1 / 40

Preventing Surgical Site Infections

Preventing Surgical Site Infections. Donald E. Fry, M.D. Professor Emeritus of Surgery University of New Mexico. Prevention of SSIs. Objectives Reduce the inoculum of bacteria at the surgical site Surgical Site Preparation Antibiotic Strategies

meris
Télécharger la présentation

Preventing Surgical Site Infections

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Preventing Surgical Site Infections Donald E. Fry, M.D. Professor Emeritus of Surgery University of New Mexico

  2. Prevention of SSIs Objectives • Reduce the inoculum of bacteria at the surgical site • Surgical Site Preparation • Antibiotic Strategies • Optimize the microenvironment of the surgical site • Enhance the physiology of the host

  3. Hair Removal of the Surgical SiteRazor vs. Clipper Percent SSI Infection Discharge 30-day Follow up PM Razor 5.2% 8.8% AM Razor 6.4% 10% PM Clipper 4.0% 7.5% AM Clipper 1.8% 3.2% Alexander JW et al: Arch Surg 1983; 118:347-52.

  4. Antiseptic Preparation of the Surgical Site • Isopropyl alcohol, povidone iodine, and chlorhexidine are all recommended.* ChoiceCommentary Isopropyl alcohol Flammable Povidone Iodine Must dry for maximum antibacterial effect Chlorhexidine Colorless; even distribution at surgical site is an issue *Mangram AJ at al: Am J Infect Control 1999; 27:97-132.

  5. Immunocompromised Surgical HostMicroenvironment of the Surgical Site VariableCausationEffect Hemoglobin/ Poor Hemostasis Iron, microbial Hematoma proliferation Dead Tissue Electrocautery Ineffective phagocytosis Foreign Bodies Braided Suture Ineffective phagocytosis Dead Space Obesity; Lack of No Drainage phagocytosis “The Germ is nothing, the terrain is everything” L. Pasteur (1895)

  6. Joseph Lister • A Surgeon from Edinburgh • Introduced the practice of using Antiseptics during surgical procedures. • Even introduced the aerosolization of antiseptics to prevent SSI.

  7. Surgical Site InfectionHistory of Preventive Strategies Antisepsis Asepsis Antibiotics

  8. Preventive Systemic AntibioticsExperimental Evidence • Cutaneous injection of bacteria • Inflammation at 24-48 hrs is proportional to the logarithm of the bacterial inoculum.

  9. Prevention of Surgical Site InfectionUse of Preventive Antibiotics: GI Surgery CephaloridinePlacebo Patients 101 98 Infections 6 29 (Polk and Lopez-Mayor, Surgery 1969; 66:97)

  10. Preventive Systemic Antibiotics:Importance of Timing(Cefazolin) 8-12Hrs Preop1Hr Preop1-4Hrs PostopNone Gastric 5% 4% 17% 22% Biliary 3% 0% 9% 11% Colon 6% 6% 15% 16% Total 4% 3% 14% 15% ( Stone, Ann Surg 1976; 184:443)

  11. Preventive Systemic AntibioticsPostoperative Administration(Cefamandole) Preop Drug Preop Drug + 5 Days of Drug+ 5 Days of Placebo Gastric 0% 0% Biliary 0% 6% Colon 11% 9% Total 5% 6% (Stone, Ann Surg 1979; 189:691)

  12. Systemic Preventive AntibioticsPenetrating Abdominal Trauma Timing# of PatientsInfection Rate Preoperative 116 7% Intraoperative 98 33% Postoperative 81 30% ( Fullen et al: J Trauma 1972; 12:282)

  13. Systemic Preventive AntibioticsAortobifemoral Bypass SSIs/PatientsInfection Rate Cefazolin 2/225 0.9% Placebo 16/237 6.8% ( Kaiser et al: Ann Surg 1978; 188:283)

  14. Systemic Preventive AntibioticsHip Fracture Surgery SSIs/PatientsInfection Rate Nafcillin 1/135 1% Placebo 7/145 5%(P<.04) (Boyd et al: JBJS 1973; 55:1251)

  15. Systemic Preventive AntibioticsOpen Fractures #Patients#Infections Cefonicid(One Day) 79 10(13%) Cefonicid(Five Day) 85 10(12%) Cefamandole(5 Day) 84 11(13%) (Dellinger et al:Arch Surg 1988; 123:333)

  16. Antibiotic ProphylaxisDemonstrated Benefit • G.I. Procedures (including appendicitis) • Oropharyngeal procedures • Vascular (abd & leg) procedures • Open heart procedures • Obstetrical and Gynecological procedures • Orthopaedic hardware placement • Craniotomy • Some “clean” procedures

  17. Systemic Preventive AntibioticsContraindications • Ventilator Patients to Prevent Pneumonia • Foley Catheters to Prevent UTI • IV Lines to Prevent Catheter Sepsis • Chest Tubes to Prevent Empyema • Open Wounds(Including Fractures)

  18. Song and Glenny: Brit J Surg 1998; 85:1232

  19. Single vs Multiple Dose Surgical Prophylaxis: Systematic Review All studies, random All studies, fixed Multi > 24h Multi < 24h Favors multiple dose Favors single dose McDonald M: Aust NZ J Surg 1998;68:388

  20. Systemic Preventive AntibioticsWhy Postoperative Administration Fails • Systemically Administered Antibiotic does not penetrate the Established Fibrin Matrix in the Wound.1 • The Closed Surgical Wound has continued Inflammation and Edema, which creates a “Halo” of Ischemia.2 Dunn D, Simmons DL: Surgery 1982; 92:513-9. Lee JT: Surgical Infections, Fry DE(Ed), Little-Brown, Boston. Pp. 145-59, 1995.

  21. Systemic Preventive AntibioticsConsequences of Prolonged Postoperative Use • Excessive Antibiotic and Drug Delivery Costs. • Increased Patterns of Antibiotic Resistance. • Increased Antibiotic-Associated Complications. Bratzler et al Arch Surg 2005, 140:174-82.

  22. Preventive Systemic AntibioticsAntibiotic-Associated Complications • Hypersensitivity • Nephrotoxicity • Hepatic Toxicity • Coagulation/Platelet Aggregation Complications • Fungal Super-infections • Clostridium difficile Enterocolitis Cunha BA: Med Clin N Am 2001; 85:149-85.

  23. Systemic Preventive AntibioticsElimination Half-life Counts • Cephalothin is gone from the wound in 90 min from time of administration. • Cefazolin in therapeutic concentrations beyond 2½ hours. Fry and Pitcher: Arch Surg 1990; 125:1490

  24. Prevention of SSIs Surgical Infection Prevention Project • Administration of antibiotic within 60 min of skin incision. • Antibiotic consistent with recommended choices. • Antibiotic should not be continued beyond 24 hours after completion of the procedure. Bratzler et al Arch Surg 2005, 140:174-82.

  25. Surgery (N) Antibiotic within 1 hour % Correct Antibiotic % Antibiotic Stopped within 24 hours % Cardiac (7,861) 45.3 95.8 34.3 Vascular (3,207) 40.0 91.9 44.8 Hip/knee (15,030) 52.0 97.4 36.3 Colon (5,279) 40.6 75.9 41.0 Hysterectomy (2,756) 52.4 90.8 79.1 All Surgeries (34,133) 47.6 92.9 40.7 Surgical Infection PreventionPerformance Stratified by Surgery

  26. Discontinuation of Antibiotics Patients were excluded from the denominator of this performance measure if there was any documentation of an infection during surgery or in the first 48 hours after surgery. Bratzler DW, Houck PM, et al. Arch Surg. 2005;140:174-182.

  27. Public Law 109-171Deficit Reduction Act of 2005 • Procedures of reporting • Each hospital must: • For the FY 2007 update, hospitals are required to complete and return a written form on which they pledge to submit data 21 clinical quality measures beginning with discharges that occur in July 2006 • Failure to report results in loss of 2% of the hospital’s annual payment update Final Inpatient Prospective Payment System Rule published August 18, 2006 in Federal Register

  28. Public Law 109-171Deficit Reduction Act of 2005 • Surgical Infection Prevention/SCIP • Antibiotic within 60 minutes incision • Antibiotic choice consistent with SIP/SCIP Recommendations • Antibiotic DCed within 24 hours surgery end time (48 hours cardiac surgery)

  29. Prevention of SSIsSomething New Potential Strategies to Augment the Host! • Oxygen Supplementation • Intraoperative Temperature Control • Glucose Control

  30. Prevention of SSIsEnhanced Oxygenation 0.30 FiO20.80 FiO2 No. Patients 250 250 SSIs 28 13 Infection Rate 11% 5% (Grief et al: NEJM 2000; 342:161)

  31. Prevention of SSIsTemperature Control To>36.5To>34.5 No. Patients 104 96 Transfused Pts. 23(22%) 34(35%)[P<.054] SSIs 6 18 Infection Rate 5.8% 18.8%(P< .009) ( Kurz et al: NEJM 1996; 334:1209)

  32. Prevention of SSIsGlucose Control Intermittent Continuous InsulinInfusion No. Patients 968 1499 Deep Sternal SSI 19 12(P<0.01) Infection Rate 2.0% 0.8% (Furnary et al: Ann Thorac Surg 1999; 67:352)

  33. Surgical Care Improvement Project: Why? Medicare could prevent* up to: 13,027 perioperative deaths 271,055 surgical complications * Major surgical cases

  34. Surgical Care Improvement Project National Goal To reduce preventable surgical morbidity and mortality by 25% by 2010

  35. Surgical Care Improvement Project (SCIP) • Preventable Complication Modules • Surgical infection prevention • Cardiovascular complication prevention • Venous thromboembolism prevention • Respiratory complication prevention

  36. Surgical Care Improvement ProjectPerformance measures - Process • Surgical infection prevention • Antibiotics • Administration within one hour before incision • Use of antimicrobial recommended in guideline • Discontinuation within 24 hours of surgery end • Glucose control in cardiac surgery patients • Proper hair removal • Normothermia in colorectal surgery patients • Reporting of SSI rates by Hospital is expected to be the first surgical outcome measure for reporting.

  37. Preventive Antibiotics in Colorectal Surgery • One year demonstration project of 56 hospitals. • Employed systems changes, education, and monitoring of process measures. • Marked improvement in all procedures seen compared to national data. • 27% improvement in SSI rates. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190(1):9-15.

  38. Preventing Surgical Site InfectionSummary • Appropriate Preparation of the Surgical Site • Appropriate Hair Removal • Antiseptic Preparation of the Site • Appropriate Use of Systemic Preventive Antibiotics • Administer within 60 min window before incision • Appropriate drug choice • Discontinue with 24 hours of the procedure • Optimization of the Physiology of the Host • Supplemental Oxygenation • Core Temperature Control • Glucose Control

More Related