surgical wounds and antimicrobial prophylaxis
DESCRIPTION
Surgical Wounds and Antimicrobial prophylaxis. Philip G. Murphy Consultant in Medical Microbiology, AMNCH Clinical Professor, TCD p [email protected] (ext 3919). Humanity has three great enemies: Fever, famine and war, Of these by far the greatest, By far the most terrible is fever . - PowerPoint PPT PresentationTRANSCRIPT
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Surgical Wounds and Antimicrobial prophylaxis
Philip G. Murphy
Consultant in Medical Microbiology, AMNCH
Clinical Professor, TCD
[email protected] (ext 3919)
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Humanity has three great enemies:
Fever, famine and war,
Of these by far the greatest,
By far the most terrible is fever.
William Osler
1849-1919
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History
• 1862 Pasteur
• 1865 Lister
• 1866 Semmelweiss
• 1940’s Antibiotic era
• Today ?? Postantibiotic era <2 %
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Public Health Importance of Public Health Importance of Surgical Site InfectionsSurgical Site Infections
• 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)
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Source of SSI PathogensSource of SSI Pathogens
• Endogenous flora of the patient
• Operating theater environment
• Hospital personnel (MDs/RNs/staff)
• Seeding of the operative site from distant focus
of infection (prosthetic device, implants)
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Pathogenesis
• Skin flora into wound margins / deep sites
• Surgical risk factors eg haematoma, ischaemia, prostheses
• Host factors, eg diabetes, steroid Rx
• Bacterial factors eg., innoculum, virulence eg GNB + anerobes
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Rubour,(Redness) Dolour, (pain, tenderness) Tumour, (swelling)
DiagnosisDiagnosis
FeverCRP, ESR, WBC
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SSI- Wound classifications
• Superficial• Deep• Organ/space
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Merely a flesh wound
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Wound healing - stages
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Primary Healing – Occurring when a wound is closed within a few hours of its creation. Wound edges are surgically or mechanically approximated, and collagen metabolism provides long-term
strength. Delayed Primary Healing – Occurs when a poorly delineated wound is left open to protect against
wound infection. The open wound allows for the natural host defense to debride the wound before closure.
Secondary Healing – Occurs when an open full
thickness wound is allowed to close by wound contraction and epithelialization.
Healing of Partial-Thickness Wounds – Occurs
when a partial-thickness wound is closed primarily by epithelialization. This wound healing involves the superficial portion of the dermis. There is minimal collagen deposition, and an absence of wound contraction.
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SSI Risk FactorsSSI Risk Factors
• Age• Obesity• Diabetes• Malnutrition• Prolonged preoperative
stay• Infection at remote site• Systemic steroid use• Immunotherapy• Nicotine use
• Hair removal/Shaving• Duration of surgery• Surgical technique• Haematoma• Necrosis• Foreign body• Presence of drains• Inappropriate use of
antimicrobial prophylaxis
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SSI - Classification and RatesSSI - Classification and Rates• Clean
- no intrinsic bacterial flora <2 %
• Clean / contaminated - involving a viscus with bacterial flora 8%
• Contaminated - involves spillage of viscus content 15%
• Dirty - involves inflammation or viscus perforation
40%
<30 days post-op1 year orthopaedics
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Bacterial aetiologyBacterial aetiologyCDC – NNIS dataCDC – NNIS data
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Microbiology of SSIsMicrobiology of SSIs
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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BacteriologyBacteriology
• UK Survey:
Staphylococci 40-45 %
GNB 40-45 %
other aerobes 6 %
anaerobes 5 %
• Specific surgery types have different rates:
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BacteriologyBacteriology
• Staphylococci and skin flora in bone and cardiac surgery
• GNB in biliary surgery
• Streptococci and anaerobes in gynae
• Colonic surgery:aerobic GNB 10 6-7 / G
Enterococci 10 5-6 / G
Bacteroides 10 9-11 /G
anaerobic cocci 10 10 / G
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PREVENTION IS PRIMARY!
PREVENTION IS PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!
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Theatre environment
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Theatre designTheatre design
• Min staff• 20-30 air changes/ hr• Plenum flow• Positive pressure• HEPA filtration• Asepsis: hand hygiene• Clothing• THINK HYGIENE
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Prevention 1Prevention 1• Pre-op:
avoid antibiotics, minimise hospitalisation, treat remote infection, decolonise Staph, avoid/delay shaving, chlorhexidine bath, resolve obesity/malnutrition, control smoking or diabetes
• Intra-op:Skin prep, aseptic technique, filtered air, antibiotic wound
irrigation, isolate clean / dirty surgical fields - trays, reglove & new instruments from donor vein to CABG, minimise drains, separate drain wound minimise dead space haematomas and devitalised tissue
• Post-op:minimise catheters & IV lines, maintain oxygenation hydration & nutrition
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Prevention 2Prevention 2
• Bowel preparation:
No irrigation, diets, or non- absorbable antibiotics
Theatre design & technique:
workflow zoning, air flow, CSSD, restricted staffing, aseptic technique etc.
Wound managementDressing - no touch technique,
Drainage – none or closed or vacuum drains if pus
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Antibiotic prophylaxis - principles
• First dose immediately pre-op
• maximum of 3 doses or 24h period
• Rarely > 24h
• parenteral, PR
• No non-absorbables
• Rarely required in clean or clean/contaminated
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Perioperative Antibiotics- Perioperative Antibiotics- ProphylacticProphylactic
• Prophylactic antibiotics should exist at time of contamination. Clean- contaminated and Contaminated showed reduction
• In clean only when Foreign Body is inserted• Preoperative, close to cutting time, long half- life, selected
against specific pathogens, 4-6 hours later, and for 2 postoperative doses
• Colon surgery: Oral antibiotics, poorly absorbed; neomycin- erythromycin along with mechanical preparation, and IV systemic
• Dirty: fascial closure, wet-to-dry dressing and delayed primary closure in 4-5 days
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Importance of Timing of Surgical Importance of Timing of Surgical Antimicrobial Prophylaxis (AP)Antimicrobial Prophylaxis (AP)
• Prospective study of 2,847 elective clean and clean-contaminated procedures
• Early AP (2-24 hrs before incision): 3.8% Postop AP (3-24 hrs after incision): 3.3% Periop AP (< 3 hrs after incision): 1.4% Preop AP (<2 hrs before incision): 0.6%
Classen, 1992 (NEJM 326:281-286)
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Antibiotic prophylaxis dynamics
Time of administration
Bacterial load
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Prophylaxis - specificIndication Antibiotic Durationabove knee amputation benzyl penicillin 1 dose
Cholecystectomy cefuroxime 1 dose
Appendicectomy metronidazole 3 doses
Colectomy Cefuroxime + 3 doses
metronidazole
vaginal hysterectomy as above as above
or augmentin
Prosthetic hip replacement cefuroxime 2 doses
Prosthetic heart valve cefuroxime or fluclox tid <48h
Vascular prosthesis as above as above
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Supplemental Perioperative OSupplemental Perioperative O22
• DESIGN: Randomized controlled trial, double blind
• POPULATION: Colorectal surgery (N=500)• INTERVENTION: 30% vs 80% inspired
oxygen during and up to hours after surgery
• RESULTS: SSI incidence 5.2% (80% O2) vs 11.2% (30% O2), p=0.01
Greif, R, et al , NEJM, 2000
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Seropian, 1971Method of hair removal
Razor = 5.6% SSI ratesDepilatory = 0.6% SSI ratesNo hair removal = 0.6% SSI rates
Timing of hair removalShaving immediately before = 3.1% SSI ratesShaving 24 hours before = 7.1% SSI ratesShaving >24 hours before = 20% SSI rates
Pre-operative Shaving/Hair Removal
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Surgical AttireSurgical Attire
• Scrub suits
• Cap/hoods
• Shoe covers
• Masks
• Gloves
• Gowns
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Instruments and infection controlInstruments and infection controlCSSDCSSD
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Parameters for Operating Room Parameters for Operating Room VentilationVentilation
• Temperature:
68o-73oF, depending on normal ambient temp
• Relative humidity:
30%-60%
• Air movement:
from “clean to less clean” areas
• Air changes:
>15 total per hour, (20 routine, 30 orthopaedic)
>3 outdoor air per hour
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Surgical TechniqueSurgical Technique
• Removing devitalized tissue
• Maintaining effective hemostasis
• Gently handling tissues
• Eradicating dead space
• Avoiding inadvertent entries into a viscus
• Using drains and suture material appropriately
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Treatment
• Most infection are superficial – no antibiotics• If complicated - open, drain, debride, micro & Abx• Topical Vs systemic• Saline Vs disinfectant Vs antibiotic• Target organisms Vs culture• empirical Vs culture targeted• one drug Vs two• Remove all prostheses / implants• pus collection drainage
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SurveillanceSurveillance
• Infection Control Team
• Link nurses
• Databases
• Early discharge, day surgery
• Post discharge
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Reading referenceReading reference
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf
The CDC NNIS 1999 guidance document is the comprehensive reference,(23 pages) :