Perspectives in Surgical Infections What does the Future Hold

1981- Altemeier- First meeting of SIS “Infection has always been a prominent feature of human life, and sepsis in modern surgery continues to be a significant health problem throughout the world”

Surgical infections Skin infections Complicated intra-abdominal infections Nosocomial- healthcare-associated infections: ventilator-associated pneumonia(VAP), catheter-related blood stream infection (CR-BSI)

Surgical Site and Skin Infections The most common nosocomial infection 3% of all operated patients Greater length of stay Additional costs

Surgical Site and Skin Infections The risk of SSI- strongly associated with wound class Wound class: clean, clean-contaminated, contaminated, dirty-infected Risk factors: ASA>2 Contaminated or infected wounds Prolonged operation Anemia Intra-op. blood transfusion Colonization with resistant pathogens

Prevention-National Healthcare Safety Network Timely antimicrobial prophylaxis Sterilization Proper ventilation of operating rooms Use of barriers Proper surgical skin preparation and surgical technique No shaving but rather clipping if hair removal is required Maintenance of normothermia Glicemic control Supplemental oxygen

Prevention IV antimicrobial prophylaxis within 1 hour before incision Prophylactic antimicrobials consistent with published guidelines Antimicrobial prophylaxis discontinued within 24 hours after surgery

National Healthcare Safety Network 34 000 surgical pts.-systematic random sample only 28% had prophylaxis in compliance with all three of these performance measures

NATIONAL SURGICAL INFECTION PREVENTION It has become standard for hospitals to report their compliance with these measures in part stimulated by pay-for-reporting

CHALLENGES IN SSI RESISTANT PATHOGENS INCREASING ELDERLY POPULATION MORE PTS. WITH CHRONIC DISEASES OR IMMUNOCOMPROMIZED MORE PTS. WITH ORGAN TRANSPLANTATION OR PLACEMENT OF PROSTHETIC DEVICES

MRSA- the leading causative pathogen Higher mortality rates Longer LOS Higher hospital costs Measures: 1. nasal screening of pts. on admission 2. isolation of MRSA-positive pts. 3. standardized hand hygiene 4. continued monitoring of process

Agents of surgical infections MRSA CoNS Enterococcus E coli P aeruginosa

Complicated intra-abdominal infections The principal therapy for “sourse control” is removal: Resection of an infected organ Debridement of necrotic tissue Resection of ischemic bowel Resection of perforated bowel Surgical or radiologic drainage of abscess

Clostridium difficile colitis The predominant hospital-acquired gastrointestinal infection- ribotype 027- high virulence Important nosocomial cause of morbidity and death Risk factors- perioperative antimicrobial prophylaxis, older age, administration of cefoxitin rather than cefazolin Total colectomy+end ileostomy, decrease MR-35%-65%

INFECTED NECROTIZING PANCREATITIS surgical necrosectomy-has shifted towards radiologic and laparo approaches Single intervention vs. staged serial procedure

Health care-associated infections 1.community-onset:-presence of an invasive device at time of admission, history of infection, history of surgery, hospitalization, dialysis 2. hospital-onset- cases with positive culture result from a normally sterile site obtained 48h. After admission Community-associated infections: cases with no documented community-onset health care risk factors

Healthcare-associated infection Ventilator-associated pneumonia Catheter-related blood stream infection Broad spectrum antimicrobial therapy to cover possible multi-drug-resistant pathogens, in contrast to pts. With community-acquired infections.

VAP MRSA P.aeruginosa A. baumani Enterobacter K.pneumoniae Broad spectrum antimicrobial agents, culture results, proper drug de-escalation

CR-BSI Hand hygiene Full barrier precaution during insertion site Chlorhexidine preparation of the insertion site Avoidance of the femoral vein as an insertion site Removal of all unnecessary CVCsOngoing surveillance of changes in the microbiology of CA-BSI

Surgical infections Pose complex issues related to the host, the pathogen and specific infection that results. Pathogen: virulence factors, toxin production, effective antimicrobial agents Host: explore genetic, inflammatory and immune factors of host responses SIS guidelines for the complicated Skin and soft tissue infection Diagnosis and Management of complicated intra-abdominal infections- SIS and IDS

Empiric antibiotic utilization Empiric antibiotic therapy is initiated in critically ill patients (STICU) when SIRS is undistinguishable from infection. Overuse of ab: CLOSTRIDIUM DIFFICILE infection, renal toxicity, encouragement of multi-drug resistant organisms:

Claridge’s study 1,185 pts. With an STICU stay> 2 days 26,3%- empiric AT Of those pts, only 25,6% developed a confirmed infection within 6 days of initiating empiric therapy(clinically right) 74% of pts. With empiric AT did not have an infection( clinically wrong)

Factors associated with being “clinically right” Infection on admission Receiving prior ab Being intubated

Factors associated with “clinically incorrect” Longer STICU LOS More ventilator days Development of renal dysfunction STICU death

Results Unnecessary empiric AT is associated with worse outcomes

Strategy to Reduce SSI SSI-1,6% for clean op and 4% for clean-contaminated. (Singapore-clean and clean-contaminated GI surgery+hernias) Prolongs hospital stay Extends the recovery period Causes additional pain, morbidity Excess costs

Clinical Practice Improvement Programe Strategy Target outcome- decrease SSI rate by 50% over 2 years Enhance the care of surgical pts Promote a culture of patient safety

Definitions SSI= infection within 30 days after the op. 3 types: superficial incisional, deep incisional, organ or space infection Surgical site-4 types according to the level of contamination: clean, clean-contaminated, contaminated, dirty-infected A clean site-uninfected operative site in which no inflammation is encountered and the GI, genital, urinary tract has not been entered A clean contaminated site is one in which the GI, genital, urinary tract has been entered under controlled conditions and without unusual contamination

Strategy for change- a bundle of interventions Hair shaving-replaced by clippers Standardized prophylactic ab. Guidelines AB. Given 30 min. before incision: cefazolin1-2 g.iv/ cefazolin+metro. 1g(colorectal). Redosing policy applied to op.>4h and blood loss>1l. According to the body weight Prophylactic ab. Should not be prescribed for more than 24 hours Cophalosporine III/IV generation should not be used for routine surgical prophylaxis: expensive, less active against staph. Monitor blood sugar postop. < 11.1mmol/L Monitor normotermia: warming blankets throughout the entire op.

Results SSI rate- o,5% (2006-2007) Reduction by 84% when benchmarked against 2005 Compliance with the use of clippers for hair removal preop.= 91% 87% of all pts. Had prophylaxis according to the guideline 86% had ab. Given within 30. min prior to the surgical incision 76% had BS< 11.1mmol/L 44% had body temp within normothermic range (36-38) in PACU Estimated savings in 2 years- 208,562 $

QUALITY OF CARE AND PATIENT SAFETY PROMOTE CULTURE OF GOOD PRACTICE