1. 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

2. Discussion Goals  Review of a case  Background -differences in SSI, U.S. versus Nicaragua -unique challenges  SSI survey responses

3. Discussion Goals  Future goals for research -academic collaboration

4. 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

5. Case presentation  Duodenal stump leak -taken back to OR, stump resutured -closed suction drain -T-tube placed in CBD

6. 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+ 133 -Ultrasound-multiple fluid collections

7. Case presentation  Fluids given, goal CVP 8-12mm  Broad spectrum antibiotics started  Patient back to OR for washout

8. Case presentation  OR findings -300mL pelvic collection washed out -drains left in abdomen -no leak found

9. Case presentation One commercially available VAC remained at the hospital

10. Case presentation  Patient’s SIRS abated  But negative pressure dressing needed to be changed…

11. Case presentation  Makeshift NPWT system -fenestrated IV bag -sterile gauze -2 x 32Fr. Foley catheters in gauze and exteriorized -2 layers of polyethylene film

12. Case presentation

13.  The many challenges of less resourced settings  This case illustrates that it’s often not a lack of medical ability, creativity

14. Background  SSI are reported at lower rates in the developing world  Bacterial burden vs. host factors

15. Background  Bacterial burden -patient-surgeons -operative conditions -antibiotics

16. Background  Host factors -significant variation around the world

17. Background  Regional differences -age-obesity -ASA class-nutrition -HIV, immunosuppresion-blood transfusion -glucose control-supplemental oxygen -tissue perfusion-antibiotic use

18.  Rates of obesity in Nicaragua, US

20. 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.

21. Background  Very little literature in Nicaragua on SSI, antibiotic use

22. Background  297 patients, assessed use of local protocol  Antibiotic use discordant w/protocol 69% of the time -25% received more antibiotics than listed

24. 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

26. SSI Survey  Some responses worth discussion  Very different responses based on resources -private versus public hospital -IR -lab work -U/S and CT availability

27. SSI Survey

28.  Preop trauma laparotomy? -single dose 3g unasyn  Sigmoid perforation? -unasyn or cefoxitin x 24 hours  Fecal peritonitis? -5-7 days coverage

29. 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

30. 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”

31. 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

32. 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

33. Future directions  Another important question -what happens when patients go home! -so many potential interventions, projects here