1. Healthcare Associated Infections: Preventing Surgical Site Infections Edward L. Goodman, MD September 27, 2004

2. Outline Definition Magnitude of the problem Pathophysiology Non pharmacologic methods Perioperative antimicrobials Conclusions Bibliography

3. Definitions

4. Criteria

7. Magnitude of the Problem Burke. N Eng J Med 2003;348:651-6

8. Magnitude Burke

9. Pathophysiology Surgical Factors –Wound classification Clean Clean contaminated Dirty –Emergency vs. Elective –Surgical technique –Perioperative environment

10. Pathophysiology Host factors –NNIS Stratification System Time of surgery ASA score –Rating system to predict mortality –Colonization with potential pathogens

12. Microbiology of SSI

13. Microbiology by Surgery Site

15. Is the Microbiology of SSI Predestined? Are the organisms already present on the patient? –Classically, it was taught that SSI are caused by flora entering the wound during the procedure –Studies on Staph aureus bacteremia support that mechanism

16. Endogenous Source of Staph Aureus Bacteremia

17. Do Postoperative Factors Play a Role ? MRSA SSI vs. other SSI Manian et al. CID 2003:36

18. MRSA SSI vs. MSSA SSI

20. Non Pharmacologic Operative Interventions Supplemental oxygen during surgery Maintenance of normothermia Maintenance of normoglycemia

21. Supplemental Oxygen Greif 2000: –Double blind, controlled multicenter study of 500 patients undergoing colorectal resections –Intervention: 80% vs 30% FiO 2 during and 2 hours after surgery –Reduction in SSI rate from 11.2% to 5.2% (p=0.01)

22. Supplemental Oxygen Greif et al. NEJM 2000

23. Not so fast Pryor 2004 –Double blind, randomized, controlled study in one hospital of patients undergoing a variety of abdominal surgeries –Intervention: 80% vs 35% FiO 2 during and two hours after –Increase in SSI rate from 11.3% to 25% (p=0.03)

24. Oxygen Therapy Pryor JAMA 2004

25. Maintenance of Normothermia Anesthesia influences thermoregulatory control Mild hypothermia associated with –Adverse myocardial events/vasoconstriction –Coagulopathy –Inhibits oxidative killing by PMN’s –Reduces metabolism of many drugs –Thermal discomfort

26. Anesthetic Effects on Thermoregulation Sessler CID 2002;35:1397-1404

27. Kurz, A. et al. N Engl J Med 1996;334:1209-1216 Core Temperatures during and after Colorectal Surgery in the Study Patients

28. Kurz, A. et al. N Engl J Med 1996;334:1209-1216 Postoperative Findings in the Two Study Groups

29. Maintenance of Normoglycemia Cardiothoracic surgery –In diabetic patients, maintenance of sugar <200 associated with lower risk of deep SSI (2.4% vs 1.5%, p<0.02) –Continuous intravenous insulin superior to sliding scale (2% vs 0.8%, p=0.01) Zerr et al. Ann Thor Surg 1997;63:356-61 Furnary et al. Ann Thor Surg 1999;67:352-60

30. Perioperative Antimicrobials Topical Systemic

31. Topical Mupirocin Nasal Source of Staph Aureus for subsequent SSI Preoperative topical use in nares –Only on those patients known to be carriers Resistance is becoming an issue –Prolonged use CONTRAINDICATED –No evidence of any benefit beyond five days

32. Perl, T. M. et al. N Engl J Med 2002;346:1871-1877 Overall and Staphylococcus aureus-Specific Rates of Nosocomial Infection among Patients Who Received Mupirocin and Those Who Received Placebo

33. Pre Operative Antibiotics Type of surgery –Clean contaminated Transect mucosal surfaces –Clean with high risk of infection Insertion of prosthesis Cardiac/neurosurgery Choice of drug Timing of drug Duration of drug

35. Timing of Antibiotics Classen et al. N Eng J Med 1992; 326:281-6

37. Conclusions Not possible to prevent all SSI Preoperative and intraoperative processes can reduce the rate Antibiotics alone are not the answer Prolonging prophylactic antibiotics are contraindicated Screening for MRSA colonization may become mandatory

38. Bibliography Bratzler DW, Houck PM. Antimicrobial Prophylaxis for Surgery. Clin Infect Dis 2004;38:1706-15. Burke JP. Infection Control – a problem for patient safety. N Engl J Med 2003; 348:651-6. Classen DC, Evans RS et al. The Timing of Prophylactic Administration of Antibiotics and the Risk of Surgical Wound Infections. N Eng J Med 1992;326:281-6. Furnary AP, Kerr KJ et al. Continuous Intravenous Insulin Infusion Reduces the Risk of Wound Infection in Diabetics after Open Heart Operations. Ann Thor Surg 1999;67:352-60 Gottrup F. Prevention of surgical wound infections. N Eng J Med 2000; 342:202-204. Grief R el al. Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infections. N Eng J Med 2000; 342:161- 167.

39. Bibliography Kurz A, Sessler DI et al. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. N Eng J Med 1996; 334:1209-1215. Mangram AJ, Horan TC, Pearson ML, Silver, LC, Jarvis WR, the Hospital Infection Control Practices Advisory Committee, Guideline for the prevention of surgical site infection 1999. Infection Control Hosp Epidemiol 1999;20: 247-280. Manian, FA, Meyer PL et al. Surgical Site Infections Associated with Methicillin-Resistant Staphylococcus aureus: Do Postoperative Factors Play a Role? Clin Infect Dis 2003; 36:863-868. Perl TM, Cullen JJ et al. Intranasal Mupirocin to Prevent Postoperative Staphylococcus Aureus Infection. N Eng J Med 2002; 346: 1871-77.

40. Bibliography Pryor KO, Fahey TJ et al. Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population. JAMA 2004;291:79-87. Sessler DI, Akca O. Nonpharmacological Prevention of Surgical Wound Infections. Clin Infect Dis 2002;35:1397-1404. Von Eiff C, Becker K et al. Nasal Carriage as a source Staphylococcus Aureus Bacteremia. N Engl J Med 2001; 344: 11-16. Zerr KJ, Furnary AP et al. Gluconse Control Lowers the Risk of Wound Infection in Diabetics After Open Heart Surgery. Ann Thorac Surg 1997;63:356-361