Healthcare Associated Infections: Preventing Surgical Site Infections Edward L. Goodman, MD September 27, 2004

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  • Healthcare Associated Infections: Preventing Surgical Site Infections Edward L. Goodman, MD September 27, 2004
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  • Outline Definition Magnitude of the problem Pathophysiology Non pharmacologic methods Perioperative antimicrobials Conclusions Bibliography
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  • Definitions
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  • Criteria
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  • Magnitude of the Problem Burke. N Eng J Med 2003;348:651-6
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  • Magnitude Burke
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  • Pathophysiology Surgical Factors Wound classification Clean Clean contaminated Dirty Emergency vs. Elective Surgical technique Perioperative environment
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  • Pathophysiology Host factors NNIS Stratification System Time of surgery ASA score Rating system to predict mortality Colonization with potential pathogens
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  • Microbiology of SSI
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  • Microbiology by Surgery Site
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  • Is the Microbiology of SSI Predestined? Are the organisms already present on the patient? Classically, it was taught that SSI are caused by flora entering the wound during the procedure Studies on Staph aureus bacteremia support that mechanism
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  • Endogenous Source of Staph Aureus Bacteremia
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  • Do Postoperative Factors Play a Role ? MRSA SSI vs. other SSI Manian et al. CID 2003:36
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  • MRSA SSI vs. MSSA SSI
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  • Non Pharmacologic Operative Interventions Supplemental oxygen during surgery Maintenance of normothermia Maintenance of normoglycemia
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  • Supplemental Oxygen Greif 2000: Double blind, controlled multicenter study of 500 patients undergoing colorectal resections Intervention: 80% vs 30% FiO 2 during and 2 hours after surgery Reduction in SSI rate from 11.2% to 5.2% (p=0.01)
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  • Supplemental Oxygen Greif et al. NEJM 2000
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  • Not so fast Pryor 2004 Double blind, randomized, controlled study in one hospital of patients undergoing a variety of abdominal surgeries Intervention: 80% vs 35% FiO 2 during and two hours after Increase in SSI rate from 11.3% to 25% (p=0.03)
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  • Oxygen Therapy Pryor JAMA 2004
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  • Maintenance of Normothermia Anesthesia influences thermoregulatory control Mild hypothermia associated with Adverse myocardial events/vasoconstriction Coagulopathy Inhibits oxidative killing by PMNs Reduces metabolism of many drugs Thermal discomfort
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  • Anesthetic Effects on Thermoregulation Sessler CID 2002;35:1397-1404
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  • Kurz, A. et al. N Engl J Med 1996;334:1209-1216 Core Temperatures during and after Colorectal Surgery in the Study Patients
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  • Kurz, A. et al. N Engl J Med 1996;334:1209-1216 Postoperative Findings in the Two Study Groups
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  • Maintenance of Normoglycemia Cardiothoracic surgery In diabetic patients, maintenance of sugar