9. The very first
requirement in a
hospital/Physician
/Surgeon is that it
should do the sick
no harm
10. The Definition & epidemiology of Surgical site
infections (SSIs)
Pathogenesis of SSI
Control of SSI
New initiative
11. 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
12. 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
13.
14. The overall SSI was 20.09%
In this retrospective study of Gen surg & GI surg the incidence was
3.67%
17. 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
23. 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 .
24.
25. 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
26. 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
27. 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
28. 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
29. 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
33. 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
34.
35. 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
36. 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)
37. 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
38. 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%
References
Materials & 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
39. 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 traffic
Hand hygiene before and after every patient
contact
40. New watchword
transition from
benchmarking to
zero tolerance
41.
42. 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.
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