1. Can We Further Decrease Surgical Site Infection (SSI) after Colorectal Surgery? A Lunch Symposium held during SISNA 2007 at the Westin Harbour Castle Hotel in Downtown Toronto, Ontario, Canada on Thursday April 19 th, 2007 www.sisna.org

2. FACULTY Kamal Itani, M.D. Chief of Surgery VA Boston Healthcare System Associate Chief of Surgery for Veterans Affairs Boston Medical Center Brigham and Women’s Hospital Professor of Surgery Harvard University Medical School Boston University Medical School Boston, MA Donald E. Fry, MD, FACS Professor Emeritus University of New Mexico Executive Vice-President Michael Pine and Associates Chicago, IL Samuel Eric Wilson, MD Department of Surgery University of California, Irvine Irvine, CA

3. AGENDA Bowel Preparation or Not? Kamal Itani, MD The Role of Oral Antibiotics Eric Sam Wilson, MD Prophylactic Systemic Antibiotics Donald E. Fry, MD, FACS

4. This symposium is made possible by an educational grant from Merck & Co.

5. Surgical Site Infection (SSI) Wound Classification Class 1 = Clean Class 2 = Clean-contaminated Class 3 = Contaminated Class 4 = Dirty-infected Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

6. SSI—Risk Stratification NNIS Project (CDC) 3 independent variables associated with SSI risk  ASA score >2  Contaminated or dirty-infected wound classification  Length of operation >75th percentile of the specific operation being performed NNIS=National Nosocomial Infection Surveillance; CDC = Centers for Disease Control and Prevention; ASA = Anesthesia Society of America. NNIS. CDC. Am J Infect Control. 2001;29:404-421.

7. SSI—Wound Class vs NNIS Class Wound ClassAllNNIS 0NNIS 1NNIS 2NNIS 3 Clean2.1%1.0%2.3%5.4%NA Clean- contaminated 3.3%2.1%4.0%9.5%NA Contaminated6.4%NA3.4%6.8%13.2% Dirty-infected7.1%NA3.1%8.1%12.8% All2.8%1.5%2.9%6.8%13.0% NNIS. CDC. Am J Infect Control. 2001;29:404-421. $1 billion direct cost $10 billion indirect cost

8. Initiated in 2003 by CMS and CDC, the SCIP partnership seeks to substantially reduce surgical mortality and morbidity through collaborative efforts. CMS = Centers for Medicare & Medicaid Services.

9. Procedures Included in Performance Measure Cardiac Colorectal Hip and knee replacement Abdominal and vaginal hysterectomy Vascular surgery  Aneurysm repair  Thromboendarterectomy  Vein bypass

10. Colorectal Surgery and SSI Smith et al. Ann Surg. 2004;239:599-605  Incidence 26%  Risk factors: Obesity, intraoperative hypotension  Expenses: $6200/patient Itani et al. N Engl J Med. 2006;355:2640-2651  Incidence 24.7%  Risk factors: Type of antibiotic prophylaxis, obesity, current use of tobacco, no removal of hair from the surgical site, COPD, intraoperative contamination COPD = chronic obstructive pulmonary disease.