1 Preventing Surgical Site Infections Prophylactic Antibiotics Bowel Prep and Oral Antibiotics Perioperative Hyperglycemia is Dangerous for both Diabetics and NONdiabetics PreWarming and Warming for Perioperative Normothermia Patchen Dellinger Prophylactic Antibiotics Antibiotics given for the purpose of preventing infection when infection is not present but the risk of postoperative infection is present
62
Embed
Bowel Prep and Oral Antibiotics Perioperative ... · Bowel Prep and Oral Antibiotics Perioperative Hyperglycemia is Dangerous for both Diabetics and NONdiabetics ... Juul 1987 amp/metronid
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1
Preventing Surgical Site Infections
Prophylactic Antibiotics
Bowel Prep and Oral Antibiotics
Perioperative Hyperglycemia is Dangerous for both Diabetics and NONdiabetics
PreWarming and Warming for Perioperative Normothermia
Patchen Dellinger
Prophylactic Antibiotics
Antibiotics given for the purpose of preventing infection when infection is not present but the risk of postoperative infection is present
2
Prophylactic AntibioticsQuestions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be continued?
Relative Benefit from Antibiotic Surgical Prophylaxis
Antibiotic ProphylaxisDemonstrated Benefit: All Procedures??
• Review of prophylaxis meta-analyses suggests that there is a consistent relative risk of wound infection less than one associated with antibiotic prophylaxis.
• This is independent of the type of operation or of the baseline (placebo) rate of infection.
Bowater. Ann Surg 2009;249: 551–556
5
Relative Effect of Prophylactic Antibiotics Arranged by Wound Category
Bowater. Ann Surg 2009;249: 551–556
Prophylaxis for Clean procedures?Relative reduction of SSI with prophylaxis is the
same for all procedures (30-70%)
Absolute reduction is less if baseline rate with placebo is less.
Decision on whether to use depends on 1) cost of prophylaxis ($, side effects,
generating resistance) and
2) cost of infection ($, disability, etc).
6
Prophylactic AntibioticsQuestions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be continued?
7
Parenteral Prophylactic AntibioticsFor Colectomy
Are some parenteral antibiotics better than others?
Anaerobic Coverage for Colectomy
SSI
I.V. Cefotaxime, 2 g (n=280) 44 (16%)
I.V. Cefotaxime +Metronidazole, 1.5 g (n=130) 19 (7%)
p < 0.001
Hӓkansson. Eur J Surg 1993; 159: 177-80
8
Aerobic Coverage for Colectomy
SSI
I.V. Ticarcillin (n=131) 10 (8%)3 g preop and 2 h later
Antibiotic Choice & SSI After Colectomy - Multivariate Analysis
Premier Data Base, n = 4634
Agent O.R. Range
Cefoxitin 1.0
Ertapenem 0.53 0.34 - 0.82
Cefazolin/Metron 0.58 0.33 - 1.04
Levo/Metron 0.59 0.30 - 1.14
Amp/sulbactam 0.62 0.33 - 1.15
Cefotetan 0.86 0.45 - 1.67
Eagye. Surg Infect 2011; 12: 451-7
Antibiotic Choice & SSI After Colectomy - Multivariate Analysis
MSQC, n = 4331
O.R. P
Ab SCIP compliant 0.67 0.04
Post-Op temp >36 0.40 0.01
POD #1 glucose >140 1.52 0.00
Oral antibiotics 0.54 0.00
Laparoscopic 0.59 0.00
Open time >100 min 1.65 0.00
BMI >30 1.36 0.03
Hendren. Ann Surg 2013;257.469
10
Antibiotic Choice & SSI After Colectomy
Cip
ro/M
etro
nid
Cef
az/M
etro
nid
Ert
apen
em
Am
p/S
ulb
act
Cef
azol
in
Cef
oxit
in
Cli
nd
a/G
ent
Cef
otet
an
Ad
just
eO
dd
s R
atio
s
Hendren. Ann Surg 2013;257.469
Antibiotic Choice & SSI After Colectomy
Cefazolin and metronidazole are compatible in the same I.V. bag, and the UWMC pharmacy has this combination pre-mixed and available in the O.R. pharmacy.
11
Surgical Antibiotic Prophylaxis
Bacteroides expected -Cefazolin 2 g + metronidazole 1 g, IV in O.R.
Repeat cefazolin q 3 h during procedure
Bacteroides not expected -Cefazolin 1-2 g, IV in O.R.
Repeat q 2-3 h during procedure
Alternatives
Cefazolin
Other first generation cephalosporin
Cefuroxime, cefamandole, cefonicid
Oxacillin, etc
Cefazolin plus metronidazole
Aminoglycoside or quinolone plus clindamycin or metronidazole
Ertapenem
12
Special Cases?
• Patient allergic (anaphylactoid) to β-lactam antibiotics
• High rate of MRSA wound infections locally
• Recent prolonged course of antibiotics or ICU stay
Vancomycin vs B-lactam Prophylaxis in Cardiac Surgery and Arthroplasty
22,549 Procedures in Victoria, Australia
Adjusted Odds Ratio for any SSI
Variable OR 95% CI P
Proc. Duration, min 1.003 1.002-1.004 <0.001
ASA score > 3 1.71 1.42-2.07 <0.001
Vancomycin proph 1.40 1.02-1.93 0.04
Bull. Ann Surg 2012; 256: 1089-92
13
Vancomycin vs B-lactam Prophylaxis in Cardiac Surgery and Arthroplasty
22,549 Procedures in Victoria, Australia
Adjusted Odds Ratio for SSI with MSSA
Variable OR 95% CI P
Proc. Duration, min 1.003 1.002-1.004 <0.001
ASA score > 3 1.89 1.30-2.74 <0.001
Vancomycin proph 2.79 1.60-4.87 <0.001
Bull. Ann Surg 2012; 256: 1089-92
Prophylactic AntibioticsQuestions
Which cases benefit?
Which drug should you use?
When should you start?
How much should you give?
How long should antibiotics be continued?
14
Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242.
Decisive Period For Development Of Wound Infection
Lesion Age (hrs)
Lesi
on S
ize,
(m
m)
Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic
Age of Lesion at Antibiotic Injection (Hours)
Les
ion
Siz
e, m
m (
24 H
ou
rs)
0
5
10
Penicillin, 40,000 U
Staph + Penicillin
Control
Chloramphenicol, 0.1 mg/Kg
Erythromycin, 0.1 mg/Kg
Tetracycline, 0.1 mg/Kg
0 2 4 6-2 0 2 4 6-2
0
5
10
0
5
10
0
5
10
Control Control
Control
Staph + Erythromycin
Staph + TetracyclineStaph + Chloramphenicol
Burke JF. Surgery. 1961;50:161.
15
0
1
2
3
4
≤-3 -2 -1 0 1 2 3 4 ≥5
Classen. NEJM. 1992;328:281.
Perioperative Prophylactic Antibiotics
Timing of AdministrationIn
fect
ions
(%
)
Hours From Incision
14/369
5/6995/1009
2/180
1/81
1/411/47
15/441
Timing of Prophylactic Antibiotic Administration for Total Hip Arthroplasty
van Kasteren. Clin Infect Dis 2007; 44:921
16
Timing of Prophylactic Antibiotic Administration – Cardiac, Arthroplasty, Hysterectomy
Steinberg. TRAPE. Ann Surg 2009; 250:10
Timing of Prophylactic Antibiotic Administrationand Risk of SSI
Koch.JACS 2013; 217: 628-35
4,453patients
4 minutes
Observed=444
17
Timing, Dose, Redose, Weight
All the evidence suggests that having effective drug levels in tissue and blood (more is better) during the entire operation reduces SSI risk.
Dosing close to incision, redosing, and using weight based dosing are logical ways to accomplish this.
Prophylactic AntibioticsTiming - Cefazolin
Serum Levels (mg/L)
On Call Anesth
Incision 87 148
1 hour 37 57
2 hours 25 39
DiPiro. Arch Surg 1985;120:829
18
Prophylactic AntibioticsTiming – Cefazolin
Incision
Wound closure
9
7
17
11
On Call Anesth
Muscle Levels
DiPiro JT et al. Arch Surg. 1985;120:829-832.
Prophylactic AntibioticsAdministration in the O.R.
Drugs Given I.V. Push over 5-10 Min
CefazolinDrug to incision 17 (7-29) minMuscle levels 76 (9-245) mg/kg
CefoxitinDrug to incision 22 (14-27) minMuscle levels 24 (13-45) mg/kg
DiPiro. Arch Surg 1985;120:829DiPiro. Personal Communication
19
Prophylactic AntibioticsTissue Levels at Wound Closure
Time No DrugCefoxitin of Closure Detectable
On Call 2.5 hr 38%
With Anesth 2.3 hr 14%
DiPiro. Arch Surg 1985;120:829
Prophylactic AntibioticsQuestions
• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be continued?
20
Prophylactic AntibioticsSize of Patient and Size of Dose
• Morbidly obese patients having bariatric operation
• Cefazolin levels lower than in non-obese patients at same dose
Geroulanos 1986 cefuroxime 2 days 1.1%(569 pts) cefazolin 4 days 2.5%
26
Duration of Prophylaxis:Infection and Antibiotic Resistance
Risk in Cardiac Surgery
< 48 hr >48 hr OddsShort Long Ratio
Number 1502 1139
SSI 131 (8.7%) 100(8.8%) 1.0 (0.8-1.3)
Acq Ab Res 6% 1.6 (1.1-2.6)
Harbarth. Circulation 2000;101:2916
Single vs Multiple Dose Surgical Prophylaxis: Systematic Review
0.01
0.1
1
10
100
McDonald. Aust NZ J Surg 1998;68:388
All
stu
die
s, f
ixe
d
All
stu
die
s, r
and
om
Mu
lti
> 2
4h
Mu
lti
<2
4h
Fav
ors
sin
gle
do
seF
avo
rs m
ult
iple
do
se
27
Oral Antibioticsfor Colectomy
Nichols Showed that Mechanical Bowel Prep Did Not Reduce Colon Flora
(log 10)
Coliforms Bacteroides Clostridia
No Prep 4.5 – 7.5 7.9 – 9.5 1.8 – 3.6
Prep 3.0 – 4.3 7.8 – 9.0 0.7 – 2.5
Nichols. Dis Col & Rect 1971; 14: 123-7
28
Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
88% SSI Reduction
Any SSI
Placebo (63) 27 (43%)
Neomycin (68) 28 (41%)
Neo + Tetracycline (65) 3 (5%)
p<0.01
Washington. Ann Surg 1974;180:567-71
Antibiotic and Mechanical Bowel Prep for Colectomy (18 hrs)
79% SSI Reduction
Any SSI
Placebo (56) 26 (43%)
Neo + Erythro (56) 5 (9%)
p=0.0001
Clarke. Ann Surg 1977; 186:251-9
29
Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSI
Placebo (59) 25 (42%)
Neo + Metronidazole (51) 9 (18%)
p<0.01
Matheson. Br J Surg 1978; 65:597-600
Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs)
Any SSI
Placebo (39) 16 (41%)
Kanamycin + Erythro (38) 3 (8%)
p<0.001
Wapnick. Surgery 1979; 85:317-21
30
Antibiotic and Mechanical Bowel Prep for Colectomy (18 - 48 hrs)
Bowel Prep + Placebo Oral Ab
1974 43% 5%
1977 43% 9%
1978 42% 18%
1979 41% 8%
“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery
Process Measure Study Control
Mechanical Bowel Prep No Yes
Oral Antibiotics No Yes
PreOp Warming Yes No
IntraOp Warming Yes YesFiO2 80% 30%
I.V. FluidsLimited, Colloid
> Crystalloid Per Usual
Wound Protector Yes No
SCIP Parenteral Antibiotics Yes Yes
Anthony. Arch Surg 2010; 146: 263-9
31
“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery With Removal of
Bowel Prep & Oral Antibiotics
Process Measure Study Control
Total Fluids 1800 ml 2500 ml
Crystalloid Fluids 1500 ml 2250 ml
First PACU Temp 36.7 36.3
Duration of Op 170 min 150 minAny SSI* 45% 24%
Organ/Space SSI 9% 6%
Anthony. Arch Surg 2010; 146: 263-9*p=0.003
49.3%
36.4%
11.3%
Mechanical PrepOnly
Mechanical Prepand PO
antibiotics
No Prep
Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648)
Overall SSI Rate in Michigan is 8.0%
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
32
11.2%
4.8%
10.6%
Mechanical PrepOnly
Mechanical Prepand PO antibiotics
No Prep
Surgical Site Infection Rates following Elective Colectomy
The Michigan Surgical Quality Collaborative
Propensity Matched Analysis(n=740)
Englesbe. Ann Surg 2010;252: 514–520
n=195
All patientsGet I.V. antibiotics
56%
0%
5%
10%
15%
C.difficile colitis Prolonged Ileus
No Oral Antibiotics
Oral Antibiotics
Per
cen
t o
f p
atie
nts
* P < 0.05
Oral Antibiotics with a Bowel Preparation
A Propensity Matched Analysis (n=740)
Englesbe. Ann Surg 2010;252: 514–520
All patientsGet I.V. antibiotics
33
“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery
1. Appropriate SCIP IV prophylactic antibiotics
2. Postop normothermia (T>98.6/37)
3. Oral antibiotics and bowel prep
4. Minimally invasive surgery
5. Short operative duration (<100 min)
Waits (MSQC). Surgery 2014;155: 602-6
“Evidence Based” Bundle to Prevent SSI in Colorectal Surgery
Waits (MSQC). Surgery 2014;155: 602-6
34
Bowel Prep & Oral AntibioticsVASQIP Data – 9940 patients
Cannon. Dis Col Rectum 2012; 55: 1160-6
SSI Rate Significantly Lower with
oral prep and oral antibiotics
9% vs. 18.1%
Most Recent Cochrane Review
Comparison Odds Ratio Range
Ab Proph vs none 0.34 0.28 – 0.41
Oral + I.V. vs I.V. only 0.56 0.43 – 0.74
Oral + I.V. vs Oral only 0.56 0.40 – 0.76
Greater than 2300 pts in each comparison
GRADE evidence quality HIGH
Nelson RL, Cochrane Rev 2014; #5: CD001181
35
Oral Antibiotic Bowel Prep Significantly Reduces SSI Rates and Readmission Rates in Elective Colorectal Surgery
NSQIP data on 8,415 colectomy pts
Open and Laparoscopic
No Prep 2150 25%
Mech Prep Only 3779 45%
Oral Ab + Mech Prep 2486 30%
Morris. Ann Surg 2015; 261:1034-40
Oral Antibiotic Bowel Prep Significantly Reduces SSI Rates and Readmission Rates in Elective Colorectal Surgery
NSQIP data on 8,415 colectomy pts
Open and Laparoscopic
SSI
Oral Ab 6.5%
No Oral Ab 13%
Morris. Ann Surg 2015; 261:1034-40
36
Oral Antibiotic Bowel Prep Significantly Reduces Complication Rates in
Elective Colorectal Surgery
Reduced P
Anastomotic leak < 0.001
Ileus < 0.001
Return to O.R. 0.02
Readmission < 0.001
Mortality 0.001
Morris. Ann Surg 2015; 261:1034-40
Oral Antibiotic Bowel Prep Significantly Reduces SSI Rates and Readmission Rates in Elective Colorectal Surgery
Targeted Colorectal NSQIP data on 4,999 pts, Open and Laparoscopic with detailed data on mechanical prep, use of oral antibiotics, operative approach and multiple other risk factors.
Scarborough. Ann Surg 2015; 262(2):331-7
37
Oral Antibiotic Bowel Prep Significantly Reduces SSI Rates and Readmission Rates in Elective Colorectal Surgery
30% of all hyperglycemic patients were not diabetic!
Kwon. Ann Surg. 2013; 257: 8-14
Composite InfectionHyperglycemia vs No Hyperglycemia
Nondiabetic Patients
0
5
10
15
20
All Pts Bariatric Colectomy
NormalGluc>180
All p<0.01
Kwon. Ann Surg. 2013; 257: 8-14
50
Composite Infection in Hyperglycemic Patients With
and Without Use of Insulin
Kwon. Ann Surg. 2013; 257: 8-14
Insulin reduces risk even when glucose control is not as good as desire
Operative Reintervention in Hyperglycemic Patients With
and Without Use of Insulin
Kwon. Ann Surg. 2013; 257: 8-14
Insulin reduces risk even when glucose control is not as good as desire
51
Mortality in Hyperglycemic Patients With and Without Use
of Insulin
Kwon. Ann Surg. 2013; 257: 8-14
Insulin reduces risk even when glucose control is not as good as desire
Glucose ControlProven important for SSI risk:
Cardiac surgery
General surgery
Colorectal surgery
Vascular surgery
Breast surgery
Gynecologic Oncology surgery
Hepato-pancreatico-biliary surgery
Orthopedic surgery
Trauma surgery
52
•Regardless of the Diagnosis of Diabetes(or not)
Hyperglycemia Increases
• Morbidity
• Mortality
• Length of Stay
Which Patients Are at Risk
for Hyperglycemia?
53
Glucose in NonDiabetics having Colectomy at Cleveland Clinic
Highest Gluc N (%)
< 125 mg% 816 (33%)
126-200 mg% 1289 (53%)
200 mg% 342 (14%)
All patients 2447 (100%)
Kiran, et al. Ann Surg 2013; 258:599-605
67%
Glucose in NonDiabetics having Colectomy at Cleveland Clinic
Kiran, et al. Ann Surg 2013; 258:599-605
Per
Cen
t in
cid
ence
0
1
2
3
4
5
6
7
8
<125 126-200 >200
Mort+
Sepsis¤
SSI*
Reop¤
*p<0.03, ¤ p<0.01, + p<0.05
54
Preoperative Glucose as a Screening Tool for Patients
Without Diabetes• Random glucose within 30 days of operation
• Average 8 days before operation
• 16% within one day and 29% within 3 days
• 6683 patients• <70 384 pts
• 70-99 4251 pts
• 100-139 1801 pts
• 140-179 187 pts
• >180 60 pts
Wang. J Surg Res. 2014; 186: 371-8
31%
Preoperative Glucose as a Screening Tool for Patients
Without Diabetes
Wang. J Surg Res. 2014; 186: 371-8
Pre-Op Glucose vs. Post-Op Infection, adjusted for age, gender, BMI, ASA, & type of operation.
55
SCOAP – NonDiabetics Less Likely to Receive Insulin for Hyperglycemia
Kotagal. Ann Surg 2015; 261:97-103
SCOAP Adverse Events with Hyperglycemia – Diabetics v. NonDiabetics
Kotagal. Ann Surg 2015; 261:97-103
56
PreOp CHO and Insulin ResistanceColorectal Surgery, 400 mL 3 h Preop
Wang. Br J Surg 2010; 97: 317-27
PreOp CHO and Insulin ResistanceColorectal Surgery, 400 mL 3 h Preop
Wang. Br J Surg 2010; 97: 317-27
Insu
lin
Sen
siti
vity
In
dex
57
PreOp CHO and Muscle Mass – Major Abdominal Surgery
800 mL evening, 400 mL 2 h Preop
Svanfeldt. Br J Surg 2007; 94: 1342-50
Triceps Skin Fold Arm Muscle Circum
Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of
pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee
on Standards and Practice Parameters. Anesthesiology 2011;114:495-511
It is appropriate to fast from intake of clear liquids at least 2 h before elective procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. . . . The volume of liquid ingested is less important than the type of liquid ingested.
58
Glucose Levels & SSI• The exact “best” level of glucose control in
the perioperative period is not known.
• High glucose levels unequivocally increase the risk of SSI and other perioperative infections.
• Tight glucose control in the perioperative period is tricky.
• Hypoglycemia increases the risk of morbidity and mortality.
• When algorithms are followed at UWMC hypoglycemia is very rare.
Temperature and Infection
59
Temperature and Tissue O2
tension• Subcut temp increase 4° C
• Subcut O2 tension increase 40 torr
• Linear correlation between temperature and O2 tension
• Threefold increase in local perfusion
Rabkin. Arch Surg 1987;122:221
Temperature and SSI Following Colectomy
Normo (104) Hypo (96) P
SSI 6 18 .009
Kurz. NEJM 1996;334:1209
60
Hypothermia During Anesthesia
0 2 4 6
² C o reT e m p
(°C )
El a p s e d T i m e (h )
-1
-3
-2
0
Redistribution Hypothermia
Core37°C
Vasoconstricted
Periphery31-35°C
Anesthesia
Periphery33-35°C
Core36°C
Vasodilated
61
Keeping Your Patient Warm in the O.R.
• Prewarming and active warming in the O.R. is much more important than the O.R. room temperature.
• If you raise O.R. room temperature from 20o to 27o, you still have an 10o gradient between the patient’s temperature and the room temperature and everyone in the room is miserable.
Prewarming at UWMC &First Postoperative TemperaturePost Anesthesia Care Unit (PACU) 2006
> 36o
7836/8132 (96.4%)
> 36o
& < 36.5o
1047/2647 (40%)
> 36.5o
1491/2647 (56%)
62
Perioperative Warming, Intraoperative Temperature and Complications
----
Open Abdominal Bowel Resections
Wong. Br J Surgery 2007; 94: 423-6
PeriopN=47
StandardN=56 P value
Blood loss 200 ml 400 ml 0.011
Any complication 32% 54% 0.027
SSI 13% 33% 0.09
I am happy to share these slides
I have provided the slides to the Connecticut Hospital Association