are modifiable • Preoperative patient preparations : • Showering

  34. Risk factors related to surgery • Showering 1. RCT 1530 patients by wilhborg O 1987 “Showering with chlorohexidine siginficantly reduce the SSIs when compared to the group take no shower preoperatively “

  35. Risk factors related to surgery Showering 2. Meta analysis 2006 “No significant difference between the 2 groups” Webster J et al 2006 preoperative pathing or showering with skin antiseptics to prevent SSIs cochrane data base systemic review (2)

  36. Risk factors related to surgery Showering “Bathing may reduce the skin micro-organisms but not enough to prevent SSIs”

  37. Risk factors related to surgery • Showering “in the evening and morning before surgery is better than single shower preoperatively” Edmiston CE et al (2008). Preoperative shower revisited. J Am coll surg 207:233

  38. Risk factors related to surgery • Nasal colonization : Reservoirs for staph aureus Mupirocin nasal ointment preoperatively ?? • It reduces the post operative infection in nasal carriers .# • It can lead to resistance ## • 20 % carriers

  39. In a 2008 Cochrane Database review, analysis of 8 randomized, controlled trials demonstrated that mupirocin significantly reduced the incidence of S aureus-associated SSIs. van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;4 CD006216

  40. Risk factors related to surgery • Hair : Do you want to remove hair from the incision site ? ShaveDon’t Shave

  41. Risk factors related to surgery • Hair : Meta analysis Cochrane SR 2011 evidence class 1 “Shaving is associated with higher SSIs than no shaving - 9.5 Vs 5.8 %” “Clipper are associated with lesss infection compared to razor” Tanner J et al (2011) Preoperative hair removal to reduce surgical site infection . Cochrane Database systemic review (2)

  42. Risk factors related to surgery Skin preparations: Which ? Povidone iodine Chlorohexidine – alcohol Alcohol

  43. Risk factors related to surgery Skin preparations: Which ? Povidone iodine Use of povidone Iodine as skin antiseptic is associated with lower rate of SSIs Tschudin et al 2012 No risk of SSIs from residual bacteria after using povidone iodine in 1014 cases . Ann Surg 255:556-59

  44. Risk factors related to surgery Skin preparations: Which ? Povidone iodine Use of povidone Iodine as skin antiseptic is associated with lower rate of SSIs Tschudin et al 2012 No risk of SSIs from residual bacteria after using povidone iodine in 1014 cases . Ann Surg 255:556-59

  45. Risk factors related to surgery Skin preparations: Which ? Chlorohexidine and alcohol Its superior to povidone iodine - in clean contaminated surgery Darouiche et al . 2010 Chlorohexidine- alcohol versus povidone iodine for surgical site antisepsis . New Eng J of Med

  46. Risk factors related to surgery Skin preparations: Which ? Chlorohexidine -alcohol Vs Iodine Vs alcohol There is no evidence that any one is superior to another Systemic review in 2004 , Edward P S et al preoperative skin antiseptic for prevention of SSIs in clean surgery . Cochrane dat base Sys Rev

  47. Risk factors related to surgery surgical drapes 1. It should be imperable to liquid and viruses American society for testing material 1998 2. Disposable versus re-usable drapes : There is no significant difference in SSIs RCT in 946 pts . Am J Surg 1996

  48. Risk factors related to surgery surgical drapes Adhesive drapes: “ it doesn’t allow bacterial penetration and prevent the skin bacteria from multiplying under the drapes” French et al . The plastic surgical adhesive drape an evaluation of its efficacy as microbial barrier. Ann Surg

  49. Risk factors related to surgery surgical drapes Adhesive drapes: The benefit of adhesive drapes is still questionable Meta analysis . Cochrane Sys Rev 2007

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