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.

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2013 Operation O