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Andreas Voss
1
Andreas Voss iPrevent
UMCN & CWZ Nijmegen, The Netherlands
Bratzler & Hunt, Clin Infect Dis 2006; 43:322-30.ccccc
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
Andreas Voss
2
¤ 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
Andreas Voss
3
40-75% inappropriateness in single hospitals ¤ US (Everitt et al., Infect Control Hosp Epid 1990; Silver et al., Am J Surg 1996;
Gorecki et al.,World J Surg 1999). ¤ Canada (Girotti et al., CJS 1990; Zoutman et al., Can J Surg 1999) ¤ UK (Griffiths et al., J Hosp Infect 1986) ¤ France (Bailly et al, J Hosp Inf 2001) ¤ 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) ¤ Switzerland (Parret et al., Schweiz med Wschr 1993) ¤ Israel (Finkelstein et al., Isr J Med Sci 1996) ¤ Australia (Johnston et al., Austr Clin Rev 1992)
¤ Lichtenstein-procedure (open inguinal hernia repair with mesh): -less SSI in patients with antibiotics compared to placebo Taylor EW et al. Br J Surg. 2004 Yerdel MA et al. Ann Surg 2001
Platt R et al. N Engl J Med 1990
-no difference in SSI between patients with prophylaxis (1.6%) and placebo (1.8%). Aufenacker TJ et al. Ann Surg 2004
¤ Clean ² ElecKve, non-‐traumaKc, non-‐infected ² Hip replacement, catheter/device implantaKon
¤ Clean-‐contaminated ² Open GI-‐tract, urogenital-‐tract, or airways ² GI-‐surgery, hysterectomy, open fracture, CABG
¤ Contaminated ² TraumaKc wound < 6h, leakage from GI tract, infected urine or bile
¤ Dirty/infected ² Infected, pus, fecal contaminaKon, necroKc Kssue
Woundclassification
Cruse & Ford(n=63000)
SENIC(n=59000)
Olson & Lee(n=36500)
Culver et al(n=85000)
Clean 1,5 2,9 1,3 2,1
Clean-contaminated 7,7 3,9 2,4 3,3
Contaminated 15,2 8,5 7,9 6,4
Dirty 40,0 12,6 - 7,1
Clean surgery NO except - implant surgery - high intrinsic risk for SSI
Clean contaminated procedures YES Dirty surgery = needs THERAPY
Clean contaminated and contaminated, risk of wound infection > 5-30 %
¤ Colorectal surgery [Baum, 1981] ¤ Appendectomy [Gorbach, 1991] ¤ Esophageal surgery ¤ Gastroduodenal surgery, high risk ¤ Small bowel ¤ Biliary system, high risk ¤ Gynaecological surgery [Hemsell, 1991] ¤ Head and neck surgery [Shapiro, 1991]
www.sign.ac.uk/guidelines
Andreas Voss
4
Colo-rectal appendectomy
vaginal hysterectomy
infected UT
Abd/thoracic trauma open #
1. First generation cephalosporins 2. Second generation cephalosporins 3. Third generation cephalosporins 4. Glycopeptides 5. Penicillin and betalactamase inhibitor 6. Clindamycin (allergy?)
¤ High efficacy
¤ Low toxicity à “No” side effects
¤ As narrow spectrum as possible
¤ On-‐Kme administraKon possible!
¤ Low costs
¤ 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
Andreas Voss
5
Surgery Type Antimicrobial recommendations
Hip or knee arthroplasty
Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy: " Vancomycin or clindamycin
Cardiac or vascular
Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin*
Beta-lactam allergy: " Vancomycin or clindamycin
Bratzler DW, Hunt DR. Clin Infect Dis. 2006
Surgery Type Antimicrobial recommendations
Hysterectomy " Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam
Beta-lactam allergy: " Clindamycin + gentamicin or fluoroquinolone* or aztreonam " Metronidazole + gentamicin or fluoroquinolone* " Clindamycin monotherapy
Colorectal † " Neomycin + erythromycin base; neomycin + metronidazole " Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin-sulbactam
Beta-lactam allergy: " Clindamycin + gentamicin or fluoroquinolone* or aztreonam " Metronidazole + gentamicin or fluoroquinolone*
Bratzler DW, Hunt DR. Clin Infect Dis. 2006
-24 to –2h = early - 2h = preop 0 to +3h = peri-op >3h = post-op
3.8% RR 6.7
0.6% RR 1.0
1.4% RR 2.4
3.3% RR 5.8
NEJM 1992;326:281-6
Stone Ann Surg 1976;184:443-452
SSI
Administration < 120 minutes before: RR 0.5 Administration 2 or more hours before: RR 5.3
Andreas Voss
6
… administration of the first dose within one hour… …optimal timing …is 30 minutes prior to incision…
¤ Guideline: <120 minutes before ² Could be -‐120 or -‐60 or -‐30 or -‐1 ² Do you believe that all of the above is correct?
¤ Need to agree on a range e.g. ² -‐45 to -‐15 or ² -‐90 to -‐30
¤ Depends on: ² AnKbioKc choice (penetraKon, top concentraKon, HLT)
² IndicaKon (need to be present in Kssue, equilibrium between compartments)
90 to15 minutes before incision – or - stop of blood-flow
McDonald Aust NZ J Surg 1998;68:388
Favo
rs si
ngle
dose
Fa
vors
mul
tiple
dose
Andreas Voss
7
¤ 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
¤ Overview Status quo ¤ IndicaKon ¤ Choice of anKbioKc ¤ Timing ¤ DuraKon ¤ Quality control
¤ ProporKon of paKents who have their anKbioKc dose iniKated within 1 hour before surgical incision (2 hours for vancomycin or fluoroquinolones)
¤ ProporKon of paKents who receive prophylacKc anKbioKcs consistent with current recommendaKons (published guidelines)
¤ ProporKon of paKents whose prophylacKc anKbioKcs were disconKnued within 24 hours of surgery end Kme (48 hours for cardiac surgery)
¤ ProporKon of paKents who have their anKbioKc dose iniKated within 1 hour before surgical incision*
* Or any other time/time range your quality improvement team agreed on
12.44 13.09
Andreas Voss
8
00:00
00:07
00:14
00:21
00:28
00:36
00:43
00:50
00:57Timing as agreed on ¤ Install quality improvement team
² MDs, nurses and OR management, surgeon (chair), anesthesiologist, ward staff, QM, IC, pharmacist
¤ Why is prophylaxis not given on Kme? ² Process, structure, logisKcs, responsibiliKes
¤ Consensus on how to do it ² Agree on Kme range ² Describe a realisKc process (SOP) ² Assign responsibiliKes
00:00
00:07
00:14
00:21
00:28
00:36
00:43
00:50
00:57Timing as agreed on v Antibiotic has to be in the tissue at time of
incision or stop of blood-flow
v Time period = end infusion until incision
v Could be start of infusion as long as extra time is added and everyone in the hospital knows the rules
v 2nd shot after 2-3 halftimes (3-4 h)
v 2nd shot senseless during stop blood-flow
v No prophylaxis after 24 hours