1. Post Operative Infections: Risk Factors and Prevention Strategies
Yasir Gashi
MBBS,MD,FSSUM

2. Agenda Introduction Pathophysiology
Patient related risk factors and its modification
Pre-operative aspects
Intar-operative aspects
Operating room
Use of antibiotics
Conclusions

3. Search principles

4. Search principles

5. Search principles

6. Filtering Most recent Direct conclusion for prevention Guidelines
Evidence higher classes

7. Level I (evidence from large, well-conducted, randomized, controlled clinical trials or a meta-analysis),
Level II (evidence from small, well-conducted, randomized, controlled clinical trials),
Level III (evidence from well-conducted cohort studies),
Level IV (evidence from well-conducted case-control studies),
Level V (evidence from uncontrolled studies that were not well conducted),
Level VI (conflicting evidence that tends to favor the recommendation), or
Level VII (expert opinion or data extrapolated from evidence for general principles and other procedures).

8. Level I (evidence from large, well-conducted, randomized, controlled clinical trials or a meta-analysis),
Level II (evidence from small, well-conducted, randomized, controlled clinical trials),
Level III (evidence from well-conducted cohort studies),
Level IV (evidence from well-conducted case-control studies),
Level V (evidence from uncontrolled studies that were not well conducted),
Level VI (conflicting evidence that tends to favor the recommendation), or
Level VII (expert opinion or data extrapolated from evidence for general principles and other procedures).

9. Definition POIs or SSIs
The United States Centers for Disease Control and Prevention
“Infections occurring at or near the site of surgery within 30 days after operation or within 1 year if implant is in place”
Mangram AJ et al (1999) .Quidelines for prevention of SSIs. Epidemio;. 20:

10. Epidemiology Occurs in 1.5- 2 % of all Orthopedics procedures
Associated with 9% mortality
Astagneau P et al (2001). Mortality and Morbidity associated with SSIs: J Hosp infect 48:

11. Pathophysiology Most of the infections acquired peri-operatively
Source:
Patients
Theater staff
40% is Staph A
MRSA is increasing
Poly microbial pathogens found in 1 third
5% of them include MRSA
Weigelt et al (2010). SSIs causative pathogens and associated outcomes Am J of Infect control, 38:

12. Risk factors Non Modifiable Preop Pt Prepration Modifiable
Patient related
Surgical related
Operating room related
Non Modifiable
Preop Pt Prepration
No of people
Ventilation and laminar air flow
Age / severity of illness
Showering/ skin preparation
Surgical incision and drapes/ skin prepration/ hair shaving
Modifiable
Preop Surgeon Prepration DM
OBESITY
Surgical scrub / surgical attire
MALNUTRITION
SMOKING
Intra-operative
IMUNNOSUPRESSIVE DRUGS
Duration and techniques

13. Risk factors Non Modifiable Preop Pt Prepration Modifiable
Patient related
Surgical related
Operating room related
Non Modifiable
Preop Pt Prepration
No of people
Ventilation and laminar air flow
Age / severity of illness
Showering/ skin preparation
Surgical incision and drapes/ skin prepration/ hair shaving
Modifiable
Preop Surgeon Prepration DM
OBESITY
Surgical scrub / surgical attire
MALNUTRITION
SMOKING
Intra-operative
IMUNNOSUPRESSIVE DRUGS
Duration and techniques

14. Risk factors Non Modifiable Preop Pt Prepration Modifiable
Patient related
Surgical related
Operating room related
Non Modifiable
Preop Pt Prepration
No of people
Ventilation and laminar air flow
Age / severity of illness
Showering/ skin preparation
Surgical incision and drapes/ skin prepration/ hair shaving
Modifiable
Preop Surgeon Prepration DM
OBESITY
Surgical scrub / surgical attire
MALNUTRITION
SMOKING
Intra-operative
IMUNNOSUPRESSIVE DRUGS
Duration and techniques

15. Risk factors Non Modifiable Preop Pt Prepration Modifiable
Patient related
Surgical related
Operating room related
Non Modifiable
Preop Pt Prepration
No of people
Ventilation and laminar air flow
Age / severity of illness
Showering/ skin preparation
Surgical incision and drapes/ skin prepration/ hair shaving
Modifiable
Preop Surgeon Prepration DM
OBESITY
Surgical scrub / surgical attire
MALNUTRITION
SMOKING
Intra-operative
IMUNNOSUPRESSIVE DRUGS
Duration and techniques

16. Risk factors related to patient
Non modifiable
Modifiable

17. Risk factors related to patient
Non modifiable: age and severity of the illness
Modifiable

18. Risk factors related to patient
Non modifiable
Modifiable
Diabetes Mellitus :
“Those with HBA1C less than 7 have twofold lower infection rate than those with HBA1C more than 7”
Dronge et al 2006 long term diabetic control and post operative infectious complication Arch surgery 141:

19. Risk factors related to patient
Non modifiable
Modifiable
Obesity :

20. Risk factors related to patient
Non modifiable
Modifiable
Obesity :
Incidence is increasing / one third in USA / 8 million are morbidly obese
> 300,000 death per yr
100 million $ per yr
Finkelstien EA et al (2003) national medical spending attributable to overweight and obesity , how much and who’s paying ?

21. Risk factors related to patient
Obesity
Obese Pt has a higher rate of nosocomial SSIs
Those with BMI > 30 have almost double the risk for SSIs .
0.05 % FOR NORMAL Pts BMI < 27
2.8 % FOR OBESE Pts
4% FOR MORBIDLY OBESE Pts
Canturk Z et al Nosocomial infections and obesity in surgical Pts . Obes Res 2003

22. Risk factors related to patient
Obesity : Why at higher risk ?? 1. Hypoperfusion: ischaemia / necrosis / suboptimal neutrophil oxadative killing 2. Tissue mass : capillaries ratio is high 3. Larger wound surface / high dose of bacteria/ larger dead space

23. Risk factors related to patient
Obesity : Why at higher risk ?? 4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 % BMI 50-60: 28% BMI > 60 : 10%

24. Risk factors related to patient
Obesity : Why at higher risk ?? 4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 % BMI 50-60: 28% BMI > 60 : 10%

25. Risk factors related to patient
Obesity : Why at higher risk ?? 4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 % BMI 50-60: 28% BMI > 60 : 10%

26. Risk factors related to patient
Obesity :
What to do ? 5 strategies
Tight peri-operative glucose control
Increase peri-operative O2 tension
Larger dose of antibiotics – hit for the maximum
Go for MIS whenever feasible
Delay the operation if elective and wt reduction is possible

27. Risk factors related to patient Smoking
Pulmonary and cardiovascular complications, as well as wound infections are significantly more prevalent in smokers than in non-smokers (1,2)
1. Moller, A., Villebro, N., Pedersen, T. & Tonnensen, H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. The Lancet 2002; 359:
2. Ngaage, D., Martins, E., Orkell, E., Griffin, S., Cale, A., Cowen, M. & Guvenkik, L. The impact of the duration of mechanical ventilation on the respiratory outcome in smokers undergoing cardiac surgery. Cardiovasc Surg 2002; 10(4);

28. Smoking
Cigarette smoking interferes with primary wound healing, possibly secondary to constriction of peripheral blood vessels, leading to tissue hypovolemia and hypoxia.
Hoogendoorn Jm et al . Adverse effects of smoking on healing of bones and soft tissues. Unfallchirurg. 2002;105:76–81. [PubMed]
19. Belda Fj et al Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005;294:2035–2042. [PubMed]

29. Smoking
RCT in 2003 demonstrated abstinence from smoking for as little as 4 weeks significantly reduces incisional wound infections.
Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003;238:1–5.

30. Alcohol

32. Risk factors related to patient Malnutrition
Serum albumin < 3 is ae higher risk of SSIs
No enough evidence in the literiture

33. Risk factors related to patient Immunosuppressive drugs
Unfortunately, no data are available from randomized, double-blind, controlled clinical trials.

34. Risk factors related to surgery
Almost all are modifiable
Preoperative patient
preparations :
Showering

35. Risk factors related to surgery
Showering
1. RCT 1530 patients by wilhborg O 1987
“Showering with chlorohexidine siginficantly reduce the SSIs when compared to the group take no shower preoperatively “

36. Risk factors related to surgery
Showering 2. Meta analysis 2006 “No significant difference between the 2 groups” Webster J et al 2006 preoperative pathing or showering with skin antiseptics to prevent SSIs cochrane data base systemic review (2)

37. Risk factors related to surgery
Showering “Bathing may reduce the skin micro-organisms but not enough to prevent SSIs”

38. Risk factors related to surgery
Showering
“in the evening and morning before surgery is better than single shower preoperatively”
Edmiston CE et al (2008). Preoperative shower revisited. J Am coll surg 207:233

39. Risk factors related to surgery
Nasal colonization :
Reservoirs for staph aureus
Mupirocin nasal ointment preoperatively ??
It reduces the post operative infection in nasal carriers .#
It can lead to resistance ##
20 % carriers

40. In a 2008 Cochrane Database review, analysis of 8 randomized, controlled trials demonstrated that mupirocin significantly reduced the incidence of S aureus-associated SSIs.
van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;4 CD006216

41. Risk factors related to surgery
Hair :
Do you want to remove hair from the incision site ?
Shave Don’t Shave

42. Risk factors related to surgery
Hair :
Meta analysis Cochrane SR evidence class 1
“Shaving is associated with higher SSIs than no shaving Vs 5.8 %”
“Clipper are associated with lesss infection compared to razor”
Tanner J et al (2011) Preoperative hair removal to reduce surgical site infection . Cochrane Database systemic review (2)

43. Risk factors related to surgery
Skin preparations: Which ? Povidone iodine Chlorohexidine – alcohol Alcohol

44. Risk factors related to surgery
Skin preparations:
Which ?
Povidone iodine
Use of povidone Iodine as skin antiseptic is associated with lower rate of SSIs
Tschudin et al 2012 No risk of SSIs from residual bacteria after using povidone iodine in 1014 cases . Ann Surg 255:556-59

45. Risk factors related to surgery
Skin preparations:
Which ?
Povidone iodine
Use of povidone Iodine as skin antiseptic is associated with lower rate of SSIs
Tschudin et al 2012 No risk of SSIs from residual bacteria after using povidone iodine in 1014 cases . Ann Surg 255:556-59

46. Risk factors related to surgery
Skin preparations:
Which ?
Chlorohexidine and alcohol
Its superior to povidone iodine - in clean contaminated surgery
Darouiche et al Chlorohexidine- alcohol versus povidone iodine for surgical site antisepsis . New Eng J of Med

47. Risk factors related to surgery
Skin preparations:
Which ?
Chlorohexidine -alcohol Vs Iodine Vs alcohol
There is no evidence that any one is superior to another
Systemic review in 2004 , Edward P S et al preoperative skin antiseptic for prevention of SSIs in clean surgery . Cochrane dat base Sys Rev

48. Risk factors related to surgery surgical drapes
1. It should be imperable to liquid and viruses
American society for testing material 1998
2. Disposable versus re-usable drapes : There is no significant difference in SSIs
RCT in 946 pts . Am J Surg 1996

49. Risk factors related to surgery surgical drapes
Adhesive drapes:
“ it doesn’t allow bacterial penetration and prevent the skin bacteria from multiplying under the drapes”
French et al . The plastic surgical adhesive drape an evaluation of its efficacy as microbial barrier. Ann Surg

50. Risk factors related to surgery surgical drapes
Adhesive drapes:
The benefit of adhesive drapes is still questionable
Meta analysis . Cochrane Sys Rev 2007

51. Pre-operative Preparation of Surgical Team surgical hand scrub
Aims
Removal of transient micro-organisms.
Removal of resident micro-organisms.
3. Inhibit rebound growth of micro-organisms.

52. Pre-operative Preparation of Surgical Team surgical hand scrub
Aims
Removal of transient micro-organisms.
Soap and water
2. Removal of resident micro-organisms.
Antiseptics
Inhibit rebound growth of micro-organisms.

53. Pre-operative Preparation of Surgical Team surgical hand scrub
Options
Alcohol in concentration of 60-95% or alcohol 50-95% with chlorohexidine.
Povidone iodine .

54. Pre-operative Preparation of Surgical Team surgical hand scrub
Options
Alcohol in concentration of 60-95% or alcohol 50-95% with chlorohexidine.
Both significantly lower the bacterial count
Centers for disease control and prevention (2002) Guidelines for hand hygiene in health care settings (report )
2. Povidone iodine .
Significantly lower the bacterial count

55. Pre-operative Preparation of Surgical Team surgical hand scrub
Which one is superior ?
The effect of chlorohexidine is more profound and longer lasting
Jarrah AO et al. interactive cardiovascular and thoracic Surg J 2011

56. Pre-operative Preparation of Surgical Team surgical hand scrub
For how long ?
1. Scrubbing of 3-5 min should reduce bacterial count to acceptable level .
2. Longer duration of scrubbing is useless
Chen CF et al 2012 Effects of SSIs with waterless and handscrubing protocol on bacterial growth . Am j Infec Control

57. Pre-operative Preparation of Surgical Team surgical attire
What ?
Surgical scrubs
Masks
Caps
Gloves

58. Pre-operative Preparation of Surgical Team surgical attire
why ?
Minimize the introduction of micro organisms from surgical team to patients

59. Pre-operative Preparation of Surgical Team surgical attire
What ?
Masks No scientific evidence that it prevent SSIs
Caps
Gloves Perforated gloves double the risk for SSIs

60. Pre-operative Preparation of Surgical Team surgical attire
If perforated and no prophylactic antibiotics used the risk increased to 4 times
Perforation is quite often 9% in Orthopaedics surgery
Majority of the perforation is not noticed during surgery
Double gloves is recommended
Misteli et al 2009 surgical glove perforation and risk for SSIs . Arch Surg AM J Surg

61. Intra-operative aspects
Surgical duration
Prolonged duration of surgery ae increase risk of SSIs in arthroplasty
More contamination
More bleeding
Difficulties
Wash out of the antibiotics
Leong et al 2006 duration of operation as arisk factor for SSIs . J hosp infec

62. Intra-operative aspects
Surgical technique
Skin incision
Tissue handling
Wound closure
Drainage
Patients temp and tissue oxygenation

63. Intra-operative aspects
Surgical technique
Skin incision
Scalpel versus diathermy
There is no evidence that use of diathermy is ae increase risk of SSIs
But
The National Institute for health and clinical Excellence from UK does recommended avoidance of use of diathermy in making the skin incision( 2008) Report

64. Intra-operative aspects
Surgical technique
Tissue damage and handling
Logic
Difficult to quantify
Irrigation remove debris but there is no evidence that It decrease the risk of SSIs in clean surgery

65. Intra-operative aspects
Surgical technique
Wound closure
In 1000 patients the SSIs doesn’t differ among suture material ( absorbable non absorbable mono or multi filament )
Gabrielli et al 2001 sutures and SSIs Plast Rec Surg
In contaminated wounds stapler is superior to sutures
Hochberg et al 2009 suture choice .Surg Clin North Am

66. Intra-operative aspects
Surgical technique
Drainage :
Haematoma may lead to infection
Tube connecting to outside may lead to infection

67. Intra-operative aspects
Surgical technique
Drainage :
Haematoma may lead to infection
Tube connecting to uotside may lead to infection

68. Intra-operative aspects
Surgical technique
Drainage :
Close Darin is not associate with SSIs in hip fracture but this is also related to the duration
Chifton R et al (2007) closed suction surgical wound drainage Sys Rev of RCT. Knee J

69. Intra-operative aspects
Surgical technique
Drainage :
Close Darin is not associate with SSIs in hip fracture but this is also related to the duration

70. Intra-operative aspects

71. Patients Temp, PO2 and Tissue Perf
Normo-thermia and supplemental oxygen are associated with lower SSIs compared to hypo/hyper-thermia and no oxygen
Kurz A et al 1996 Per-operative Normothermia N Eng J Med

72. Operating Room Ventilation and laminar flow
Number of people and traffic

73. Operating Room Ventilation and laminar flow The mechanism
Use of laminar air flow in orthopaedics is under discussed
Anderson D et al 2012 controversies in control measures to prevent SSIs . www. Update.com
Laminar air flow reduce the SSIs
Frieberg et al 1999 ultraclean laminar air flow AORN J

74. Operating Room Laminar air flow does not reduce SSIs
Ventilation and laminar flow
Laminar air flow does not reduce SSIs
Brand et al (2008 ) operating room laminar air flow shows no protective effect on SSIs rate in Orth and abdominal surgery. Ann Surg

76. Operating Room Ventilation and laminar flow
Number of people and traffic

77. Number of people and traffic
Dispersion of micro-organisms can occur by movements or talk.
Number of persons and their movements are associated with higher number of bacterial contamination
Its important to keep the number of staff as law as possible and minimize the needless talk
Lynch R et al 2009 measurement of foot traffic in OR .Implication for infection control Am J Med Qual

78. Antibiotics
Why?
Which ?
When ?
For how long ?

79. Antibiotics
Why?
Which ?
When ?
For how long ?

80. Antibiotics
Why?
Which ?
When ?
For how long ?

81. Antibiotics
Why?
Which ?
When ?
For how long ?

82. Antibiotics First option In case of allergy Cefazoline (1-2g iv)
Which ?
First option
In case of allergy
Cefazoline (1-2g iv)
Clindamycin ( mg)
Cefuraxime (1.5 g)
Vancomycin (1 g iv )
The American Academy of Orthopaedic Surgeons (AAOS) recommendations

83. Antibiotics
When ?
Prophylactic antibiotics should be administered within one hour prior to skin incision
Additional intraoperative doses of antibiotic are advised if:
1. The duration of the procedure exceeds one to two times the antibiotic’s half-life.
2. There is significant blood loss during the procedure.
The American Academy of Orthopaedic Surgeons (AAOS) recommendations

84. Antibiotics When ? Antibiotic Frequency of Administration Cefazolin
Every 2-5 hours
Cefuroxime
Every 3-4 hours
Clindamycin
Every 3-6 hours
Vancomycin
Every 6-12 hours
The American Academy of Orthopaedic Surgeons (AAOS) recommendations

85. Antibiotics For how long ?
Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery.
Medical literature provides no evidence of benefit when they are continued past 24 hours
The American Academy of Orthopaedic Surgeons (AAOS) recommendations

87. Conclusion
Although some areas are still controversial in prevention of SSIs, strong guidelines are available supporting some measures as tools for control and prevention of postoperative infections.

88. عزيز انت يا وطني برغم قساوة المحن
Thank You