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

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Presentation on theme: "Post Operative Infections: Risk Factors and Prevention Strategies Yasir Gashi MBBS,MD,FSSUM."— Presentation transcript:

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

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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 % 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 Patient relatedSurgical related Operating room related Non ModifiablePreop Pt Prepration No of people Ventilation and laminar air flow Age / severity of illnessShowering/ skin preparation Surgical incision and drapes/ skin prepration/ hair shaving ModifiablePreop Surgeon Prepration DM OBESITY Surgical scrub / surgical attire MALNUTRITION SMOKING Intra-operative IMUNNOSUPRESSIVE DRUGS Duration and techniques

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

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

15 Risk factors Patient relatedSurgical related Operating room related Non ModifiablePreop Pt Prepration No of people Ventilation and laminar air flow Age / severity of illnessShowering/ skin preparation Surgical incision and drapes/ skin prepration/ hair shaving ModifiablePreop 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 whos 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 % FOR NORMAL Pts BMI < % 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: 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]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]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

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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 Dont Shave

42 Risk factors related to surgery Hair : Meta analysis Cochrane SR 2011 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 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 doesnt 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 1.Removal of transient micro-organisms. 2.Removal of resident micro-organisms. 3. Inhibit rebound growth of micro-organisms.

52 Pre-operative Preparation of Surgical Team surgical hand scrub Aims 1.Removal of transient micro-organisms. Soap and water 2. Removal of resident micro-organisms. Antiseptics 3.Inhibit rebound growth of micro-organisms. Antiseptics

53 Pre-operative Preparation of Surgical Team surgical hand scrub Options 1.Alcohol in concentration of 60-95% or alcohol 50-95% with chlorohexidine. 2.Povidone iodine.

54 Pre-operative Preparation of Surgical Team surgical hand scrub Options 1.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 doesnt 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 1.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 1.Laminar air flow reduce the SSIs Frieberg et al 1999 ultraclean laminar air flow AORN J

74 Operating Room 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

75

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

77 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 Which ? First optionIn 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 antibiotics half-life. 2. There is significant blood loss during the procedure. The American Academy of Orthopaedic Surgeons (AAOS) recommendations

84 Antibiotics When ? AntibioticFrequency of Administration CefazolinEvery 2-5 hours CefuroximeEvery 3-4 hours ClindamycinEvery 3-6 hours VancomycinEvery 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

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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


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