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Surgical Site Infections:The Foundation
What Are We Doing Together Over the Next Two Months
• Talk about ways to prevent surgical site infections and venous thromboembolism in surgical patients.
• Webinars every two-weeks where we will discuss methods that appear in the literature and that are “low-hanging fruit”.
• The topics that we discuss are things that:– will make the most difference to your patients– have clear evidence– are things that you can put into place in your ORs
We Will Not Go Into Step-By Step Instructions On How To Put These Methods Into Place
Today’s Topics• Brief History of Infection Prevention Techniques• Prophylactic Antibiotic Administration• Weight Based Dosing• Re-dosing• Discontinuing Antibiotics
Common Sense Science• Bacteria cause infection• Bacteria are everywhere• It is a battle against the bacteria
Ignaz Semmelweiss Joseph ListerLouis Pasteur
Brief History of Infection Prevention
Surgery – 1969Postoperative Wound Infection:
A Prospective Study of Determinant Factors and Prevention
Polk HC Jr, Lopez-Mayor JF
Surgical Technique, Prophylactic Antibiotics and SSI
Polk. Surgery 1969;66:97-103
Different Ways of Preventing SSI’s
• Pre-operative screenings• Proper Hair Removal• Skin Prep• Hair Prep• Hand Hygiene• Prophylactic Antibiotics• Surgical Technique• Glucose Control• Hyperoxia
• OR Traffic• Bowel Prep• Temperature Control• Transfusion• Maintenance of
hemostasis and perfusion• Wound Protectors• Communication• Teamwork
Preventing SSI’sPre-Incision Incision/Surgery Post Op
Patient
• Basics of Skin Prep
• Showers• Skin Wipes
• Hair Removal• Weight Based
Dosing• MRSA Screening • Glucose Control
• Glucose Control• Hyperoxia
• Wound care• Dressings
Operation
• Antibiotic• Bowel Prep
• Re-dosing• Operating Time• Use of Tourniquet• Surgical Technique• Wound protectors
Environment
• Basics of Sterility• Instrument Sterility• Hand Hygiene• Temperature
Control• Teamwork• Culture
• Basics of Sterility• Instrument Sterility• Hand Hygiene• OR Traffic• Temperature Control• Teamwork• Culture
• Discontinue antibiotics
• Teamwork• Culture
Rates of Surgical Site Infection and Benefit From Prophylactic Antibiotics
•
Operation Antibiotic Yes
Antibiotic No
Number Needed to Treat
Colon 4-12% 24-48%3-5
Other (mixed) GI 4-6% 15-29%4-9
Vascular 1- 4% 7-17%10-17
Cardiac 3-9% 44-49% 2-3
Hysterectomy 1-16% 18-38% 3-6
Craniotomy 0.5-3% 4-12% 9-29
Spinal Operation 2.2% 5.9% 27
Total Joint Replacement
0.5-1% 2-9%12-100
Breast & Hernia Operation
3.5% 5.2% 58
Dellinger, Patchen 2013. Hospital Engagement Network
Common Sense Science: Timing of Antibiotics
• In order for antibiotics to be effective they need to be in the tissue at the time that the incision is made.
• It can take more time to reach some tissues than others.
• Antibiotics can’t get to tissue that has no blood flow.
Classen. NEJM. 1992;328:281.
Perioperative Prophylactic Antibiotics
Timing of AdministrationIn
fect
ion
s (%
)
Hours From Incision
14/369
5/6995/1009
2/180
1/81
1/411/47
15/441
Common Sense Science:Weight Based Dosing
• Larger patients have more tissue and larger blood volumes.
• Standard antibiotics doses given to larger patients will result in lower blood and tissue levels of antibiotics.
• The dose of prophylactic antibiotic should be adjusted for larger patients.
Obesity Map
Prophylactic Antibiotics:Size of Patient and Size of Dose
• Morbidly obese patients having bariatric surgery have higher infection rates.
• Cefazolin levels are lower in obese patients than in non-obese patients at same dose.
• Cefazolin dose changed from 1 g to 2 g:– Infection rate at 1g: 16.5%– Infection rate at 2g: 5.6%
Forse RA. Surgery 1989;106:750
Ancef• Pediatric Dosing:
– 25 – 50 mg/kg/day divided into three doses• 70kg x 50 = 3500• 3500/3 = ~1000 or 1 gram• 100kg x 50 = 5000• 5000/3 = ~ 1700 or 2 grams
Recommended Adult Dosing• < 80 kg -------- 1 gram• > 80 kg -------- 2 grams
Common Sense Science: Antibiotic Re-dosing
• The blood level of all antibiotics decreases with time.
• When the level falls enough, the infections “fighting power” of the antibiotic is no longer effective.
• A second [or third] dose of antibiotics should be given to prevent surgical site infection.
Results When You Re-Dose Antibiotics
How Long Between Re-Dosing?
• It turns out that if antibiotics are re-dosed they can remain clinically effective.
• There is probably some variability in this [different surgical procedures can change drug metabolism].
• Other factors can decrease this interval.
Common Sense Science: Discontinuing Prophylactic
Antibiotics• The primary effect of giving antibiotics during
surgery comes from the initial dose given before the incision and additional doses given while the incision is open.
• That is when most of the bacteria contamination occurs.
• Additional doses of antibiotics given after the wound is closed have minimal or no effect on the development of surgical site infections.
Antibiotic Resistance is a Big Problem
NEJM: Pallares et al. Vol. 333:474-480.
Staphylococcus Aureus
Emerging Infectious Diseases: Vol.7 No. 2. Chambers, H.F.
Vancomycin
Take Home Messages• This is hard.• The GREATER GOOD.• My patient.
??Questions
Upcoming Calls• Thursday, May 16th 2:00-2:45: The Impact
of Communication, Teamwork, and Culture on SSI’s.
• Thursday, May 30th 2:00-2:45: Preventing SSI’s When Preparing Our Patients for Surgery
Office Hours:Wednesday 2:00-3:00
