1. Andreas Voss
Andreas
Voss
iPrevent
UMCN
&
CWZ
Nijmegen,
The
Netherlands
To reduce preventable surgical
morbidity and mortality by 25%
by 2010
US national costs: $130-845 million/year
à saving = $ 32.5 to 212.5 million/year
Bratzler & Hunt, Clin Infect Dis 2006; 43:322-30.ccccc
1

2. Andreas Voss
¤ 80-­‐year-­‐old
male
receiving
a
knee
prosthesis
is
brought
to
the
OR
at
10:00
am
for
pre-­‐operaKve
preparaKon
and
anaesthesia.
¤ Surgeons
requested
1
g
of
cefotaxim
to
be
given
as
prophylaxis.
Prophylaxis
was
given
by
anaesthesiologist
at
10:10
am.
¤ OR
nurse
immediately
starts
with
“standard
prepara4on”
for
knee
surgery,
starts
disinfecKng
the
skin
at
10:30
am
and
the
first
incision
of
the
surgeons
is
set
at
10:42
am.
¤ Due
to
unforeseen
complicaKons
the
surgery
takes
longer
than
expected
and
the
surgeon
orders
a
second
dose
of
the
anKbioKc,
that
is
given
at
12:40
am.
¤ A9er
the
operaKon
the
surgeon
orders
2
further
deliveries
of
the
anKbioKc
for
7
pm
of
the
same
day
and
7
am
of
the
next
day.
¤
1g
Cefotaxim
²
dose?
²
choice
of
ceph.
¤
Standard
prep
for
knee
surgery
and
AB-­‐shot
at
10:10h,
first
incision
at
10:42h
¤
Second
dose
12:42h
¤
A[er
2
extra
doses
2

3. Andreas Voss
¤ Lichtenstein-procedure
40-75% inappropriateness in single hospitals
(open inguinal hernia repair with mesh):
¤ US (Everitt et al., Infect Control Hosp Epid 1990; Silver et al., Am J Surg 1996; -less SSI in patients with antibiotics
Gorecki et al.,World J Surg 1999). compared to placebo
¤ Canada (Girotti et al., CJS 1990; Zoutman et al., Can J Surg 1999) Taylor EW et al. Br J Surg. 2004
¤ UK (Griffiths et al., J Hosp Infect 1986) Yerdel MA et al. Ann Surg 2001
¤ France (Bailly et al, J Hosp Inf 2001)
Platt R et al. N Engl J Med 1990
¤ Italy (Mozillo et al., Eur J Epidemiol 1988; Motola et al., J Chemother 1998)
¤ Belgium (Sasse et al., J Antimicrob Chemother 1998)
¤ The Netherlands (Gyssens et al., J Antimicrob Chemother 1996) -no difference in SSI between patients with
¤ Switzerland (Parret et al., Schweiz med Wschr 1993) prophylaxis (1.6%) and placebo (1.8%).
¤ Israel (Finkelstein et al., Isr J Med Sci 1996)
¤ Australia (Johnston et al., Austr Clin Rev 1992) Aufenacker TJ et al. Ann Surg 2004
¤ Clean
² ElecKve,
non-­‐traumaKc,
non-­‐infected
Wound Cruse & Ford SENIC Olson & Lee Culver et al
classification (n=63000) (n=59000) (n=36500) (n=85000)
² Hip
replacement,
catheter/device
implantaKon
¤ Clean-­‐contaminated
Clean 1,5 2,9 1,3 2,1
² Open
GI-­‐tract,
urogenital-­‐tract,
or
airways
Clean-
7,7 3,9 2,4 3,3
contaminated
² GI-­‐surgery,
hysterectomy,
open
fracture,
CABG
¤ Contaminated
Contaminated 15,2 8,5 7,9 6,4
² TraumaKc
wound
<
6h,
leakage
from
GI
tract,
Dirty 40,0 12,6 - 7,1
infected
urine
or
bile
¤ Dirty/infected
² Infected,
pus,
fecal
contaminaKon,
necroKc
Kssue
Clean contaminated and contaminated,
Clean surgery NO risk of wound infection > 5-30 %
except - implant surgery
¤ Colorectal surgery [Baum, 1981]
- high intrinsic risk for SSI
¤ Appendectomy [Gorbach, 1991]
¤ Esophageal surgery
¤ Gastroduodenal surgery, high risk
Clean contaminated procedures YES
¤ Small bowel
Dirty surgery = needs THERAPY ¤ Biliary system, high risk
¤ Gynaecological surgery [Hemsell, 1991]
¤ Head and neck surgery [Shapiro, 1991]
www.sign.ac.uk/guidelines
3

4. Andreas Voss
Abd/thoracic
Colo-rectal vaginal infected
trauma
appendectomy hysterectomy UT
open #
1. First generation cephalosporins ¤ High
efficacy
2. Second generation cephalosporins ¤ Low
toxicity
à
“No”
side
effects
3. Third generation cephalosporins ¤ As
narrow
spectrum
as
possible
4. Glycopeptides ¤ On-­‐Kme
administraKon
possible!
5. Penicillin and betalactamase inhibitor ¤ Low
costs
6. Clindamycin (allergy?) ¤ Different
from
AB
used
for
treatment
¤ Optimal dose is not exactly known
¤ For most drugs, therapeutic dose is used
¤ Half-life of the drug needs to be considered
¤ Increase the dose for obese patients
Forse RA et al. Surgery 1989;106:750-6
Nightingale & Quintiliani, Pharmacotherapy 1991;11:6S-13S
4

5. Andreas Voss
Surgery Type Antimicrobial recommendations Surgery Type Antimicrobial recommendations
Hysterectomy " Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-
Hip or knee Preferred: Cefazolin or cefuroxime sulbactam
arthroplasty If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy:
" Clindamycin + gentamicin or fluoroquinolone* or aztreonam
Beta-lactam allergy: " Metronidazole + gentamicin or fluoroquinolone*
" Vancomycin or clindamycin " Clindamycin monotherapy
Colorectal † Neomycin + erythromycin base; neomycin + metronidazole
Cardiac or Preferred: Cefazolin or cefuroxime "
" Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin-
vascular If patient high risk for MRSA: Vancomycin* sulbactam
Beta-lactam allergy:
Beta-lactam allergy:
" Clindamycin + gentamicin or fluoroquinolone* or aztreonam
" Vancomycin or clindamycin " Metronidazole + gentamicin or fluoroquinolone*
Bratzler DW, Hunt DR. Clin Infect Dis. 2006 Bratzler DW, Hunt DR. Clin Infect Dis. 2006
NEJM 1992;326:281-6
3.8% 0.6%
RR 6.7 RR 1.0
-24 to –2h = early - 2h = preop
1.4% 0 to +3h = peri-op >3h = post-op 3.3%
RR 2.4 RR 5.8
SSI
Administration < 120 minutes before: RR 0.5
Stone Ann Surg 1976;184:443-452 Administration 2 or more hours before: RR 5.3
5

6. Andreas Voss
…optimal timing …is 30 minutes prior to incision…
… administration of the first dose within one hour…
¤ Guideline:
<120
minutes
before
¤ Depends
on:
² Could
be
-­‐120
or
-­‐60
or
-­‐30
or
-­‐1
² AnKbioKc
choice
(penetraKon,
top
concentraKon,
HLT)
² Do
you
believe
that
all
of
the
above
is
correct?
² IndicaKon
(need
to
be
present
in
Kssue,
equilibrium
between
¤ Need
to
agree
on
a
range
e.g.
compartments)
² -­‐45
to
-­‐15
or
² -­‐90
to
-­‐30
90 to15 minutes
before incision – or -
stop of blood-flow
Favors multiple dose
Favors single dose
McDonald Aust NZ J Surg 1998;68:388
6

7. Andreas Voss
¤ Most
studies
have
confirmed
efficacy
of
≤12
hrs
of
prophylacKc
anKbioKcs
¤ Many
studies
have
shown
efficacy
of
a
single
dose
¤ Whenever
compared,
the
shorter
course
has
been
as
effecKve
as
the
longer
course
and
results
in
less
anKbioKc
resistance
¤ ProporKon
of
paKents
who
have
their
anKbioKc
¤ Overview
Status
quo
dose
iniKated
within
1
hour
before
surgical
¤ IndicaKon
incision
(2
hours
for
vancomycin
or
fluoroquinolones)
¤ Choice
of
anKbioKc
¤ ProporKon
of
paKents
who
receive
prophylacKc
anKbioKcs
consistent
with
current
¤ Timing
recommendaKons
(published
guidelines)
¤ DuraKon
¤ ProporKon
of
paKents
whose
prophylacKc
¤ Quality
control
anKbioKcs
were
disconKnued
within
24
hours
of
surgery
end
Kme
(48
hours
for
cardiac
surgery)
¤ ProporKon
of
paKents
who
have
their
12.44 13.09
anKbioKc
dose
iniKated
within
1
hour
before
surgical
incision*
* Or any other time/time range your quality improvement team agreed on
7

8. Andreas Voss
00:57
Timing as agreed on ¤ Install
quality
improvement
team
00:50 ² MDs,
nurses
and
OR
management,
surgeon
(chair),
anesthesiologist,
ward
staff,
QM,
IC,
pharmacist
00:43
00:36
¤ Why
is
prophylaxis
not
given
on
Kme?
00:28
² Process,
structure,
logisKcs,
responsibiliKes
00:21
00:14
¤ Consensus
on
how
to
do
it
00:07
² Agree
on
Kme
range
00:00
² Describe
a
realisKc
process
(SOP)
² Assign
responsibiliKes
Timing as agreed on v Antibiotic has to be in the tissue at time of
00:57
incision or stop of blood-flow
00:50
00:43 v Time period = end infusion until incision
00:36
v Could be start of infusion as long as extra time is
00:28 added and everyone in the hospital knows the rules
00:21
v 2nd shot after 2-3 halftimes (3-4 h)
00:14
00:07 v 2nd shot senseless during stop blood-flow
00:00
v No prophylaxis after 24 hours
8