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Salzer

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Salzer

  1. 1. Antibiotic Prophylaxis for Surgical Procedures Bill Salzer University of Missouri-Columbia 9/29/07 [email_address]
  2. 2. Preventing Surgical Infections <ul><li>Antibiotic prophylaxis </li></ul><ul><li>Drugs- which when, how many doses? </li></ul><ul><li>Non antibiotic measures- evidence based </li></ul><ul><li>Hair removal </li></ul><ul><li>Normothermia </li></ul><ul><li>Oxygen supplementation </li></ul><ul><li>Normoglycemia </li></ul>
  3. 3. 0 4 8 1 2 Alexander JW et al. Arch Surg. 1983;118:347–352. Hair-Removal Techniques and SSIs Infection, % Discharge 30-Day Follow-up 5.2% (14/271) 8.8% (23/260) 6.4% (17/266) 10% (26/260) 4% (10/250) 7.5% (18/241) 1.8% (4/226) 3.2% (7/216) PM AM PM AM Razor Razor Clipper Clipper
  4. 4. Perioperative Normothermia <ul><li>200 CRS patients </li></ul><ul><ul><li>Control: Routine intraoperative thermal care (mean temperature 34.7 ° C) </li></ul></ul><ul><ul><li>Treatment: Active warming (mean temperature 36.6 ° C) </li></ul></ul><ul><li>Incidence of SSI </li></ul><ul><ul><li>Control 19% (18/96) </li></ul></ul><ul><ul><li>Treatment 6% (6/104); P =0.009 </li></ul></ul>Kurz A et al. N Engl J Med. 1996;334:1209–1215.
  5. 5. Supplemental Oxygen <ul><li>500 CRS patients </li></ul><ul><ul><li>80% or 30% inspired oxygen during operation and for 2 hours post surgery </li></ul></ul><ul><ul><li>All patients received prophylactic antibiotics </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>Arterial and subcutaneous P O 2 higher in 80% oxygen group </li></ul></ul><ul><ul><li>Lower incidence of SSIs with higher supplemental oxygen (5.2% vs 11.2%; P =0.01) </li></ul></ul>Greif et al. N Engl J Med. 2000;342:161–167.
  6. 6. <ul><li>1,000 cardiothoracic surgery patients with preoperative hemoglobin A1c (HbA1c) levels measured </li></ul><ul><ul><li>300 known diabetic patients </li></ul></ul><ul><ul><li>42 with undiagnosed diabetes </li></ul></ul><ul><li>Incidence of SSI </li></ul><ul><ul><li>Diabetes (known and undiagnosed) 5.8% (20/342) </li></ul></ul><ul><ul><li>Without diabetes 1.5% (10/658) </li></ul></ul><ul><ul><li>Diabetes with HbA1c ≥8% 7.9% (10/126) </li></ul></ul><ul><ul><li>Diabetes with HbA1c <8% 4.0% (7/174) </li></ul></ul>SSIs and Glucose Levels (cont) Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612.
  7. 7. SSIs and Post-op Glucose Levels Latham R et al. Infect Control Hosp Epidemiol. 2001;22:607–612. Adapted with permission from the University of Chicago Press © 2001. 3.32 28 (3%) 5 (7%) ≥ 300 2.97 69 (8%) 11 (15%) 250–299 2.54 154 (17%) 21 (29%) 200–249 1.00 651 (72%) 35 (49%) <200 (referrent) Odds ratio Noninfected patients (n=902) Infected patients (n=72) Glucose level (mg/dL)
  8. 8. SSIs and Glucose Levels 0 1 2 3 4 5 6 7 8 100–150 150–200 200–250 250–300 Day 1 Blood Glucose (mg/dL) Deep Infection Rate, % Zerr KJ et al. Glucose control lowers the risk of wound infection in diabetics after open heart operations, page 360. Reprinted from The Annals of Thoracic Surgeons , Vol. 63. Copyright 1997, with permission from the Society of Thoracic Surgeons. All rights reserved. 1.3% 1.6% 2.5% 6.7% P =0.002
  9. 9. Preoperative Strategies to Limit SSIs: Skin Surface Preparations <ul><li>Antiseptic showers </li></ul><ul><ul><li>Reduced bacterial counts by 3.5 log 10 from baseline 1 </li></ul></ul><ul><ul><li>No evidence that they affect SSIs 2 </li></ul></ul><ul><li>Skin preparation in the operating room (OR) </li></ul><ul><ul><li>Usually iodophors, alcohol-containing products, or chlorhexidine gluconate 2 </li></ul></ul>1. Seal LA et al. Am J Infect Control. 2004;32:57–62. 2. Mangram AJ et al. Am J Infect Control. 1999;27:97–134.
  10. 10. Antimicrobial Prophylaxis <ul><li>Antimicrobial agent to prevent or reduce infection </li></ul><ul><li>Ideally </li></ul><ul><li>Targeted antibiotic </li></ul><ul><li>Narrow spectrum agent </li></ul><ul><li>Targeting few pathogens </li></ul><ul><li>Short term </li></ul>
  11. 11. Surgical Prophylaxis- Principles <ul><li>Its not the tool it’s the craftsman </li></ul><ul><li>You can’t kill everything </li></ul><ul><li>Surgical wound and deeper infections </li></ul><ul><li>Focus on likely pathogens-what are you cutting? </li></ul><ul><li>Narrow spectrum, long half life drugs </li></ul><ul><li>Dose timing- pre-incision, close </li></ul><ul><li>Single pre-op dose adequate for most </li></ul><ul><li>Good vs bad effects </li></ul><ul><li>Effect of prior hospitalization, antibiotics </li></ul>
  12. 12. Antibiotic Prophylaxis-Caveats <ul><li>You can’t kill everything </li></ul><ul><li>Adverse drug effects </li></ul><ul><li>Select resistant pathogens </li></ul><ul><li>C diff colitis </li></ul><ul><li>Select more virulent pathogens </li></ul><ul><li>Avoid drugs/classes that are used for therapy </li></ul>
  13. 13. Evidence Based? <ul><li>A-I </li></ul><ul><li>GI tract, oropharynx, vascular, craniotomy, ortho-implants, cardiac, hysterectomy, C-section, </li></ul><ul><li>B-I- clean </li></ul><ul><li>Breast, hernia </li></ul><ul><li>B-III </li></ul><ul><li>Implant prosthetic, low risk gastric or biliary, open GU </li></ul><ul><li>C-III </li></ul><ul><li>Minimally invasive- laparoscopic procedures </li></ul><ul><li>? ERCP </li></ul>
  14. 14. Major Pathogens in SSI 0% 5% 10% 15% 20% Infections, % Staphylococcus aureus Coagulase-negative Staphylococcus Enterococcus spp. Escherichia coli Pseudomonas aeruginosa Enterobacter spp. NNIS Report. Am J Infect Control. 1996;24:380–388.
  15. 15. Beta-lactams for Surgical Prophylaxis <ul><li>Cefazolin- “Ancef” or “Kefzol” </li></ul><ul><li>Ideal properties- cost, 1/2 life-2 hr, spectrum </li></ul><ul><li>1-2 gr pre-op, repeat q4-6h if long job, bleeder </li></ul><ul><li>Post-op doses? Probably not needed </li></ul><ul><li>Cefotetan or cefoxitin- colon, anaerobes, GYN </li></ul><ul><li>Cefotetan- t1/2 3.5 h, cefoxitin- 1 hr </li></ul><ul><li>Ertapenem </li></ul><ul><li>Colon surgery, t1/2 -4 hr </li></ul>
  16. 16. Failure of Prophylaxis at 4 Weeks Posttreatment (Evaluable Population) C diff colitis 1.7% 0.6% 4.1 14 2.9 10    Anastomotic Leak 7.7 26 8.4 29    Unexplained Antibiotic Use 31 105 18.2 63    Surgical Site Infection – 13.3 – 20.4, – 6.1 42.8 145 29.5 102 Any Failure % 95% CI % n % n Reason for Failure Estimated Difference (A - B) Cefotetan (B) (n=339) Ertapenem (A) (n=346)
  17. 17. Penicillin Allergic? <ul><li>What type? </li></ul><ul><li>Anaphylactoid or rash? </li></ul><ul><li>Allergic to cephalosporins? </li></ul><ul><li>Prior surgeries? </li></ul><ul><li>Truly allergic </li></ul><ul><li>Vancomycin </li></ul><ul><li>Clindamycin </li></ul><ul><li>Colon- clindamycin or metronidazole combos </li></ul>
  18. 18. Vancomycin for Surgical Prophylaxis <ul><li>Serious beta-lactam allergy </li></ul><ul><li>? Excess MRSA, MRSE in ortho, CT surgery </li></ul><ul><li>Will CA-MRSA emerge? </li></ul><ul><li>Vancomycin I gr IV </li></ul><ul><li>Start 1 hr pre-op, don’t give fast, 1 hour infusion </li></ul>
  19. 19. Perioperative Prophylactic Antibiotics: Timing of Administration Infections, % Hours From Incision 14/369 5/699 5/1,009 2/180 1/61 1/41 1/47 15/441 0 1 2 3 4 ≤– 3 >–2 >–1 0 1 2 3 4 ≥ 5 Classen DC et al. N Engl J Med . 1992;326:281–286. Copyright © 1992 Massachusetts Medical Society. All rights reserved.
  20. 20. Surgical Prophylaxis- One Dose? <ul><li>Single Preop dose </li></ul><ul><li>Evidence based, 0ne better than none, ?post-op </li></ul><ul><li>Cost, toxicity, etc </li></ul><ul><li>Preop + 24 hours </li></ul><ul><li>No evidence it’s better than 1 preop </li></ul><ul><li>Cost </li></ul><ul><li>Toxicity </li></ul><ul><li>Superinfection with resistant organisms </li></ul><ul><li>More C diff </li></ul>
  21. 21. Impact of Prolonged Antibiotic Prophylaxis <ul><li>2,641 patients undergoing CABG </li></ul><ul><ul><li>Group 1 <48 hours of antibiotics </li></ul></ul><ul><ul><li>Group 2 >48 hours of antibiotics </li></ul></ul><ul><li>SSI rates </li></ul><ul><ul><li>Group 1 9% (131/1,502) </li></ul></ul><ul><ul><li>Group 2 9% (100/1,139) </li></ul></ul><ul><ul><li>Odds ratio 1.0 (95% CI: 0.8–1.3) </li></ul></ul><ul><li>Increased antibiotic resistant pathogens – Group 2 </li></ul><ul><ul><li>Odds ratio 1.6 (95% CI: 1.1–2.6) </li></ul></ul>CABG = coronary artery bypass grafting; CI = confidence interval. Harbarth S et al. Circulation . 2000;101:2916–2921.
  22. 22. Single- vs Multiple-Dose Surgical Prophylaxis: Systematic Review McDonald M et al. Aust NZ J Surg . 1998;68:388–396. Adapted with permission from Blackwell Synergy © 1998. Favors single dose Favors multiple dose All studies, fixed All studies, random Multi > 24h Multi < 24h
  23. 23. Website Resource www. surgical infection prevention .org
  24. 24. SIP Program Quality Indicators <ul><li>Quality Indicator No. 1 </li></ul><ul><ul><li>Proportion of patients who receive antibiotics within 1 hour before surgical incision </li></ul></ul><ul><li>Quality Indicator No. 2 </li></ul><ul><ul><li>Proportion of patients who receive prophylactic antibiotics consistent with current recommendations </li></ul></ul><ul><li>Quality Indicator No. 3 </li></ul><ul><ul><li>Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours of surgery end time </li></ul></ul>Bratzler DW. Available at: http://www.medqic.org/scip/pdf/spkrnotesSIP_to_SCIP_101205.ppt . Accessed May 26, 2006.
  25. 25. Preventing Surgical Infections <ul><li>Patient safety </li></ul><ul><li>Education- QA/QI issues </li></ul><ul><li>Cost of Post-op and nosocomial infections </li></ul><ul><li>Big brother is watching </li></ul><ul><li>How? </li></ul><ul><li>Evidence-based approach </li></ul><ul><li>Appropriate perioperative antibiotics </li></ul><ul><li>Appropriate perioperative nonantibiotic measures </li></ul>

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