SURGICAL SITE INFECTIONS

Teguh Sarry Hartono

PPDS Mikrobiologi Klinik

Oktober 2010

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Historical background

• Until the ends of the 19th cent., infection was the greatest risk associated with any surgical procedure.

• Increasing knowledge regarding relationship between bacteria and infection, led to series of discoveries and the development of techniques that ultimately paved the way for modern surgery.

Historical background...........

• Pasteur studied the relationship between bacteria and putrefaction.

• Lister recognized the role of bacterial in surgical wound infections and in 1867 introduced

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• In 20th cent., the standarization of aseptic practices in the operating room greatly improved the safety of clean operative procedures, but operating involving anatomic structures with dense a endogenous that cannot eliminate before surgery , such as colon and rectum, continued to carry a very high risk of infection.

Historical background...........

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CDC (1999) :• US : approx. 27 million surgical procedures / yearare performed each

year.• National Nosocomial Infections Surveillance (NNIS) system reported :

• SSIs : 3rd most frequently reported nosocomial infection, accounting for 14% - 16% of all nosocomial infections among hospitalized patients.

• During 1986 to 1996, SSI surveillance reported 15,523 SSIs following 593,344 operations (CDC, unpublished data).

• Among surgical patients, SSIs were the most common nosocomial infection, accounting for 38% of all such infections, 2/3 were confined to the incision , 1/3 involved organs or spaces accessed during the operation.

• 77% of the death of surgical patients with nosocomial were reported to be related to the infection, and the majority (93%) were serious infections involving organs or spaces accessed during the operation.

Public Health Importance of Surgical Site Infections

Mangram AJ. Guideline for prevention of surgical site infection, 1999. Infection control and hospital epidemiology. Vol. 20 No. 4. 1999

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• In U.S., >40 million inpatient surgical procedures each year; 2-5% complicated by surgical site infection

• SSIs second most common nosocomial infection (24% of all nosocomial infections)

• Prolong hospital stay by 7.4 days• Cost $400-$2,600 per infection (TOTAL:

$130-$845 million/year)

Pearson ML. Prevention of Surgical Site Infections: Considerations in Measuring Effectiveness. Ppt presentation. www.fda.gov/ohrms/dockets/.../2005-4098S1_02_FDA-Pearson.ppt Accessed on 9102010

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Emerging Challenges

Challenges in detecting SSIs• Lack of standardized methods for

post-discharge/outpatient surveillance • Increased number of outpatient surgeries• Shorter postoperative inpatient stays

Antimicrobial Prophylaxis• Increasing trend toward resistant organisms may

undermine the effectiveness of existing recommendations for antimicrobial prophylaxis

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Criteria for defining SSIs (NNIS)

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Superficial incisional

(skin or subcutaneous tissue)

• Infection ≤30 days after procedure and at least 1 of the following:

– Purulent drainage from superficial lesion/organisms isolated aseptically

– At least 1: pain/tenderness, swelling, redness, heat– Superficial incision deliberately opened by surgeon

unless culture negative

• or SSI diagnosed by surgeon or attending physician

Defining Surgical Site Infections

Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press. All rights reserved.

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Defining Surgical Site Infections (cont.)

Deep incisional

(deep soft tissue at incision site)

• Infection ≤30 days after procedure (no implant) or

≤1 year (with implant) plus at least 1 of of the following:– Purulent drainage from deep in incision but not from

organ/space – Spontaneous dehiscence or surgical opening of deep

incision with fever, pain, or tenderness– Abscess or other evidence of infection involving deep

incision

• or SSI diagnosed by surgeon or attending physician

Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press. All rights reserved.

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Defining Surgical Site Infections (cont)

Organ/space

(any site other than incision)

• Infection ≤30 days after procedure (no implant) or

≤1 year (with implant) plus at least 1 of the following:– Purulent drainage from a drain placed through a stab

wound into organ/space– Organisms isolated from a culture of fluid or tissue– Abscess or other evidence of infection involving the

organ/space found by histopathologic examination, X-ray, or reoperation

• or SSI diagnosed by surgeon or attending physician

Horan TC et al. Infect Control Hosp Epidemiol. 1992;13:606–608. Figure reproduced with permission. Copyright © 1992 University of Chicago Press. All rights reserved.

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Surgical Wound Classification

• Class 1 – Clean• Uninfected operative wound, no inflammation

• Class II – Clean-Contaminated• Alimentary tract (and others), under controlled conditions

without unusual contamination

• Class III – Contaminated• Major breaks in sterile technique, eg, gross spillage from the

gastrointestinal tract• Incisions encountering acute inflammation

• Class IV – Dirty-Infected • Old traumatic wounds with dead tissue, infection, perforated

viscera

Mangram AJ et al. Am J Infect Control. 1999;27:97–134.

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Pathogenesis

Pathogen Sources

Endogenous• Patient flora

• skin • mucous membranes• GI tract

• Seeding from a distant focus of infection

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Pathogen Sources

Exogenous• Surgical Personnel (surgeon and team)

• Soiled attire• Breaks in aseptic technique• Inadequate hand hygiene

• OR physical environment and ventilation • Tools, equipment, materials brought to the operative field

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Pathogenesis

VirulenceBacterial dose

Impairedhost resistance

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If a surgical site is contaminated with >105

microorganisms per gram of tissue, the risk of SSI is markedly increased. However, the dose of contaminating microorganisms required to produce infection may be much lower when foreign material is present at the site (i.e., 100 staphylococci per gram of tissue introduced on silk sutures)

Pathogenesis.....

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Microorganisms may contain or produce toxins and other substances that increase their ability to invade a host, produce damage within the host, or survive on or in host tissue. For example, many gram-negative bacteria produce endotoxin, which stimulates cytokine production. In turn, cytokines can trigger the systemic inflammatory response syndrome that sometimes leads to multiple system organ failure.

One of the most common causes of multiple system organ failure in modern surgical care is intraabdominal infection.

Pathogenesis.....

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Some bacterial surface components, notably polysaccharide capsules, inhibit phagocytosis, a critical and early host defense response to microbial contamination.

Certain strains of clostridia and streptococci produce potent exotoxins that disrupt cell membranes or alter cellular metabolism. A variety of icroorganisms,including gram-positive bacteria such as coagulasenegative staphylococci, produce glycocalyx and an associated component called “slime,”which physically shields bacteria from phagocytes or inhibits the binding or penetration of antimicrobial agents.

Although these and other virulence factors are well defined, their mechanistic relationship to SSI development has not been fully determined.

Pathogenesis.....

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Microbiology of SSIs

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Staphylococcusaureus

17%

Coagulase neg.staphylococci

12%

Escherichiacoli10%

Enterococcusspp.8%

Pseudomonasaeruginosa

8%

Staphylococcusaureus

20%

Coagulase neg.staphylococci

14%

Escherichiacoli8%

Enterococcusspp.12%

Pseudomonasaeruginosa

8%

1986-1989(N=16,727)

1990-1996(N=17,671)

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0%

5%

10%

15%

20%

Infe

ctio

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%

Staphyl

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us

Coagula

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ive

Staphyl

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Entero

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Escher

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Pseudom

onas

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ginosa

Entero

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r spp.

Major Pathogens in SSI

NNIS Report. Am J Infect Control. 1996;24:380–388.

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Microbiology of SSIs • Unusual pathogens

• Rhizopus oryzea - elastoplast adhesive bandage• Clostridium perfringens - elastic bandages• Rhodococcus bronchialis - colonized health care personnel• Legionella dumoffii and pneumophila - tap

water• Pseudomonas multivorans - disinfectant

solution

• Cluster of unusual SSI pathogens formal epidemiologic investigation

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Organisms Causing SSIJanuary 2006-October 2007

Staphylococcus aureus30.0%

Coagulase-negative staphylococci 13.7%Enterococcus spp.

11.2%Escherichia coli 9.6%Pseudomonas aeruginosa

5.6%Enterobacter spp

4.2%Klebsiella pneumoniae 3.0%Candida spp.

2.0%Klebsiella oxytoca

0.7%Acinetobacter baumannii

0.6%

N=7,025

Hidron AI, et.al., Infect Control Hosp Epidemiol 2008;29:996-1011Hidron AI et.al., Infect Control Hosp Epidemiol 2009;30:107–107(ERRATUM)

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SSI Risk Factors

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SENIC Risk Index

• Abdominal operation• Operation greater than

2 hours• Class III or IV surgical

wounds• Three or more

diagnosis at time of discharge

Risk of Infection

0 1%

13.6%

2 9%

317%

427%

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NNIS Risk Index

• ASA score above 2• Level of

contamination• Operative time

greater than 75 percentile of normal

1 Normal healthy patient

2 Mild systemic disease

3 Severe systemic disease

4 Life threatening systemic disease

5 Moribund patient with less than 24 hr life expectancy

6 Organ donation

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Important Modifiable Risk Factors

• Antimicrobial prophylaxis• Inappropriate choice (procedure specific)• Improper timing (pre-incision dose)• Inadequate dose based on body mass index,

procedures >3h, or increased blood loss• Skin or site preparation ineffective

• Removal of hair with razors• Colorectal procedures

• Inadequate bowel prep/antibiotics• Improper intraoperative temperature regulation

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Additional Modifiable Risk Factors • Excessive OR traffic• Inadequate wound dressing protocol• Improper glucose control• Colonization with preexisting microorganisms• Inadequate intraoperative oxygen levels

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Prevention Strategies

• Core Strategies• High levels of

scientific evidence

• Demonstrated feasibility

• Supplemental Strategies• Some scientific

evidence• Variable levels of

feasibility

*The Collaborative should at a minimum include core prevention strategies. Supplemental prevention strategies also may be used. Most core and supplemental strategies are based on HICPAC guidelines. Strategies that are not included in HICPAC guidelines will be noted by an asterisk (*)

after the strategy. HICPAC guidelines may be found at www.cdc.gov/hicpac

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Prevention Strategies: Core Preoperative Measures

Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines• Administer within 1 hour prior to incision*

• 2hr for vancomycin and fluoroquinolones• Select appropriate agents on basis of

• Surgical procedure• Most common SSI pathogens for the procedure• Published recommendations

*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84.

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Prevention Strategies: Core

Preoperative Measures

• Remote infections-whenever possible:• Identify and treat before elective operation• Postpone operation until infection has resolved

• Do not remove hair at the operative site unless it will interfere with the operation; do not use razors • If necessary, remove by clipping or by use of a

depilatory agent

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Prevention Strategies: Core

Preoperative Measures • Skin Prep

• Use appropriate antiseptic agent and technique for skin preparation

• Maintain immediate postoperative normothermia*

• Colorectal surgery patients• Mechanically prepare the colon (Enemas, cathartic

agents)• Administer non-absorbable oral antimicrobial agents

in divided doses on the day before the operation

*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84.

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Prevention Strategies: Core

Intraoperative Measures

• Operating Room (OR) Traffic• Keep OR doors closed during surgery except as

needed for passage of equipment, personnel, and the patient

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Prevention Strategies: CorePostoperative Measures

• Surgical Wound Dressing• Protect primary closure incisions with sterile dressing for

24-48 hrs post-op

• Control blood glucose level during the immediate post-operative period (cardiac)*• Measure blood glucose level at 6AM on POD#1 and #2

with procedure day = POD#0• Maintain post-op blood glucose level at <200mg/dL

• Discontinue antibiotics within 24hrs after surgery end time (48hrs for cardiac)*

*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of NationalQuality Measures. Surg Infect 2008;9(6):579-84.

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Prevention Strategies: Supplemental Preoperative

• Nasal screen and decolonize only Staphylococcus aureus carriers undergoing elective cardiac and other procedures (i.e., orthopaedic, neurosurgery procedures with implants) with preoperative mupirocin therapy*Bode LGM, etal. Preventing SSI in nasal carriers of Staph aureus.  NEJM 2010;362:9-17

• Screen preoperative blood glucose levels and maintain tight glucose control POD#1 and POD#2 in patients undergoing select elective procedures (e.g., arthroplasties, spinal fusions)*NOTE: These supplemental strategies are not part of the 1999 HICPAC Guideline for Prevention of

Surgical Site Infections

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Prevention Strategies: Supplemental

Perioperative

• Redose antibiotic at the 3 hr interval in procedures with duration >3hrs (* See exceptions to this recommendation in*Engelman R, et al. The Society of Thoracic Surgeons Practice Guideline Series:Antibiotic Prophylaxis in Cardica Surgery, Part II:Antibiotic Choice. Ann Thor Surg 2007;83:1569-76

• Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30)*Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29 (Suppl 1):S51-S61

• Use at least 50% fraction of inspired oxygen intraoperatively and immediately postoperatively in select procedure(s)*Maragakis LL, Cosgrove SE, Martinez EA, et al. Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Anesthesiology 2009;110:556-562. andMeyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: The PROXI randomized clinical trial. JAMA 2009;302:1543-1550.

NOTE: These supplemental strategies are not part of the 1999 HICPAC Guideline for Prevention of Surgical Site Infections

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Prevention Strategies: Supplemental

Postoperative

• Feedback of surgeon specific infection rates.

Measurement: Surgical Care Improvement Project (SCIP) Process Measures

Quality Indicator Numerator DenominatorAppropriate antibiotic choice

Number of patients who received the appropriate prophylactic antibiotic

All patients for whom prophylactic antibiotics are indicated

Appropriate timing of prophylactic antibiotics

Number of patients who received the prophylactic antibiotic within 1hr prior to incision (2hr: Vancomycin or Fluoroquinolones)

All patients for whom prophylactic antibiotics are indicated

Appropriate discontinuation of antibiotics

Number of patients who received prophylactic antibiotics and had them discontinued in 24 h (48h cardiac)

All patients who received prophylactic antibiotics

Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84. 40of 46

Quality Indicator Numerator DenominatorAppropriate hair removal

Number of patients who did not have hair removed or who had hair removed with clippers

All surgical patients

Normothermia Number of patients with postoperative temperature ≥36.0oC

All surgical patients

Glucose control Number of cardiac surgery patients with glucose control at 6AM POD1 and POD2 (operation = POD0)

Patients undergoing cardiac surgery

Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality Measures. Surg Infect 2008;9(6):579-84.

Measurement: Surgical Care Improvement Project (SCIP) Process Measures (cont.)

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Antimicrobial Prophylaxis for Surgery

Clinical Infectious Diseases 2004; 38:1706–15

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DEPARTMENT OF SURGERY PROPHYLACTIC ANTIBIOTIC ADMINISTRATION Always check for allergy prior to administration – call for alternate orders if allergy reported or patient is < 18 years of age. Administer medication to ensure antibiotic is infused within 0-60 minutes prior to time of infusion (* within 30 minutes)

Category

Surgery

Antibiotic

Dose

Infusion Time Recommended Re-dosing

Interval

Appendectomy Cefotetan 1 gm IV 3-5 min 4-6 hours Colorectal surgery of any type Cefotetan 1 gm IV 3-5 min 4-6 hours

Abdominal

Gastroduodenal or small bowel surgery Cefotetan 1 gm IV 3-5 min 4-6 hours Cardiac Pacer and other implants Cefazolin 2 gm IV 3-5 min 2-5 hours General Any implanted foreign body, eg Marlex for hernia Cefazolin 2 gm IV 3-5 min 2-5 hours

Abortion – second trimester Cefazolin 2 gm IV 3-5 min 2-5 hours Hysterectomy – abdominal vaginal Cefazolin 2 gm IV 3-5 min 2-5 hours

OB/GYN

C-Section* Cefazolin 2 gm IV 3-5 min Esophageal surgery of any type Clindamycin &

Gentamicin 600-900 mg IV 1.5 mg/kg IV

60 min (30 mg/min) 30-60 min

3-6 hours 3-6 hours

Laryngectomy Clindamycin & Gentamicin

600-900 mg IV 1.5 mg/kg IV

60 min (30 mg/min) 30-60 min

3-6 hours 3-6 hours

Oral surgery of any type Clindamycin & Gentamicin

600-900 mg IV 1.5 mg/kg IV

60 min (30 mg/min) 30-60 min

3-6 hours 3-6 hours

Head & Neck

Pharyngeal surgery – excluding T&A Clindamycin & Gentamicin

600-900 mg IV 1.5 mg/kg IV

60 min (30 mg/min) 30-60 min

3-6 hours 3-6 hours

Internal fixation of fracture Cefazolin 2 gm IV 3-5 min 2-5 hours Orthopedic Joint replacement Cefazolin 2 gm IV 3-5 min 2-5 hours Pulmonary Resection Cefazolin 2 gm IV 3-5 min 2-5 hours Thoracic Thoracotomy Cefazolin 2 gm IV 3-5 min 2-5 hours Amputation (administer prior to tourniquet inflation)

Cefazolin 2 gm IV 3-5 min 2-5 hours

Arterial surgery, including all aortic surgery Cefazolin 2 gm IV 3-5 min 2-5 hours Valve or bypass grafts Cefazolin 2 gm IV 3-5 min 2 hours when on

bypass machine

Vascular

Vascular access devices, implants or repairs Cefazolin 1 gm IV 3-5 min 2-5 hours Note: If a patient is unable to receive a cephalosporin because of a true B-lactam allergy (urticaria, pruritis angioedema, bronchospasm, hypotension, or arrhythmia) Clindamycin or Vancomycin (1 gm IV 120 minutes prior to incision) are recommended alternatives for gram-positive bacterial coverage. Prolonged use of prophylactic antimicrobials is associated with emergence of resistant bacterial strains. Published evidence demonstrates that antimicrobial prophylaxis after wound closure is unnecessary, and recommend prophylaxis end within 24 hours after the operation.

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References

1. Delinger EP. Surgical Site Infections. In Jarvis WR. Bennett & Bachman’s Hospital Infections. Lippincott William & Wilkins 2007

2. Mangram AJ. Guideline for prevention of surgical site infection, 1999. Infection control and hospital epidemiology. Vol. 20 No. 4. 1999

3. Pearson ML. Prevention of Surgical Site Infections: Considerations in Measuring Effectiveness. Ppt presentation. www.fda.gov/ohrms/dockets/.../2005-4098S1_02_FDA-Pearson.ppt Accessed on 9102010

4. Barie PS. Controversies in Prevention of Surgical Site Infections Ppt presentation. http://www.acs-tr.com/ppt/Philip%20S.Barie%20Controversies%20in%20Prevention%20o Accessed on 9102010

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5. Torres SIB. Surgical Site Infection (SSI) ToolkitActivity C: ELC Prevention Collaboratives. www.cdc.gov/hai/ppt/SSItoolkit03242010.pptx Acessed on 9102010

6. Bratzler DW, Houck PM. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases 2004; 38:1706–15

7. Yakima Valley Memorial. Surgical Site Infection Collaborative. http://www.100kliveswashington.org/SSICollaborative10-20-05.ppt Accessed on 23092010

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Thanks..........

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