The presentation is solely meant for Academic purpose
The presentation is solely meant for Academic purpose
Nothing to disclose
BEFORE AFTER
The very first
requirement in a
hospital/Physician
/Surgeon is that it
should do the sick
no harm
The Definition & epidemiology of Surgical site infections (SSIs)
Pathogenesis of SSI
Control of SSI
New initiative
Mr. M underwent PPI 6 months back, now presented with a fever, swelling & pain at the surgical site.
SSI?
1. Yes
2, No
3. Ask CT surgeons
4. I’ll like to call the professor
5. I am googling
Must have one of following within 30 days post-op (1 year if implant): ◦ Purulent drainage ◦ Positive culture ( proper sample) ◦ Pain, inflammation, opening of wound needed
Types of SSI Incisional infections ◦ Superficial (skin, subcutaneous tissue) ◦ Deep (fascia, muscle)
Organ space infections
The overall SSI was 20.09%
In this retrospective study of Gen surg & GI surg the incidence was
3.67%
Clinical
Culture based
Outpatient follow-up
Feedback
Monitoring reduce SSI rates by 35-50%
Endogenous sources:
◦Majority of cases
◦Wound is a moist, devitalized, warm area
◦Directly proportional to inoculum, fewer organisms needed if foreign body present
Exogenous sources
Hematogenous and lymphatic sources
Dorairajan Sureshkumar et al AIFIC 2013 Abstract
1. Diab. mellitus/perioeperative hyperglycemia
2. Concurrent tobacco use 3. Obesity 4. Malnutrition 5. Low preoperative albumin 6. Remote infection at the time of
surgery 7. Prolonged preoperative stay 8. Prior site irradiation 9. Concurrent steroid use 10. Colonization with S.aureus
1. Shaving of site, the night prior to procedure
2. Use of razor for hair removal
3. Improper preoperative skin preparation
4. Improper antimicrobial prophylaxis (wrong drug, dose & timing)
5. Failure to timely redose for prolonged procedure
6. Inadequate OR ventilation
7. Increased OR traffic
8. Poor surgical technique (tissue trauma, poor hemeostasis)
9. Break in sterile technique, asepsis
10. Perioperative hypothermia & hypoxia
Preoperative factors ◦ Resolve
malnutrition & obesity
◦ Discontinue cigarette smoking
◦ Maximize diabetes control
Intraoperative & Postoperative factors ◦ Minimize dead space,
devitalized tissue & hematoma
◦ Consider supplemental O2 ◦ Maintain Perioperative
normothermia ◦ Maintain hydration &
nutrition ◦ Minimize postoperative
hyperglycemia (<200 for 48 hours)
Preoperative factors ◦ Minimize preoperative
stay ◦ Avoid preoperative
antibiotic use ◦ Treat remote sites of
infection ◦ Avoid shaving at surgical
site ◦ Delay hair removal until
time of surgery (clippers) ◦ Administer timely
antibiotic prophylaxis ◦ Eliminate S.aureus nasal
colonization .
Intra & postoperative factors ◦ Carefully prepare skin with
chlorhexidine containing solution
◦ Rigoursly adhere to aseptic techniques
◦ Maintain high flow of filtered air
◦ Redose of antibiotics in prolonged procedure
◦ Minimize OR traffic ◦ Minimize drains & bring
through separate incision.
Previous day admission ◦ Prolonged pre-op stay results in colonization by
hospital flora ◦ 6% infection rate for 1 day vs 14.7% for >21 days
Control infections at other sites (3 fold increase)
Stop smoking (31% to 5%) 30 days pre-op Same day hair removal just before surgery
(3% vs 20%) Clipping or depilation only, avoid razors One study showed craniotomy without hair
removal had same infection rate
Rationale is that most patients get Staph aureus from their own nose
Nasal swab screening and decolonization with mupirocin for 3 days reduced all site Staph infections from 7.7% to 4% (NEJM 2002)
If done ensure that the mupirocin course is finished pre-op
PCR screening followed by mupirocin nasal ointment and chlorhexidine soap versus controls
Rate of SSI 3.4% vs 7.2% (RR 0.42) Protection from deep space SSI even better (RR
0.21) Bottom line: applicable for cardiac surgery,
implant, immunosuppressed) ◦ N Engl J Med 2010;362:9
RCT compared chlorhexidine-alcohol vs povidone-iodine for clean contaminated surgery
9.1 vs 16.5% SSI rates respectively
Unclear if povidone-iodine was allowed to evaporate
N Engl J Med 2010;362:18
Numerous studies show an increased risk for nosocomial infections with blood transfusion (app. double)
Avoid blood unless: ◦ Patient actively bleeding
◦ Hb<7.0
◦ Critical coronary ischemia
Clearly effective in reducing the incidence of surgical site infections
Antibiotics have to be in the system at time of incision and for duration of surgery, give first dose in theater < 1 hour before incision.
No role for oral antibiotics for a few days later
No role for antibiotics after day one or continuing till drains removed
Antibiotics don’t protect against infections at other sites
General surgery Cardiac, orthopedic, gynecolgic
Based on anticipated contaminating flora ◦ Staphylococcus aureus is most common
◦ Gram negatives & anaerobes if mucosae breached
◦ (Dorairajan Sureshkumar et al unpublished data GPC is the common colonizer at hospital admission)
2 g cefazolin or 1.5 g cefuroxime usually recommended
Give extra intra-op dose for surgeries >3 hrs duration
Antibiotic resistance is increasing alarmingly and we are running out of antibiotics to treat patients ◦ MRSA ◦ ESBL ◦ pan resistant Pseudomonas ◦ pan resistant Acinetobacter
Every clean case that gets an antibiotic is colonized by resistant organisms- this spreads to other patients
Study shows that broad spectrum antibiotic use predisposes to resistant infection later
No preventive role after skin is closed
2000 B.C – Here, eat this root. (pre-antibiotic era)
1000 A.D – That root is heathen, say this prayer
1940 A.D – That potion is snake oil, swallow this pill.
1985 A.D – That pill is ineffective, take this new antibiotic
2012 A.D – That antibiotic is placebo. Here, eat this root or pray. (post antibiotic era)
Vancomycin or teicoplanin ◦ Can use single dose if outbreak of MRSA for
hardware insertion eg prosthetic valve
Aminoglycosides
Cefoperazone-sulbactam
Other third generation cephaloporins
Piperacillin-tazobactam
Meropenem or imipenem
Linezolid
Results Background
Objective
Materials & Methods
Conclusion
References
Our study indicates the importance of surgical
antibiotic guidelines and feed back by the
infection control team in reducing unnecessary
antibiotic usage in surgical practice.
To study the adherence to local hospital
guidelines for antimicrobial prophylaxis in
surgery, and explore ways of improving
adherence.
In western countries despite extensive
knowledge and guidelines on surgical
antibiotic prophylaxis, implementation is
often suboptimal. Only a minority of
hospitals in a developing country like India
have an antibiotic policy and surgical
antibiotic prophylaxis guidelines. There is a
need to study adherence to antibiotic
prophylaxis guidelines in India.
A prospective evaluation of the use of
antimicrobial prophylaxis in patients
undergoing surgery at our hospital was
carried out from July 2009 to March
2010. Three criteria were evaluated: 1.
Antibiotic choice 2. Timing of the
antibiotic in relation to surgery and
3.Duration of administration. The
response to feedback provided by the
infection control team regarding
duration was also evaluated,
During the study period 1161 elective surgeries were performed. One hundred
percent compliance to all the three criteria was observed in 49.30% of cases.
Correct antibiotic selection was done in 74.80% of surgeries, timing of the first
dose was appropriate in 99.70% cases. The most frequent encountered
deviation from the policy was unnecessary prolongation of prophylaxis in
41.60% of cases. However in 34.13% of cases where prophylaxis was
prolonged, the surgeon accepted the infection control team’s feed back to stop
antibiotic prophylaxis.
Summary
The results showed a significantly high level
of adherence with guidelines concerning the
choice and timing of antibiotic. The infection
control team’s feed back lead to stopping of
antibiotic in 34.13% of times. Nearly 50 % of
the time all the three parameters were
followed by the surgeons.
Adherence to Surgical Antibiotics Prophylaxis guidelines
99.70%
74.80%
58.40%49.30% 49.30%
0%
20%
40%
60%
80%
100%
First dose within 1 hour Followed guidelines for
antibiotic selection
Antibiotics stopped within
24 hours
Followed guidelines for
antibiotic selection and
stopped within 24 hours
Followed guidelines for
antibiotic selection and
stopped within 24 hours
and first dose within 1
hour% of cases
Adherence to local hospital guidelines for
surgical antimicrobial prophylaxis: a
multicentre audit in Dutch hospitals. JAC
(2003) 51 1389-1396
Sureshkumar et al ICAAC Boston 2010
Give antibiotics within one hour before incision and stop same day
Avoid shaving, esp previous day
Warm and oxygenate patient
Tight intra-op and post-op glucose control
Control your OR traffic
Hand hygiene before and after every patient contact
New watchword transition from benchmarking to zero tolerance
1. Restrict hospital admission to 6-12 hours before surgery 2. Do not shave/razor the surgical site
3. Use antibiotic as per surgical prophylaxis guidelines
4. Administer antibiotics 0-60 minutes before incision
5. Redose if surgery is prolonged more than three hours and stop when surgery is over.
If interested enroll your name with us
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2013 Operation O