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Download Prevent Surgical Site Infections in Gastrointestinal Surgery
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Preventing Surgical Site Infections for Gastrointestinal Surgery Dr CHIA Chi Fung (Queen Elizabeth Hospital) Joint Hospital Surgical Grand Round Jan 2017 Wound matters M/70, Newly found Ca rectum Hx of lap R hemicolectomy for Ca caecum APR + Total colectomy + End-ileostomy done Post-op discharge from laparotomy wound on D7 Wound C/ST: Proteus, E Coli, Pseudomonas Prolonged hospital stay for wound care till D23 Wound matters F/83, Strangulated incisional hernia Hx of LAR for Ca rectum Small bowel resection and defect repair done Gapping with purulent discharge on D6 Wound swab: Klebsiella, Enterococcus CT: Inflammatory change at wound Subcutaneous collection at abdominal wall Given TPN, daily dressings Meropenem, vancomycin Surgical Site Infections (SSI) Procedure-related infection at or near incision Within 30 days (or within 90 days if prosthetic material) Translates to morbidity, hospital stay, cost and mortality Microbiology: Skin flora Endogenous flora of involved viscus / mucosa Risk Factors Age Underlying Illness Obesity Smoking Wound Classification Clean: up to 3% Clean-contaminated: up to 8% Contaminated: up to 15% Dirty: up to 40% How to prevent SSIs? Pre-op preparation Nutrition, S aureus decontamination, Bathing Bowel Preparation Peri-op care Oxygenation, Perfusion Sterile environment, Hand decontamination Skin preparation Antibiotics on induction and impregnated sutures Wound protectors Wound irrigation Bowel Preparation Polyethylene glycol, Sodium phosphate Good or bad? Intraluminal faecal mass Bacterial load ?? Liquefies faeces Intra-op spillage Bowel Preparation Yes or No? NICE 2008: ✗ IDSA 2014: ? to combine with oral antibiotics WHO 2016: ✓ with oral antibiotics If only bowel prep, worse than none Meta-analysis 13 RCTs: OR 1.31 (95%CI 1.00-1.72) Benefits other than SSI not taken into account Oral Antibiotics with bowel prep Better than bowel prep alone Meta-analysis 11 RCTs: OR 0.56 (95%CI 0.37-0.83) What type? What dose? No conclusive evidence High intraluminal concentrations, poor absorption Against facultative Gram-ve & anaerobic bacteria E.g. Neomycin + Metronidazole ? Oral antibiotics alone ? Side effect profile Surgical Site Preparation What to use? NICE 2013: Iodine or Chlorhexidine IDSA 2014: Alcohol-containing WHO 2016: Alcohol-based chlorhexidine Limitation Small effect size ~ 4 fewer in 100 ? Cost-effective Wound Protector Minimize wound-edge contamination Yes or No? NICE 2013: ✓ abdominal IDSA 2014: ✓ GI & biliary WHO 2016: ✓ abdominal Lower risk of SSI ~ 10 fewer in 100 Very low quality evidence May not be cost-effective Wound Irrigation Physical removal + Dilution + Local antibacterial effect How? Syringe pressure? Pulsed irrigation? What? Saline? Povidine-iodine? Antibiotics? Wound Irrigation Yes or No? NICE 2008: ✗ IDSA 2014: ✓ povidine-iodine WHO 2016: ✓ povidine-iodine Remains debate Mainly based on old evidence or evidence from non-GI surgeries ? Wound irritation What’s the trend? Oral antibiotics goes with bowel prep Alcohol-based chlorhexidine for skin prep Consider use of wound protectors Wound irrigation with povidone-iodine To know more Thanks
