1. Perspectives in Surgical Infections
What does the Future Hold

2. 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”

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

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

5. 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

6. 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

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

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

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

10. 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

11. 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

12. Agents of surgical infections
MRSA
CoNS
Enterococcus
E coli
P aeruginosa

13. 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

14. 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%

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

16. 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

17. 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.

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

19. 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

20. 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

21. 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:

22. 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)

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

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

25. Results
Unnecessary empiric AT is associated with worse outcomes

26. 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

27. 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

28. 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

29. 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.

30. 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 $

31. QUALITY OF CARE AND PATIENT SAFETY
PROMOTE CULTURE OF GOOD PRACTICE