SSI Bundle


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SSI Bundle

  1. 1. The presentation is solely meant forAcademic purpose
  2. 2. Nothing to disclose
  4. 4. The very first requirement in ahospital/Physician/Surgeon is that itshould do the sick no harm
  5. 5.  The Definition & epidemiology of Surgical site infections (SSIs) Pathogenesis of SSI Control of SSI New initiative
  6. 6.  Mr. M underwent SSI? PPI 6 months back,  1. Yes now presented with  2, No a fever, swelling &  3. Ask CT surgeons pain at the surgical  4. I’ll like to call the site. professor  5. I am googling
  7. 7.  Must have one of following within 30 days post-op (1 year if implant): ◦ Purulent drainage ◦ Positive culture ( proper sample) ◦ Pain, inflammation, opening of wound needed Types of SSI Incisional infections ◦ Superficial (skin, subcutaneous tissue) ◦ Deep (fascia, muscle) Organ space infections
  8. 8. The overall SSI was 20.09%In this retrospective study of Gen surg & GI surg the incidence was3.67%
  9. 9.  Clinical Culturebased Outpatient follow-up Feedback Monitoring reduce SSI rates by 35-50%
  10. 10.  Endogenous sources: ◦ Majority of cases ◦ Wound is a moist, devitalized, warm area ◦ Directly proportional to inoculum, fewer organisms needed if foreign body present Exogenous sources Hematogenous and lymphatic sources
  11. 11. Dorairajan Sureshkumar et al AIFIC 2013 Abstract
  12. 12.  1. Diab. mellitus/perioeperative hyperglycemia 2. Concurrent tobacco use 3. Obesity 4. Malnutrition 5. Low preoperative albumin 6. Remote infection at the time of surgery 7. Prolonged preoperative stay 8. Prior site irradiation 9. Concurrent steroid use 10. Colonization with S.aureus
  13. 13.  1. Shaving of site, the night prior to procedure 2. Use of razor for hair removal 3. Improper preoperative skin preparation 4. Improper antimicrobial prophylaxis (wrong drug, dose & timing) 5. Failure to timely redose for prolonged procedure 6. Inadequate OR ventilation 7. Increased OR traffic 8. Poor surgical technique (tissue trauma, poor hemeostasis) 9. Break in sterile technique, asepsis 10. Perioperative hypothermia & hypoxia
  14. 14.  Preoperative  Intraoperative & factors Postoperative factors ◦ Resolve ◦ Minimize dead space, malnutrition & devitalized tissue & obesity hematoma ◦ Consider supplemental O2 ◦ Discontinue ◦ Maintain Perioperative cigarette smoking normothermia ◦ Maximize diabetes ◦ Maintain hydration & control nutrition ◦ Minimize postoperative hyperglycemia (<200 for 48 hours)
  15. 15.  Preoperative factors  Intra & postoperative ◦ Minimize preoperative factors stay ◦ Carefully prepare skin with ◦ Avoid preoperative chlorhexidine containing antibiotic use solution ◦ Treat remote sites of ◦ Rigoursly adhere to aseptic infection techniques ◦ Avoid shaving at surgical ◦ Maintain high flow of filtered air site ◦ Redose of antibiotics in ◦ Delay hair removal until prolonged procedure time of surgery (clippers) ◦ Minimize OR traffic ◦ Administer timely ◦ Minimize drains & bring antibiotic prophylaxis through separate incision. ◦ Eliminate S.aureus nasal colonization .
  16. 16.  Previous day admission ◦ Prolonged pre-op stay results in colonization by hospital flora ◦ 6% infection rate for 1 day vs 14.7% for >21 days Control infections at other sites (3 fold increase) Stop smoking (31% to 5%) 30 days pre-op Same day hair removal just before surgery (3% vs 20%) Clipping or depilation only, avoid razors One study showed craniotomy without hair removal had same infection rate
  17. 17.  Rationale is that most patients get Staph aureus from their own nose Nasal swab screening and decolonization with mupirocin for 3 days reduced all site Staph infections from 7.7% to 4% (NEJM 2002) If done ensure that the mupirocin course is finished pre-op PCR screening followed by mupirocin nasal ointment and chlorhexidine soap versus controls Rate of SSI 3.4% vs 7.2% (RR 0.42) Protection from deep space SSI even better (RR 0.21) Bottom line: applicable for cardiac surgery, implant, immunosuppressed) ◦ N Engl J Med 2010;362:9
  18. 18.  RCT compared chlorhexidine-alcohol vs povidone-iodine for clean contaminated surgery 9.1 vs 16.5% SSI rates respectively Unclear if povidone-iodine was allowed to evaporate  N Engl J Med 2010;362:18
  19. 19.  Numerous studies show an increased risk for nosocomial infections with blood transfusion (app. double) Avoid blood unless: ◦ Patient actively bleeding ◦ Hb<7.0 ◦ Critical coronary ischemia
  20. 20.  Clearly effective in reducing the incidence of surgical site infections Antibiotics have to be in the system at time of incision and for duration of surgery, give first dose in theater < 1 hour before incision. No role for oral antibiotics for a few days later No role for antibiotics after day one or continuing till drains removed Antibiotics don’t protect against infections at other sites
  21. 21. Cardiac, orthopedic,General surgery gynecolgic
  22. 22.  Based on anticipated contaminating flora ◦ Staphylococcus aureus is most common ◦ Gram negatives & anaerobes if mucosae breached ◦ (Dorairajan Sureshkumar et al unpublished data GPC is the common colonizer at hospital admission) 2 g cefazolin or 1.5 g cefuroxime usually recommended Give extra intra-op dose for surgeries >3 hrs duration
  23. 23.  Antibiotic resistance is increasing alarmingly and we are running out of antibiotics to treat patients ◦ MRSA ◦ ESBL ◦ pan resistant Pseudomonas ◦ pan resistant Acinetobacter Every clean case that gets an antibiotic is colonized by resistant organisms- this spreads to other patients Study shows that broad spectrum antibiotic use predisposes to resistant infection later No preventive role after skin is closed
  24. 24.  2000 B.C – Here, eat this root. (pre-antibiotic era) 1000 A.D – That root is heathen, say this prayer 1940 A.D – That potion is snake oil, swallow this pill. 1985 A.D – That pill is ineffective, take this new antibiotic 2012 A.D – That antibiotic is placebo. Here, eat this root or pray. (post antibiotic era)
  25. 25.  Vancomycin or teicoplanin ◦ Can use single dose if outbreak of MRSA for hardware insertion eg prosthetic valve Aminoglycosides Cefoperazone-sulbactam Other third generation cephaloporins Piperacillin-tazobactam Meropenem or imipenem Linezolid
  26. 26. Background Results Summary In western countries despite extensive The results showed a significantly high level knowledge and guidelines on surgical During the study period 1161 elective surgeries were performed. One hundred of adherence with guidelines concerning the antibiotic prophylaxis, implementation is percent compliance to all the three criteria was observed in 49.30% of cases. choice and timing of antibiotic. The infection often suboptimal. Only a minority of Correct antibiotic selection was done in 74.80% of surgeries, timing of the first control team’s feed back lead to stopping of hospitals in a developing country like India dose was appropriate in 99.70% cases. The most frequent encountered antibiotic in 34.13% of times. Nearly 50 % of have an antibiotic policy and surgical deviation from the policy was unnecessary prolongation of prophylaxis in the time all the three parameters were antibiotic prophylaxis guidelines. There is a 41.60% of cases. However in 34.13% of cases where prophylaxis was followed by the surgeons. need to study adherence to antibiotic prolonged, the surgeon accepted the infection control team’s feed back to stop prophylaxis guidelines in India. antibiotic prophylaxis.Objective Conclusion To study the adherence to local hospital Our study indicates the importance of surgical guidelines for antimicrobial prophylaxis in Adherence to Surgical Antibiotics Prophylaxis guidelines antibiotic guidelines and feed back by the surgery, and explore ways of improving infection control team in reducing unnecessary adherence. antibiotic usage in surgical practice. 100% 80% ReferencesMaterials & Methods 60% 99.70% Adherence to local hospital guidelines for 40% 74.80% surgical antimicrobial prophylaxis: a A prospective evaluation of the use of 58.40% multicentre audit in Dutch hospitals. JAC antimicrobial prophylaxis in patients 49.30% 49.30% 20% (2003) 51 1389-1396 undergoing surgery at our hospital was carried out from July 2009 to March 2010. Three criteria were evaluated: 1. 0% Antibiotic choice 2. Timing of the First dose within 1 hour Followed guidelines for Antibiotics stopped within Followed guidelines for Followed guidelines for antibiotic in relation to surgery and antibiotic selection 24 hours antibiotic selection and antibiotic selection and 3.Duration of administration. The stopped within 24 hours stopped within 24 hours and first dose within 1 response to feedback provided by the % of cases hour infection control team regarding duration was also evaluated, Sureshkumar et al ICAAC Boston 2010
  27. 27.  Give antibiotics within one hour before incision and stop same day Avoid shaving, esp previous day Warm and oxygenate patient Tight intra-op and post-op glucose control Control your OR trafficHand hygiene before and after every patient contact
  28. 28.  New watchword transition from benchmarking to zero tolerance
  29. 29.  1. Restrict hospital admission to 6-12 hours before surgery 2. Do not shave/razor the surgical site 3. Use antibiotic as per surgical prophylaxis guidelines 4. Administer antibiotics 0-60 minutes before incision 5. Redose if surgery is prolonged more than three hours and stop when surgery is over. If interested enroll your name with us
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  31. 31. 2013 Operation O