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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 Brief History of Infection Prevention Ignaz Semmelweiss Louis Pasteur Joseph Lister Surgery – 1969 Postoperative 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’s Pre-Incision • Patient • • Glucose Control Hyperoxia • • Basics of Skin Prep • Showers • Skin Wipes Hair Removal Weight Based Dosing MRSA Screening Glucose Control • • Antibiotic Bowel Prep • • • • • Re-dosing Operating Time Use of Tourniquet Surgical Technique Wound protectors • • • • Basics of Sterility Instrument Sterility Hand Hygiene Temperature Control Teamwork Culture • • • • • • • Basics of Sterility Instrument Sterility Hand Hygiene OR Traffic Temperature Control Teamwork Culture • • Operation Environment Incision/Surgery • • Post Op • • Wound care Dressings • Discontinue antibiotics Teamwork Culture • • Rates of Surgical Site Infection and Benefit From Prophylactic Antibiotics Operation Antibiotic Yes Antibiotic No Colon 4-12% 24-48% Number Needed to Treat 3-5 4-9 Other (mixed) GI 4-6% 15-29% Vascular 1- 4% 7-17% 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% Breast & Hernia Operation 3.5% 5.2% 10-17 12-100 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. Perioperative Prophylactic Antibiotics 14/369 Timing of Administration Infections (%) 15/441 1/41 1/47 1/81 2/180 5/699 5/1009 Hours From Incision Classen. NEJM. 1992;328:281. 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 Resources Website: www.safesurgery2015.org Email: [email protected]