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EMERGING EVIDENCE AROUND SURGICAL
PROPHYLAXIS:“the UPSIDES and the
DOWNSIDES”
Part 1: EXAMINING CAUSE AND EFFECT
Presented by Wendy Runge, RN, BScN, CIC
Infection Control Practitioner, Calgary AB
HEALTH CARE ASSOCIATED INFECTIONS (HCAI)
• THE BIG 3: SSI, CLI, VAP
• PREVENTION RESEARCH HAS IDENTIFIED EVIDENCE-BASED INTERVENTIONS(CLASS 1 EVIDENCE)
HOWEVER,
“NO GOOD DEED GOES UNPUNISHED”(Clare Boothe Luce)
SSI AND RISK
• RISK INCREASED BY:
– PATIENT FACTORS
– SURGICAL PROCEDURE
• RISK MAY BE DECREASED BY:
– COMPLIANCE WITH EVIDENCE-BASED PRACTICE
PROPHYLAXIS: the rationale
• SKIN CAN’T BESTERILISED
• SKIN FLORA WILL BETRACKED INTO DEEPERTISSUES
• PROVIDES SHORT-TERMSUPPORT FOR THE IMMUNE SYSTEM
ASSOCIATED RISKS
• INCREASED/IMPROPER USE OF ANTIBIOTICS HAS BEEN IMPLICATED IN: ANTIMICROBIAL RESISTANCE
– Clostridium difficile ASSOCIATED DIARRHEA (CDAD)
Staphylococcus aureus
• COMMON SKIN BACTERIUM
• PENICILLIN INTRODUCED1943; BY 1960, 80%RESISTANCE REPORTED
• 1ST CASE OF METHICILLIN- RESISTANCE WAS SEEN IN 1961 (MRSA)
• RELATIVELY SLOW EMERGENCE UNTIL 1990s
MRSA
• ADAPTS AND SHARES GENETIC INFORMATION
• ANTIMICROBIAL PRESSURE WILL SELECT FOR RESISTANT STRAINS
• RECENT EPIDEMIOLOGY:
– COMMUNITY ACQUISITION
– POOR ADHERANCE TO HAND HYGIENE IN HEALTH CARE
Emerging MRSA Epidemic Strains
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
1995n=227
1996n=309
1997n=638
1998n=565
1999n=1083
2000n=773
2001n=1461
2002n=1365
2003n=1450
2004n=1658
2005n=1122
Year
Perc
ent M
RSA
Isol
ates CMRSA7
CMRSA8
CMRSA9
CMRSA10
Presented at the CNISP 2006 Annual Meeting
Clostridium difficile
• FOUND IN LOWER BOWEL, CAN BE PART OF RESIDENT FLORA
• SPORE-FORMER; SURVIVES FOR EXTENDED PERIODS IN THE ENVIRONMENT
• EXCRETES TOXINS WHICH CAN CAUSE TISSUE DAMAGE
C.difficile: Vegetative vs Spore
Vegetative form: metabolically active - Produces Toxin A & B (? Other)- Killed by some antibiotics only- Oxygen exposure kills
Spores: not metabolically active- No Toxin production, - Not affected by antibiotics- Oxygen exposure doesn’t kill
Dr. Michelle Alfa Ph.D, FCCMDiagnostic Services of ManitobaSt. Boniface General Hospital Site
CDAD (C. difficile associated diarrhea)
• ANTIMICROBIAL PRESSUREMAY ALLOW FOR OVERGROWTH
• RECOGNIZED AS PRIMARY CAUSE OF ANTIBIOTIC ASSOCIATED DIARRHEA IN 1978
• RECENT EMERGENCE OF NEW STRAINS CAUSING MORE SEVERE DISEASE
CDAD
• ANTIMICROBIALS MOST OFTEN IMPLICATED:
– CLINDAMYCIN
– 2ND AND 3RD GENERATION CEPHALOSPORINS
– FLUOROQUINOLONES
CDAD: MORE TO THE STORY?
• 2000 – 2001: LARGEST MULTICENTRE OUTBREAK TO DATE REPORTED IN CALGARY
• INVESTIGATIONAL FINDINGS:– FRAIL ELDERLY WITH MULTIPLE
COMORBIDITIES– ENVIRONMENTAL
CONTAMINATION– UNRESTRICTED USE OF
CLINDAMYCIN
CDAD PREVENTION
• ANTIMICROBIAL STEWARDSHIP
• ELIMINATING ENVIRONMENTAL RESERVOIRS
• CONTACT ISOLATION OF SUSPECT AND CONFIRMED CASES
PROPHYLAXIS DONE RIGHT!
• TARGETS THE ORGANISMS MOST LIKELY AT THE SURGICAL SITE
• DELIVERED AT THE OPTIMAL TIME
• PROPHYLAXIS VS TREATMENT
• “BUGS & DRUGS 2006 ANTIMICROBIAL REFERENCE BOOK”
Risk Evaluation of Risk Evaluation of Clostridium difficileClostridium difficile-Associated Diarrhea -Associated Diarrhea
Following Antimicrobial Prophylaxis Following Antimicrobial Prophylaxis in Patients Undergoing in Patients Undergoing
Cardiac, Vascular or Thoracic Surgery in a Cardiac, Vascular or Thoracic Surgery in a Tertiary Care Trauma CenterTertiary Care Trauma Center
D.J.G. Thirion, M.Sc., Pharm.D., BCPSD.J.G. Thirion, M.Sc., Pharm.D., BCPS
Clinical Assistant Professor, PharmacistClinical Assistant Professor, Pharmacist
Hôpital du Sacré-Cœur de MontréalHôpital du Sacré-Cœur de Montréal
Faculty of Pharmacy, Université de MontréalFaculty of Pharmacy, Université de Montréal
Paper K-351Paper K-351
ICAAC 2006ICAAC 2006
BackgroundBackground
Antimicrobial prophylaxis (AP) is Antimicrobial prophylaxis (AP) is standard of practice forstandard of practice for– Cardiac, thoracic, vascular surgery Cardiac, thoracic, vascular surgery
AP decreases surgical site infections AP decreases surgical site infections (SSIs)(SSIs)
Risk of Risk of C. difficileC. difficile associated associated diarrhea (CDAD) has been low diarrhea (CDAD) has been low historically (1.2%)historically (1.2%) Harbarth Harbarth et al.et al. J Hosp Inf 2001;48:93-97 J Hosp Inf 2001;48:93-97
Antibiotic prophylaxis protocolAntibiotic prophylaxis protocol
Promoting rational use of antibiotic Promoting rational use of antibiotic prophylaxis in surgery canprophylaxis in surgery can Surgical Site Infections Surgical Site Infections length of staylength of stay therapeutic use of antimicrobialstherapeutic use of antimicrobials
Improve costsImprove costs
Thirion DJG et al. Thirion DJG et al. Applied Therapeutics. 2004Applied Therapeutics. 2004
Appropriate use to decrease risks Appropriate use to decrease risks (pitfalls!)(pitfalls!)
Adverse reactionsAdverse reactions– Allergic or toxic reactionsAllergic or toxic reactions– Clostridium difficileClostridium difficile (superinfection) (superinfection) (Spencer RC. AAC 1998)(Spencer RC. AAC 1998)
Development of resistanceDevelopment of resistance– Vancomycin resistant enterococci (VRE)Vancomycin resistant enterococci (VRE)
CDADCDAD
Outbreak in Quebec, Canada associated Outbreak in Quebec, Canada associated with new strain (BI/NAP1 toxinotype III)with new strain (BI/NAP1 toxinotype III)– Average rate of up to 20 cases/1000 Average rate of up to 20 cases/1000
admissionsadmissions– Increased mortality, morbidityIncreased mortality, morbidity– Increased severity of diseaseIncreased severity of disease
Onset of disease closely related to Onset of disease closely related to antimicrobial exposureantimicrobial exposure
Outbreak of CDAD may expose pts to Outbreak of CDAD may expose pts to higher adverse risk with APhigher adverse risk with AP
Loo V, Loo V, et al.et al. N Engl J Med 2005;353:2442-9. N Engl J Med 2005;353:2442-9.McDonald LC, McDonald LC, et al.et al. N Engl J Med 2005;353:2433-41. N Engl J Med 2005;353:2433-41.
AssessmentAssessment
Adverse outcomes with CDAD may Adverse outcomes with CDAD may surpass benefits of APsurpass benefits of AP
Purpose:Purpose:– To evaluated the risk of CDAD and its To evaluated the risk of CDAD and its
complicationscomplications– Following APFollowing AP– In cardiac, thoracic, and vascular In cardiac, thoracic, and vascular
surgerysurgery
MethodologyMethodology
Retrospective cohort studyRetrospective cohort study University affiliated tertiary trauma centerUniversity affiliated tertiary trauma center Pts who underwentPts who underwent
– Cardiac surgeryCardiac surgery– Thoracic surgeryThoracic surgery– Vascular surgeryVascular surgery
January 1January 1stst 2002 to December 31 2002 to December 31stst 2004 2004 AP 4 hours prior to and up to 2 hours AP 4 hours prior to and up to 2 hours
after beginning of surgeryafter beginning of surgery 2 surgeries in the same patient were 2 surgeries in the same patient were
considered as separate eventsconsidered as separate events Pts who did not receive AP were excludedPts who did not receive AP were excluded
OutcomesOutcomes
PRIMARY OUTCOMEPRIMARY OUTCOME– Occurrence of CDADOccurrence of CDAD (post-op. up to 1 mo. post-op.)(post-op. up to 1 mo. post-op.)
• Positive Positive C. difficileC. difficile toxin A and/or B assay and 3 or more toxin A and/or B assay and 3 or more episodes of diarrhea/dayepisodes of diarrhea/day
• Endoscopic evidence of pseudomembranous colitisEndoscopic evidence of pseudomembranous colitis• Histopathological evidence of Histopathological evidence of C. difficileC. difficile colitis colitis
– Complications of CDADComplications of CDAD(from hospitalisation and up to 3 months post CDAD)(from hospitalisation and up to 3 months post CDAD)
• Pseudomembranous colitisPseudomembranous colitis• Toxic megacolonToxic megacolon• PerforationPerforation• Surgery or colectomySurgery or colectomy• RelapseRelapse• DeathDeath
•Septic choc Septic choc •ICU admission forICU admission for
Dehydration Dehydration Electrolyte Electrolyte
disordersdisordersHypovolemia Hypovolemia Septic shockSeptic shock
1 of 31 of 3
OutcomesOutcomes
SECONDARY OUTCOMESECONDARY OUTCOME Risk factors for CDADRisk factors for CDAD Surgical site infectionsSurgical site infections
– SuperficialSuperficial< 30 days post-op< 30 days post-op
– DeepDeep< 30 days post-op < 30 days post-op
< 1 year post-op if material implant< 1 year post-op if material implant
Statistical analysisStatistical analysis
Rates of CDAD (95% CI)Rates of CDAD (95% CI) Risk of complications with CDADRisk of complications with CDAD Rates of SSIs (95% CI)Rates of SSIs (95% CI) Logistic regression for influence of Logistic regression for influence of
different risk factors on the incidence different risk factors on the incidence of CDAD (OR, 95% CI)of CDAD (OR, 95% CI)
Baseline characteristics of patients undergoing Baseline characteristics of patients undergoing cardiac, thoracic or vascular surgerycardiac, thoracic or vascular surgery
Baseline characteristicsBaseline characteristics GlobalGlobaln = 1688n = 1688
CardiacCardiacn = 832n = 832
ThoracicThoracicn = 350n = 350
VascularVascularn = 506n = 506
Mean age Mean age (years) 64.164.1 63.663.6 60.960.9 67.067.0
Percentage of women Percentage of women 31.031.0 27.227.2 39.139.1 31.831.8
Hospital stayHospital stay Mean duration Mean duration (days SD)
15.9 15.9 19.3 19.3 15.1 15.1 11.5 11.5 19.6 19.6 22.3 22.3 14.7 14.7 25.9 25.9
Median days Median days (range) 11 (1-187)11 (1-187) 12 (1-144)12 (1-144) 13 (2-236)13 (2-236) 8 (1-387)8 (1-387)
Co-morbiditiesCo-morbidities
Mean number of co-morbiditiesMean number of co-morbidities 3.33.3 3.83.8 3.33.3 2.52.5
Diabetes (%)Diabetes (%) 22.322.3 26.926.9 13.413.4 20.920.9
COPD (%)COPD (%) 19.819.8 9.09.0 49.749.7 16.816.8
Active malignancy (%)Active malignancy (%) 17.117.1 1.41.4 76.976.9 1.61.6
Anemia (%)Anemia (%) 7.07.0 6.66.6 8.68.6 6.76.7
Renal insufficiency (CrCl Renal insufficiency (CrCl 30 mL/min) 30 mL/min) (%)(%)
3.63.6 3.43.4 1.11.1 5.75.7
Heart failure (%)Heart failure (%) 2.42.4 3.73.7 0.90.9 1.41.4
Rhumatoid Arthritis (%)Rhumatoid Arthritis (%) 0.90.9 0.80.8 0.90.9 1.21.2
Gastro-intestinal disease (CD, UC) (%)Gastro-intestinal disease (CD, UC) (%) 0.50.5 0.60.6 00 0.60.6
SD, standard deviation; COPD, chronic obstructive pulmonary disease; CrCl, creatinine clearance; UC, SD, standard deviation; COPD, chronic obstructive pulmonary disease; CrCl, creatinine clearance; UC, ulcerative colitis; CD, crohn’s disease.ulcerative colitis; CD, crohn’s disease.
Rate of CDAD, complications of CDAD, Rate of CDAD, complications of CDAD, and SSIs in cardiac, thoracic and and SSIs in cardiac, thoracic and
vascular surgery patientsvascular surgery patients
GlobalGlobal CardiacCardiac ThoracicThoracic VascularVascular
Number of patientsNumber of patients 16881688 832832 350350 506506
Number of CDADsNumber of CDADsaa 8282 3535 2424 2323
Number of Number of complicationscomplicationsbb 2121 99 88 44
Number of superficial Number of superficial SSIsSSIs 4747 2525 33 1919
Number of deep SSIsNumber of deep SSIscc 1212 88 00 44
a: CDAD was evaluated up to 30 days after surgerya: CDAD was evaluated up to 30 days after surgeryb: Complications were evaluated up to 3 months post-CDADb: Complications were evaluated up to 3 months post-CDADc: SSIs were evaluated up to 1 year post surgeryc: SSIs were evaluated up to 1 year post surgery
Rates of CDAD, complications of CDAD, Rates of CDAD, complications of CDAD, superficial SSIs and deep SSIs in superficial SSIs and deep SSIs in
cardiac, thoracic and vascular surgerycardiac, thoracic and vascular surgery
0
1
2
3
4
5
6
7
8
Cardiac (n=832) Thoracic (n=350) Vascular (n=506)
Type of surgery
CDAD
CDAD complications
Superficial SSI
Deep SSI
Over a 3 year period (2002-2004)Over a 3 year period (2002-2004)
Rat
e (%
)R
ate
(%)
ObservationsObservations
Pts developed CDAD on average 9 d Pts developed CDAD on average 9 d (range 2-30 d) post-surgery (range 2-30 d) post-surgery
CDAD pts had longer hospital stay CDAD pts had longer hospital stay (32.1 d vs 15.1 d) than non-CDAD pts(32.1 d vs 15.1 d) than non-CDAD pts
AP was the only antibiotic received AP was the only antibiotic received in perioperative care in perioperative care – 45.1% of patients with CDAD45.1% of patients with CDAD– from 3 months before surgery until from 3 months before surgery until
diagnosis of CDADdiagnosis of CDAD No CDAD related deaths reportedNo CDAD related deaths reported
Rate of CDAD per year in cardiac, Rate of CDAD per year in cardiac, thoracic and vascular surgerythoracic and vascular surgery
2,3
4,63,9
10,6
0,5
7,7
6,15,5 5,6
0
2
4
6
8
10
12
2002 2003 2004
Year of surgery
Cardiac
Thoracic
Vascular
Rat
e (%
)R
ate
(%)
n = 1688n = 1688
Logistic regression of potential risk Logistic regression of potential risk factors for CDAD among surgical ptsfactors for CDAD among surgical pts
Potential risk factorsPotential risk factors Odd ratioOdd ratio 95% C.I.95% C.I. P-valueP-value
LowerLower UpperUpper
Parenteral nutritionParenteral nutrition 6.46.4 2.72.7 15.015.0 <0.001<0.001
Enteral nutritionEnteral nutrition 4.34.3 2.32.3 8.28.2 <0.001<0.001
Diabetes Diabetes 0.90.9 0.50.5 1.51.5 0.60.6
COPDCOPD 2.02.0 1.21.2 3.43.4 0.010.01
UC/CDUC/CD 3.73.7 0.40.4 31.431.4 0.20.2
Renal insufficiencyRenal insufficiencyaa 1.61.6 0.60.6 4.34.3 0.30.3
Heart failureHeart failure 1.81.8 0.60.6 5.75.7 0.30.3
AnemiaAnemia 1.41.4 0.60.6 2.92.9 0.40.4
MalignancyMalignancy 1.31.3 0.70.7 2.42.4 0.40.4
ImmunosupressionImmunosupression 00 00 -- 1.01.0
H2 antagonistsH2 antagonists 2.52.5 0.80.8 7.47.4 0.10.1
PPIPPI 1.01.0 0.60.6 1.71.7 1.01.0
RARA 00 00 -- 1.01.0
a: Renal insufficiency defined as a creatinine clearance less than 30mL/mina: Renal insufficiency defined as a creatinine clearance less than 30mL/min
Antimicrobial agents used, moment of Antimicrobial agents used, moment of administration, and duration of administration, and duration of
antimicrobial prophylaxisantimicrobial prophylaxisCardiac (%) Cardiac (%)
(n = 832)(n = 832)Thoracic (%) Thoracic (%)
(n = 350)(n = 350)Vascular (%)Vascular (%)
(n = 506)(n = 506)
CefazolinCefazolin 43.943.9 74.974.9 91.191.1
Cloxacillin + Cloxacillin + AmpicillinAmpicillin
52.552.5 2.42.4 4.24.2
VancomycineVancomycine 3.43.4 3.53.5 3.23.2
OtherOther 0.20.2 19.219.2 1.51.5
Moment of Moment of administrationadministration a, b a, b
34.134.1 12.312.3 16.316.3
Duration of AP Duration of AP 24 24 hourshours
45.345.3 78.178.1 83.183.1
Duration of AP > 24 Duration of AP > 24 hourshours
54.754.7 21.921.9 16.916.9
a: Administration of antimicrobial prophylaxis between 30 minutes to 1 hour before the surgical incision. a: Administration of antimicrobial prophylaxis between 30 minutes to 1 hour before the surgical incision. b: Documentation of the moment of administration was absent from charts in 25.7% of charts overall. b: Documentation of the moment of administration was absent from charts in 25.7% of charts overall.
DiscussionDiscussion
AP is not without risk, especially in epidemic AP is not without risk, especially in epidemic areas of CDADareas of CDAD – AP exposes patients to a AP exposes patients to a highhigh risk of CDAD, which can risk of CDAD, which can
lead to additional morbidity, length of stay, and hospital lead to additional morbidity, length of stay, and hospital costs. costs.
– The risk of CDAD with AP use outweighs the benefits in The risk of CDAD with AP use outweighs the benefits in thoracic surgery. thoracic surgery.
AP in surgeries at low risk of SSIs needs to be re-AP in surgeries at low risk of SSIs needs to be re-evaluated in the context of CDAD outbreaks.evaluated in the context of CDAD outbreaks.
Confirms other reports that enteral and parenteral Confirms other reports that enteral and parenteral nutrition, and COPD are risks for development of nutrition, and COPD are risks for development of CDADCDAD
AcknowledgementsAcknowledgements
David Banon, B. Pharm.David Banon, B. Pharm.1, 21, 2
Catherine Ferland, B. Pharm. Catherine Ferland, B. Pharm. 1, 21, 2
Anik Thibodeau, B. Pharm. Anik Thibodeau, B. Pharm. 1, 21, 2
Karine Wilhelmy , B. Pharm. Karine Wilhelmy , B. Pharm. 1, 21, 2
Pierre J. Laflamme, MDPierre J. Laflamme, MD11
Gilbert Pichette, MDGilbert Pichette, MD11
Thérèse Bigras, M.Sc.Inf., MBAThérèse Bigras, M.Sc.Inf., MBA11
Anne Filion, B.Pharm., M.Sc. Anne Filion, B.Pharm., M.Sc. 11
Lucie Blais, Ph.D. Lucie Blais, Ph.D. 1, 21, 2
1.1.
2.2.
Definitions of SSIsDefinitions of SSIs
SuperficialSuperficial– < 30 days post-op< 30 days post-op
++– Skin or soft tissue involvment onlySkin or soft tissue involvment only
++– One of the followingOne of the following
» Purulent drainagePurulent drainage» S/sx of infection and opening of the wound by the S/sx of infection and opening of the wound by the
surgeonsurgeon» Diagnosis of superficial surgical site infectionDiagnosis of superficial surgical site infection» Positive culture from site using aseptic techniquePositive culture from site using aseptic technique
Definitions of SSIsDefinitions of SSIs
DeepDeep– < 30 days post-op or< 30 days post-op or– < 1 year post-op if material implants< 1 year post-op if material implants ++– Infection seems related to surgeryInfection seems related to surgery ++– Affects deep tissue including fascia and muscleAffects deep tissue including fascia and muscle ++– One of the followingOne of the following
» Purulent drainage from deep wound ( but not cavity or Purulent drainage from deep wound ( but not cavity or organ)organ)
» Spontaneous dehiscance opening of the deep wound by Spontaneous dehiscance opening of the deep wound by the surgeon when T>38°C or localized painthe surgeon when T>38°C or localized pain
» Abcess or evidence of infection by direct or radiological Abcess or evidence of infection by direct or radiological exam, subsequent surgery, or histopathologyexam, subsequent surgery, or histopathology
» Diagnosis of deep SSIDiagnosis of deep SSI
Definition of CDAD complicationsDefinition of CDAD complications
ICU admissionICU admission– Dehydration, electrolyte disorders, hypovolemia, septic shockDehydration, electrolyte disorders, hypovolemia, septic shock
Septic shockSeptic shock– Hypotension SBP < 90 mmHg, decrease > 40 mmHg, in the Hypotension SBP < 90 mmHg, decrease > 40 mmHg, in the
absence of other causes absence of other causes + 2 of the following:+ 2 of the following:– temp > 38°C or < 36°C, HR > 90 bpm, RR > 20/min, pCO2 < 32 temp > 38°C or < 36°C, HR > 90 bpm, RR > 20/min, pCO2 < 32
mmHg, WBC > 12 000 or < 4000, or > 10% bandsmmHg, WBC > 12 000 or < 4000, or > 10% bands Pseudomembranous colitis: confirmed by endoscopyPseudomembranous colitis: confirmed by endoscopy Toxic megacolon: > 6 cm dilation, confirmed by X-ray, Toxic megacolon: > 6 cm dilation, confirmed by X-ray,
+ 3 of the following:+ 3 of the following:fever > 38.5°C, tachycardia HR>120 bpm, WBC > 10 500, anemia, fever > 38.5°C, tachycardia HR>120 bpm, WBC > 10 500, anemia,
dehydration, confusion, electrolyte disorders, hypotensiondehydration, confusion, electrolyte disorders, hypotension Colon perforation: confirmed by radiographyColon perforation: confirmed by radiography Relapse: readmissioin to the hospital for CDAD following Relapse: readmissioin to the hospital for CDAD following
initial remissioninitial remission Death as confirmed on death certificateDeath as confirmed on death certificate
Rates of CDAD, complications of CDAD, Rates of CDAD, complications of CDAD, overall SSIs in cardiac, thoracic and overall SSIs in cardiac, thoracic and
vascular surgeryvascular surgery
0
1
2
3
4
5
6
7
8
9
10
Cardiac (n=832) Thoracic (n=350) Vascular (n=506)
Type of surgery
CDAD
CDAD complications
Overall SSI
Over a 3 year period (2002-2004)Over a 3 year period (2002-2004)
Rat
e (%
)R
ate
(%)
95% CI95% CI
Prevention and ChangePrevention and Change
Questions to consider in Prevention
Questions to consider in Prevention
What is the burden of diseaseIs there any proven benefit from the intervention?If there is, how great is it ?Are there any adverse effects of the intervention?If there are, what are they, how serious are they, and how frequently do they occur?Informed consent.
What is the burden of diseaseIs there any proven benefit from the intervention?If there is, how great is it ?Are there any adverse effects of the intervention?If there are, what are they, how serious are they, and how frequently do they occur?Informed consent.
Size of benefitSize of benefit
Multiple studies actual results varied however OR in ranges of 0.30 to 0.5 in antibiotic vs placebo trials
Number needed to treat (NNT) approximately 6
Multiple studies actual results varied however OR in ranges of 0.30 to 0.5 in antibiotic vs placebo trials
Number needed to treat (NNT) approximately 6
Adverse events - frequencyAdverse events - frequency
Gillespie 2000 - Cochrane collaboration
RR 1.83 (0.96 -3.5)Crabtree TD, et al. Am Surg. 1999. 65:507-511. In16% of post surgical patients with C. difficile colitis the antibiotics were prophylactic.Antibiotic resistance - associated with antibiotic use - ? relevance to a single dose regimen
Gillespie 2000 - Cochrane collaboration
RR 1.83 (0.96 -3.5)Crabtree TD, et al. Am Surg. 1999. 65:507-511. In16% of post surgical patients with C. difficile colitis the antibiotics were prophylactic.Antibiotic resistance - associated with antibiotic use - ? relevance to a single dose regimen
Evidence supports the use of prophylactic antibiotics.
the current benefit : harm ratio is favorable
However:
Evidence supports the use of prophylactic antibiotics.
the current benefit : harm ratio is favorable
However:
SummarySummary
Microorganisms are not boring-change is constant
The healthcare system should not be boring - change needs to be constant.
Microorganisms are not boring-change is constant
The healthcare system should not be boring - change needs to be constant.
MRSAMRSAAn abridged and selected
HistoryAn abridged and selected
History
Pre Penicillin 1942Mortality sepsis secondary pneumonia, osteomyelitis, cellulitis > 80%
Pre Penicillin 1942Mortality sepsis secondary pneumonia, osteomyelitis, cellulitis > 80%
Penicillin 1942Mortality sepsis secondary pneumonia, osteomyelitis, cellulitis 35%
Penicillin 1942Mortality sepsis secondary pneumonia, osteomyelitis, cellulitis 35%
1945 Penicillinase lactamase
1945 Penicillinase lactamase
Mid 1940s Penicillin resistance. Mortality rates increase to pre penicillin era
Mid 1940s Penicillin resistance. Mortality rates increase to pre penicillin era
late 1940s - 1950s Staphylococcal epidemics (Golden Staph)- Birth of Hospital Infection Control
late 1940s - 1950s Staphylococcal epidemics (Golden Staph)- Birth of Hospital Infection Control
1959 semi synthetic penicillins-methicillin1959 semi synthetic penicillins-methicillin
1961 MRSA England1961 MRSA England
1963 MRSA outbreaks Europe1963 MRSA outbreaks Europe
1967 MRSA in US1967 MRSA in US
1968 first hospital MRSA outbreak in US1968 first hospital MRSA outbreak in US
1980 first reports from LTCF1980 first reports from LTCF
1992 aboriginal children western Australia CA MRSA
1992 aboriginal children western Australia CA MRSA
2000 multiple outbreaks, prisons, schools, schools, athletic teams, Military, increasing prevalence children. (CA MRSA)
2000 multiple outbreaks, prisons, schools, schools, athletic teams, Military, increasing prevalence children. (CA MRSA)
1995 -change in sensitivity profiles - Europe
1995 -change in sensitivity profiles - Europe
1999 17% Nosocomial MRSA - Harbor UCLA SCC mec IV (CA MRSA)
1999 17% Nosocomial MRSA - Harbor UCLA SCC mec IV (CA MRSA)
55.3 % ICU isolates HA MRSA55.3 % ICU isolates HA MRSA
∂∂
1975 2.1% ICU S. aureus are MRSA in the US
1975 2.1% ICU S. aureus are MRSA in the US
∂∂
1986 Cluster of MRSA in Aboriginal community Canada
1986 Cluster of MRSA in Aboriginal community Canada
Interesting times ahead
Interesting times ahead
Change is constantSurveillance is mandatory
Change is constantSurveillance is mandatory
2003 Harbor UCLA 53% Nosocomial MRSA - is CA phenotype SCC mec type IV
2003 Harbor UCLA 53% Nosocomial MRSA - is CA phenotype SCC mec type IV
Evolution in Health Care Systems
Evolution in Health Care Systems
Surgical Infection Prevention(SIP) project.Antibiotic selection suspended as a publically reported measure of hospital quality.Reasons:
MRSA - guidelines not in agreement on when Vancomycin should be used as prophylaxis-what is a high prevalence of MRSA?Antibiotic shortages.Conflicting guidelines regarding preventing SSI and endocarditis in surgical patients.
Surgical Infection Prevention(SIP) project.Antibiotic selection suspended as a publically reported measure of hospital quality.Reasons:
MRSA - guidelines not in agreement on when Vancomycin should be used as prophylaxis-what is a high prevalence of MRSA?Antibiotic shortages.Conflicting guidelines regarding preventing SSI and endocarditis in surgical patients.
RememberRemember
Organisms change.
New knowledge is accumulating.
There is an absolute need to monitor what is happening in your institution.
There is a need for organizations such as Safer Healthcare Now to regularly review the recommendations in their guidelines.
Organisms change.
New knowledge is accumulating.
There is an absolute need to monitor what is happening in your institution.
There is a need for organizations such as Safer Healthcare Now to regularly review the recommendations in their guidelines.
Thank you and have a good dayThank you and have a good day
