Surgical Site Infection in Nicaragua Surgical Infection Society 35 th Annual Meeting-April 17, 2015 Universidad Nacional Autonoma Nicaragua/Brown University Roberto Silva MD, Milton Mairena MD, Andrew Stephen MD
Discussion Goals Review of a case Background -differences in SSI, U.S. versus Nicaragua -unique challenges SSI survey responses
Discussion Goals Future goals for research -academic collaboration
Case presentation A 49 year old man transferred from a regional hospital to Lenin Fonseca Hospital in Managua 3 weeks after subtotal gastrectomy for adenocarcinoma. -Rouxen-Y reconstruction
Case presentation Duodenal stump leak -taken back to OR, stump resutured -closed suction drain -T-tube placed in CBD
Case presentation Transferred when succus emerged from midline wound When patient arrived -39.6C -HR 110, BP 70/50 mm, RR 30 -WBC 16k, Na Ultrasound-multiple fluid collections
Case presentation Fluids given, goal CVP 8-12mm Broad spectrum antibiotics started Patient back to OR for washout
Case presentation OR findings -300mL pelvic collection washed out -drains left in abdomen -no leak found
Case presentation One commercially available VAC remained at the hospital
Case presentation Patient’s SIRS abated But negative pressure dressing needed to be changed…
Case presentation Makeshift NPWT system -fenestrated IV bag -sterile gauze -2 x 32Fr. Foley catheters in gauze and exteriorized -2 layers of polyethylene film
Case presentation
The many challenges of less resourced settings This case illustrates that it’s often not a lack of medical ability, creativity
Background SSI are reported at lower rates in the developing world Bacterial burden vs. host factors
Background Bacterial burden -patient-surgeons -operative conditions -antibiotics
Background Host factors -significant variation around the world
Background Regional differences -age-obesity -ASA class-nutrition -HIV, immunosuppresion-blood transfusion -glucose control-supplemental oxygen -tissue perfusion-antibiotic use
Rates of obesity in Nicaragua, US
Background Are SSIs more/less common in less developed settings than here in the United States? We need to continue to define the incidence of SSI in less developed settings.
Background Very little literature in Nicaragua on SSI, antibiotic use
Background 297 patients, assessed use of local protocol Antibiotic use discordant w/protocol 69% of the time -25% received more antibiotics than listed
SSI Survey 8 question survey on use of antibiotics, imaging in trauma scenarios -trauma laparotomy periop antibiotics -sigmoid perforation-duration of coverage -wound management with contamination -workup of postsplenectomy abscess -drains in RUQ for liver trauma -antibiotics for the open abdomen
SSI Survey Some responses worth discussion Very different responses based on resources -private versus public hospital -IR -lab work -U/S and CT availability
SSI Survey
Preop trauma laparotomy? -single dose 3g unasyn Sigmoid perforation? -unasyn or cefoxitin x 24 hours Fecal peritonitis? -5-7 days coverage
SSI Survey Wound with fecal peritonitis? -spaced primary closure with nylons -delayed primary closure Postsplenectomy abscess? -pretty much always start with U/S Intraabdominal abscess? -IR, laparoscopy, reexploration
SSI Survey Drains for RUQ trauma? -majority use them -remove when effluent is clear Open abdomen? -prefer to keep patients on antibiotics -“concerns about ward, ICU conditions”
Future directions Start with more reliable survey data -define the problem, registry -medical student, resident projects -Nicaraguan residents Promote academic involvement in Nicaragua -single biggest complaint of trainees
Future directions Deep space infection -define imaging options, antibiotic plans -train surgeons to do U/S drainage? -not sure more specialists are the answer Superficial infections -scoring systems for SSI -compare abdominal wall thickness-CT, in OR -comorbidities
Future directions Another important question -what happens when patients go home! -so many potential interventions, projects here