Perspectives in Surgical Infections What does the Future Hold

Sepsis in modern surgery still a major problem throughout the world

SEPSIS Sepsis is the systemic response to infection and is defined as the presence of SIRS in addition to a documented or presumed infection

SIRS>2 VARIABLES T>38 or<36 degree celsius HR>90 RR>20 or PaCO2<32 mmHg WBC>12000mmc or>4000mmc

SEVERE SEPSIS CRITERIA SEPSIS+ORGAN DISFUNCTION Hypotension, hypoperfusion SBP<90 mm Hg or reduction of more than 40 mm Hg from baseline in the absence of other causes of hypotension Lactic acidosis

SEPTIC SHOCK Severe sepsis with hypotension, despite adequate fluid resuscitation

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

Nosocomial risk A. Health-care system contact 1. None 2. Appointments-clinical examination 3. Long H-stay/invasive procedures B. Previous antibiotherapy 1. Without 2. With ab. therapy C. Pacient 1. Young patient without comorbidities 2. Old patient with comorbidities 3. Pacient with immunodefficiency

Nosocomial risk I. Pacient without risk: A.1 + B.1 + C.1 II. Pacient at risk of infection with (ESBL): Cel putin A.2 sau B.2 sau C.2 III. Pacient at risk of inf. with Pseudomonas ae. sau Acinetobacter baumanii : A.3 sau C.3.

Key facts Antimicrobial resistance (AMR) threatens the effective prevention and treatment of infection It is an increasingly serious threat to global public health AMR is present in all parts of the world. New resistance mechanisms emerge and spread globally.

Key facts There are high proportions of antibiotic resistance in bacteria that cause common infections (e.g. urinary tract infections, pneumonia, bloodstream infections) in all regions of the world. A high percentage of hospital-acquired infections are caused by highly resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria. Patients with infections caused by drug-resistant bacteria are generally at increased risk of worse clinical outcomes and death, and consume more healthcare resources.

What is antimicrobial resistance? Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it. Resistant microorganisms (including bacteria, fungi, viruses and parasites) are able to withstand attack by antimicrobial drugs, so that standard treatments become ineffective and infections persist, increasing the risk of spread to others.

Why that? The evolution of resistant strains is a natural phenomenon that occurs when microorganisms replicate themselves erroneously or when resistant traits are exchanged between them. The use and misuse of antimicrobial drugs accelerates the emergence of drug-resistant strains. Poor infection control practices, inadequate sanitary conditions and inappropriate food-handling encourages the further spread of AMR.

Why is antimicrobial resistance a global concern? New resistance mechanisms emerge and spread globally threatening our ability to treat common infectious diseases, resulting in death and disability of individuals. Without effective anti-infective treatment, many standard medical treatments will fail or turn into very high risk procedures.

AMR kills Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in : - prolonged illness, - higher health care expenditures, -greater risk of death.

AMR hampers the control of infectious diseases AMR reduces the effectiveness of treatment; thus patients remain infectious for a longer time, increasing the risk of spreading resistant microorganisms to others. Although MDR-TB is a growing concern, it is still largely under-reported, compromising control efforts.

AMR increases the costs of health care When infections become resistant to first-line drugs, more expensive therapies must be used. A longer duration of illness and treatment, often in hospitals, increases health care costs as well as the economic burden on families and societies.

AMR jeopardizes health care gains to society The achievements of modern medicine are put at risk by AMR. Without effective antimicrobials for prevention and treatment of infections, the success of organ transplantation, cancer chemotherapy and major surgery would be compromised.

Present situation Resistance in bacteria WHO’s 2014 report on global surveillance of antimicrobial resistance reveals that antibiotic resistance is no longer a prediction for the future; it is happening right now, across the world, and is putting at risk the ability to treat common infections in the community and hospitals. Without urgent, coordinated action, the world is heading towards a post-antibiotic era, in which common infections and minor injuries, which have been treatable for decades, can once again kill. Resistance to one of the most widely used antibacterial drugs for the oral treatment of urinary tract infections caused by E. coli – fluoroquinolones – is very widespread. Resistance to first-line drugs to treat infections caused by Staphlylococcus aureus – a common cause of severe infections acquired both in health-care facilities and in the community – is also widespread. Resistance to the treatment of last resort for life-threatening infections caused by common intestinal bacteria – carbapenem antibiotics – has spread to all regions of the world. Key tools to tackle antibiotic resistance – such as basic systems to track and monitor the problem – reveal considerable gaps. In many countries, they do not even seem to exist.

What accelerates the emergence and spread of antimicrobial resistance? The development of AMR is a natural phenomenon. However, certain human actions accelerate the emergence and spread of AMR. The inappropriate use of antimicrobial drugs, favours the emergence and selection of resistant strains, and poor infection prevention and control practices contribute to further emergence and spread of AMR.

Need for concerted actions AMR is a complex problem driven by many interconnected factors. As such, single, isolated interventions have little impact. Coordinated action is required to minimize emergence and spread of AMR.

People can help tackle resistance by: using antibiotics only when they are prescribed by a certified health professional; completing the full treatment course, even if they feel better; never sharing antibiotics with others or using leftover prescriptions

Health workers and pharmacists can help tackle resistance by: enhancing infection prevention and control; prescribing and dispensing antibiotics only when they are truly needed; prescribing and dispensing the right antibiotic(s) to treat the illness.

Policymakers can help tackle resistance by: strengthening resistance tracking and laboratory capacity; strengthening infection control and prevention; regulating and promoting appropriate use of medicines; promoting cooperation and information sharing among all stakeholders.

Policymakers, scientists and industry can help tackle resistance by: fostering innovation and research and development of new vaccines, diagnostics, infection treatment options

In 2011, the theme of World Health Day was “Antimicrobial resistance: no action today, no cure tomorrow”, and a six-point policy package was published to assist countries with tools to combat antimicrobial resistance. In 2014, WHO published its first global report on surveillance of antimicrobial resistance, with data provided by 114 countries.

WHO is guiding the response to AMR by: bringing all stakeholders together to agree on and work towards a coordinated response; strengthening national stewardship and plans to tackle AMR; generating policy guidance and providing technical support for Member States; actively encouraging innovation, research and development.

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 Klebsiella Enterococcus E coli Ps. Aeruginosa Acinetobacter

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

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

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:

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.

QUALITY OF CARE AND PATIENT SAFETY PROMOTE CULTURE OF GOOD PRACTICE