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SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington.

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Presentation on theme: "SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington."— Presentation transcript:

1 SSI Evidence – a Surgeon’s Perspective E. Patchen Dellinger, MD University of Washington

2 Caring for the Critically Ill Patient ABC= airway, breathing, circulation

3 Preventing Surgical Site Infections (SSI) ABC= airway, breathing, circulation = temperature, oxygen, fluids ABCD - Add drugs (antibiotics) Add- glucose control proper hair removal surgical technique teamwork other ??

4 Prophylactic Antibiotics Questions Which cases benefit? Which drug should you use? When should you start? How much should you give? How long should antibiotics be continued?

5 Relative Benefit from Antibiotic Surgical Prophylaxis OperationProphylaxis (%)Placebo (%)NNT* Colon Other (mixed) GI Vascular Cardiac Hysterectomy Craniotomy Spinal operation Total joint repl Brst & hernia ops

6 Antibiotic Prophylaxis Demonstrated Benefit: All Procedures?? Review of prophylaxis meta-analyses suggests that there is a consistent relative risk of wound infection less than one associated with antibiotic prophylaxis. This is independent of the type of operation or the baseline (placebo) rate of infection. Bowater. Ann Surg 2009;249: 551–556

7 Prophylactic Antibiotics Questions Which cases benefit? Which drug should you use? When should you start? How much should you give? How long should antibiotics be continued?

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9 Surgical Antibiotic Prophylaxis My Choices Bacteroides expected Cefazolin 2 g + Metronidazole 1g, IV in OR Repeat cefazolin q 3 h during procedure Bacteroides not expected Cefazolin 2 g, IV in OR Repeat q 3 h during procedure

10 Alternatives Cefazolin Other first generation cephalosporin Cefuroxime, cefamandole, cefonicid Oxacillin, etc Cefazolin plus metronidazole Ertapenem Aminoglycoside or quinolone plus clindamycin or metronidazole

11 Prophylactic Antibiotics Questions Which cases benefit? Which drug should you use? When should you start? How much should you give? How long should antibiotics be continued?

12 Burke. In: Hunt, ed. Wound Healing and Wound Infection, New York: Appleton, 1980:242. Decisive Period For Development Of Wound Infection Lesion Age (hrs) Lesion Size, (mm)

13 Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic Age of Lesion at Antibiotic Injection (Hours) Lesion Size, mm (24 Hours) Penicillin, 40,000 U Staph + Penicillin Control Chloramphenicol, 0.1 mg/Kg Erythromycin, 0.1 mg/Kg Tetracycline, 0.1 mg/Kg Control Control Control Staph + Erythromycin Staph + Tetracycline Staph + Chloramphenicol Burke JF. Surgery. 1961;50:161.

14 Classen. NEJM. 1992;328:281. Perioperative Prophylactic Antibiotics Timing of Administration Infections (%) Hours From Incision 14/369 5/699 5/1009 2/180 1/81 1/41 1/47 15/441

15 Prophylactic Antibiotics Timing - Cefazolin Serum Levels (mg/L) On CallAnesth Incision hour hours2539 DiPiro. Arch Surg 1985;120:829

16 Prophylactic Antibiotics Timing – Cefazolin Incision Wound closure No Drug Dectectable % % On CallAnesth Muscle Levels DiPiro JT et al. Arch Surg. 1985;120:

17 Prophylactic Antibiotics Administration in the O.R. Drugs Given I.V. Push over 5-10 Min Cefazolin Drug to incision17 (7-29)min Muscle levels76 (9-245)mg/kg Cefoxitin Drug to incision22 (14-27)min Muscle levels24 (13-45)mg/kg DiPiro. Arch Surg 1985;120:829 DiPiro. Personal Communication

18 Timing of Prophylactic Antibiotic Administration – Cardiac, Arthroplasty, Hysterectomy Steinberg. TRAPE. Ann Surg 2009; 250:10

19 Repeat Antibiotic Prophylaxis Doses in Gastrointestinal Procedures Surgical Site Infections Percent Scher. Am Surg 1997;63:59

20 Prophylactic Antibiotics Questions Which cases benefit? Which drug should you use? When should you start? How much should you give? How long should antibiotics be continued?

21 Cardiac Surgery Prophylaxis Effect of Serum Levels None Present 3/11 2/175 Serum Level at Wound Closure Infection Goldmann. J Thorac Cardiovasc Surg. 1977;73: P =.002

22 Cardiac Surgery Prophylaxis Effect of Atrial Appendage Levels Yes No 6 13 Infected Cephalothin (mg/l) Platt. Ann Intern Med. 1984;101: P =.02

23 Prophylactic Antibiotics Size of Patient and Size of Dose Morbidly obese patients having bariatric operation with a high infection rate Cefazolin levels lower 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

24 Gentamicin Levels and SSI Risk for Colectomy Closing Gent level (mg/L)D.M. (%)Stoma (%)Age SSI No SSI p Gent level < 0.5 at close had 80% SSI rate (p=0.003). Zelenitsky. Antimicrob Ag Chemother 2002;46:

25 Dose of Antibiotic for Prophylaxis Always give at least a full therapeutic dose of antibiotic. Consider the upper range of doses for large patients and/or long operations. Repeat doses for long operations.

26 New ASHP / IDSA / SHEA / SIS Antibiotic Prophylaxis Guidelines Cefazolin 120 kg3 g Vancomycin15 mg/kg Gentamicin5 mg/kg dosing wgt = ideal wgt + 40% of excess wgt Bratzler. Surgical Infections2013;14:73-156

27 Prophylactic Antibiotics Questions Which cases benefit? Which drug should you use? When should you start? How much should you give? How long should antibiotics be continued?

28 Antibiotic Prophylaxis Duration Most studies have confirmed efficacy of  12 hrs. Many studies have shown efficacy of a single dose. Whenever compared, the shorter course has been as effective as the longer course.

29 Duration of Prophylaxis Colorectal AuthorDrugDurationInfection Törnqvist 1981doxycycline1 dose10% 3 days19% Juul 1987amp/metronid1 dose6% 3 days6%

30 Duration of Prophylaxis Joint Replacement AuthorDrugDurationInfection Pollard 1979cephaloridine12 hours1.4% (hips)flucloxacillin14 days1.3% Heydemann 1986cefazolin1 dose0 (hips and knees)24 hours1% 48 hours0 7 days 1.5%

31 Duration of Prophylaxis: Infection and Antibiotic Resistance Risk in Cardiac Surgery 48 hrOdds ShortLongRatio Number SSI131 (8.7%)100(8.8%)1.0 ( ) Acq Ab Res6%1.6 ( ) Harbarth. Circulation 2000;101:2916

32 Single vs Multiple Dose Surgical Prophylaxis: Systematic Review McDonald. Aust NZ J Surg 1998;68:388 All studies, fixed All studies, random Multi > 24h Multi < 24h Favors single dose Favors multiple dose

33 Relative Benefit from Antibiotic Surgical Prophylaxis OperationProphylaxis (%)Placebo (%)NNT* Colon Other (mixed) GI Vascular Cardiac Hysterectomy Craniotomy Spinal operation Total joint repl Brst & hernia ops

34 When I started my residency in 1970 all patients having colectomy got a bowel prep as inpatients before their operation, and we had just seen the first widely believed paper that demonstrated a beneficial effect of parenteral prophylactic antibiotics for patients having GI operations. Oral antibiotics were not used.

35 Effect of Mechanical Bowel Prep on Colon Flora (log 10 ) ColiformsBacteroidesClostridia No Prep 4.5 – – – 3.6 Prep 3.0 – – – 2.5 Nichols. Dis Col & Rect 1971; 14: 123-7

36 Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs) Any SSI Placebo (63)27 (43%) Neomycin (68)28 (41%) Neo + Tetracycline (65)3 (5%) p<0.01 Washington. Ann Surg 1974;180:567-71

37 Antibiotic and Mechanical Bowel Prep for Colectomy (18 hrs) Any SSI Placebo (56)26 (43%) Neo + Erythro (56)5 (9%) p= Clarke. Ann Surg 1977; 186:251-9

38 Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs) Any SSI Placebo (59)25 (42%) Neo + Metronidazole (51)9 (18%) p<0.01 Matheson. Br J Surg 1978; 65:

39 Antibiotic and Mechanical Bowel Prep for Colectomy (48 hrs) Any SSI Placebo (39)16 (41%) Kanamycin + Erythro (38)3 (8%) p<0.001 Wapnick. Surgery 1979; 85:317-21

40 Antibiotic and Mechanical Bowel Prep for Colectomy ( hrs) Bowel Prep +PlaceboOral Ab %5% %9% %18% %8%

41 Sometime in the 1980’s most American and Canadian surgeons adopted oral antibiotic regimens while most European surgeons abandoned oral antibiotics.

42 Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel Prep for Colectomy Lewis. Can J Surg 2002; 45: Parenteral only Parenteral + Oral p < 0.002

43 Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel Prep for Colectomy – Meta-Analysis Lewis. Can J Surg 2002; 45: Parenteral only Parenteral + Oral

44 MBP – yes / no? Antibiotics – oral / I.V. / both? Guenaga. Cochrane Database Syst Rev,2009(1):p.C Nelson. Cochrane Database Syst Rev, 2009,(1): p.CD SSI Rate NG

45 Bowel Preparation Prior to Elective Colectomy in Michigan (n=1648) Overall SSI Rate in Michigan is 8.0% Englesbe. Ann Surg 2010;252: 514–520 All patients Get I.V. antibiotics

46 Surgical Site Infection Rates following Elective Colectomy The Michigan Surgical Quality Collaborative Propensity Matched Analysis (n=740) Englesbe. Ann Surg 2010;252: 514–520 n=195 All patients Get I.V. antibiotics

47 Percent of patients * P < 0.05 Oral Antibiotics with a Bowel Preparation A Propensity Matched Analysis (n=740) Englesbe. Ann Surg 2010;252: 514–520 All patients Get I.V. antibiotics

48 “Evidence Based” Bundle to Prevent SSI in Colorectal Surgery Process MeasureStudyControl Mechanical Bowel PrepNoYes Oral AntibioticsNoYes PreOp WarmingYesNo IntraOp WarmingYes FiO280%30% Wound ProtectorYesNo SCIP Parenteral AntibioticsYes Any SSI*45%24% Anthony. Arch Surg 2010; 146: 263-9

49 “Evidence Based” Bundle to Prevent SSI in Colorectal Surgery 1.Appropriate SCIP IV prophylactic antibiotics 2.Postop normothermia (T>98.6/37) 3.Oral antibiotics and bowel prep 4.Minimally invasive surgery 5.Short operative duration (<100 min) Waits (MSQC). Surgery 2014;epub

50 “Evidence Based” Bundle to Prevent SSI in Colorectal Surgery Waits (MSQC). Surgery 2014;epub

51 Oral Antibiotics Without Bowel Prep? VASQIP, 9940 patients, 112 hospitals IncidenceSSI Bowel prep, no oral Ab39%20% No prep at all, no oral Ab20%18% Bowel prep + oral Ab34%9% No prep + oral Ab (n=723)7%8% Cannon. Dis Col Rectum 2012; 55:

52 Oral Antibiotics for Colorectal Operations Cannon. Dis Col Rectum 2012; 55:

53 Differential Parenteral Efficacy and Addition of Oral Antibiotics AgentOdds RatioRange Cefaz/Metron1.0Reference Amp/Sulbactam Cefotetan Cefoxitin Add Oral Ab* Deierhoi. JACS 2013; 217:763-9 *P <

54 Most Recent Cochrane Review ComparisonOdds RatioRange Ab Proph vs none – 0.41 Oral + I.V. vs I.V – 0.74 Oral + I.V. vs Oral – 0.76 Greater than 2300 pts in each comparison GRADE evidence quality HIGH Nelson RL, Cochrane Rev 2014; #5: CD001181

55 Conclusions - ? If you are not going to give any oral antibiotics then the MBP is not necessary and there is a suggestion of harm along with more GI symptoms. However, if you are going to take my colon out I will suffer through the bowel prep and take oral antibiotics in advance of the operation for the lowest SSI rate!

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62 Oxygen and SSI

63 Hunt. Am J Med. 1981;70:712. Influence of Oxygen on the Development of Wound Infection Hours After Innoculation Diameter Infectious Necrosis (mm)

64 Wound Oxygen Tension & SSI Observed-Expected SSI Rate Maximum wound pO 2 Hopf. Arch Surg 1997;132:

65 Near InfraRed O2 Saturation in the Surgical Incision at 12 hrs Ives. Br J Surg 2007;94:87-91 p < 0.04 Abdominal Operations

66 Oxygen and SSI Oxygen tension in the wound is important. How to translate that into clinical practice that lowers SSI is less obvious.

67 Temperature and SSI (Oxygen)

68 Temperature and Tissue O 2 tension Subcut temp increase 4° C Subcut O 2 tension increase 40 torr Linear correlation between temperature and O 2 tension Threefold increase in local perfusion Rabkin. Arch Surg 1987;122:221

69 Temperature and SSI Following Colectomy Normo (104)Hypo (96)P SSI Kurz. NEJM 1996;334:1209

70 Local Warming and SSI after Clean Operations LocalSystemicControl SSI*5 (4%)8 (6%)19 (14%) Post-op antibiotics*9 (7%)9 (7%)22 (16%) Melling. Lancet 2001;358:876 * p < 0.01

71 Perioperative Warming, Intraoperative Temperature and Complications ---- Open Abdominal Bowel Resections Wong. Br J Surgery 2007; 94: Periop N=47 Standard N=56P value Blood loss200 ml400 ml0.011 Any complication32%54%0.027 SSI13%33%0.09

72 Redistribution Hypothermia Core 37°C Vasoconstricted Periphery 31-35°C Anesthesia Periphery 33-35°C Core 36°C Vasodilated

73 Keeping Your Patient Warm in the O.R. Prewarming and active warming in the O.R. is much more important than the O.R. room temperature. If you raise O.R. room temperature from 20 o to 27 o, you still have an 10 o gradient between the patient’s temperature and the room temperature and everyone in the room is miserable.

74 Prewarming at UWMC & First Postoperative Temperature Post Anesthesia Care Unit (PACU) 2006 > 36 o 7836/8132 (96.4%) > 36 o & < 36.5 o 1047/2647 (40%) > 36.5 o 1491/2647 (56%)

75 Oxygen (FiO 2 ) and SSI

76 Spinal Surgery, FiO 2, & SSI Maragakis. Anesthesiol 2009; 110:556-62

77 Meta-Analysis: FiO 2 & SSI Qadan. O 2 & SSI.Review. Arch Surg 2009; 144: Mayzler Pryor Greif Belda Myles

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79 FiO 2, SSI, Atelectasis, & Respiratory Failure PROXI Trial Outcome 80% FiO 2 N=685 30% FiO 2 N=701 Adjusted Odds RatioP SSI131 (19.1%)141 (20.1%) – Atelectasis54 (7.9%)50 (7.1%) – Resp Failure38 (5.5%)31 (4.4%) – Meyhoff. JAMA 2009; ;302:

80 FiO 2, SSI, Atelectasis, & Respiratory Failure PROXI Trial Outcome 80% FiO 2 N=685 30% FiO 2 N=701 Adjusted Odds RatioP SSI131 (19.1%)141 (20.1%) – Atelectasis54 (7.9%)50 (7.1%) – Resp Failure38 (5.5%)31 (4.4%) – Meyhoff. JAMA 2009; ;302:

81 Simply Increasing FiO 2 is Not Enough Oxygen has to get to the incision to make a difference  FiO 2  Regional anesth  Temperature  Fluid replacement  Cardiac output  Vasopressors  Vasoconstriction  etc.

82 Glucose and SSI

83 Diabetes, Glucose Control, and SSIs After Median Sternotomy Latham. ICHE 2001; 22:

84 Hyperglycemia and Risk of SSI after Cardiac Operations Hyperglycemia - doubled risk of SSI Hyperglycemic: 48% of diabetics 12% of nondiabetics 30% of all patients 47% of hyperglycemic episodes were in nondiabetics Latham. Inf Contr Hosp Epidemiol. 2001;22:607 Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604

85 Deep Sternal SSI and Glucose Zerr. Ann Thorac Surg 1997;63:356

86 Furnary et al. Ann Thorac Surg 1999:67:352 Glucose Control and Deep Sternal Wound Infections

87 Early (48h) Postoperative Glucose Levels and SSI after Vascular Surgery Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5 <103 mg% mg% mg% >151 mg%

88 Postop Glucose (within 48h) and SSI – General Surgery Ata. Arch Surg 2010: 145: Glucose

89 Risk Adjusted Odds Ratios for Infection and Operative Intervention Colectomy and Bariatric Operations Kwon. Ann Surg. 2013; 257: 8-14

90 Composite Infection in Hyperglycemic Patients With and Without Use of Insulin Kwon. Ann Surg. 2013; 257: 8-14

91 Glucose in NonDiabetics having Colectomy at Cleveland Clinic Highest GlucN (%) < 125 mg%816 (33%) mg%1289 (53%) 200 mg%342 (14%) All patients2447 (100%) Kiran, Ann Surg 2013;258:599–605 67%

92 Glucose in NonDiabetics having Colectomy at Cleveland Clinic Kiran, Ann Surg 2013;258:599–605 Per Cent incidence

93 Preoperative Glucose as a Screening Tool for Patients Without Diabetes Random glucose within 30 days of operation Average 8 days before operation 16% within one day and 29% within 3 days 6683 patients <70384 pts pts pts pts >18060 pts Wang. J Surg Res. 2014; 186: %

94 Preoperative Glucose as a Screening Tool for Patients Without Diabetes Wang. J Surg Res. 2014; 186: 371-8

95 Glucose Levels & SSI The exact “best” level of glucose control in the perioperative period is not known. High glucose levels unequivocally increase the risk of SSI and other perioperative infections. Tight glucose control in the perioperative period is tricky. Hypoglycemia increases the risk of morbidity and mortality.

96 Some Things New Teamwork, Communication, and Discipline

97 BMRI = Behavioral Marker Risk Index Briefing, Information sharing, Inquiry, Vigilance and Awareness

98 Prior to Skin Incision: Briefing Nursing/Tech reviews:  Equipment issues (instruments ready, trained on, requested implants available, gas tanks full)  Sharps management plan  Other patient concerns Anesthesia reviews:  Airway or other concerns  Special meds (beta blockers, etc.)  Allergies  Conditions affecting recovery All Team Members (Attending Surgeon Leads):  Each person introduces self by name and role  Surgeon, Anesthesia team and Nurse confirm patient (at least 2 identifiers), site, procedure  Personnel exchanges: timing, plan for announcing changes  Description of procedure and anticipated difficulties  Expected duration of procedure  Expected blood loss & blood availability  Need for instruments/supplies/IV access beyond those normally used for the procedure  Questions/issues from any team member and invitation to speak up at any time in the procedure

99 Prior to Skin Incision: Process Control If case expected to be ≥ 1 hour, add: Surgeon reviews:  Glucose checked for diabetics  Insulin protocol initiated if needed  DVT/PE chemoprophylaxis and/or mechanical prophylaxis plan in place  If patient on beta blocker, post- op plan formulated  Re-dosing plan for antibiotics  Specialty-specific checklist Surgeon reviews (as applicable):  Essential imaging displayed; right and left confirmed  Antibiotic prophylaxis given in last 60 minutes  Active warming in place  Special instruments and/or implants

100 After Skin Closure Complete: No Retained Objects, Debriefing, Care Transition Surgeon and Anesthesia:  Key concerns for patient recovery  What is the plan for pain mgmt?  What is the plan for prevention of PONV?  Does patient need special monitoring (time in RR, ICU, tele?)  If patient has elevated blood glucose, plan for insulin drip formulated  If patient on beta blocker, post- op continuation plan formulated All Team Members (Attending Surgeon Leads):  Confirm final needles/sponges/ instruments count correct  Nursing/Tech show Surgeon and Anesthesia all sponges and laps in holders (“Show Me Ten”)  Confirm name of procedure  If specimen, confirm label and instructions (e.g., orientation of specimen, 12 lymph nodes for colon CA)  Equipment issues to be addressed?  Response planned (who/when)  What could have been better?  Improvement planned (who/when)

101 Checklist and Complications BeforeAfter n=3773n=3955 SSI6.2%3.4% Unplan Return-O.R.2.4%1.8% Any Complic11.0%7.0% Death1.5%0.8% Haynes. NEJM 2009; 360: 491-9

102 Checklist and Complications BeforeAfter n=3760n=3820 SSI3.8%2.7% Complic/100 pts Pts with Complic15.4%10.6% Death1.5%0.8% de Vries. NEJM 2010; 363:

103 Checklist Completion and Complications Checklist CompletionComplic Above median7.1% Below median11.7% de Vries. NEJM 2010; 363:

104 Checklist Completion and Mortality Adjusted Odds Ratio Mortality All patients0.85 ( ) van Klei. Ann Surg 2012; 255: 44-9

105 Checklist Completion and Mortality Adjusted Odds Ratio Mortality All patients0.85 ( ) Completed0.44 ( ) Partial1.09 ( ) Not done1.16 ( van Klei. Ann Surg 2012; 255: 44-9

106 JAMA 2010; 304:

107 Neily. JAMA 2010; 304: Team Training and Mortality

108 Not Discussed Due to Time but probably or possibly(?) important Screening and decolonizing S. aureus Skin prep Sterile technique “Wound protectors?” Impregnated sutures? Prevention of “nonsurgical” infections Management of the incision after operation?

109 Preventing SSI Have good teamwork at all times Prewarm the patient Enough of the right antibiotic at the right time and repeat if necessary Don’t shave Thorough skin prep Warm the patient in the O.R. High FiO 2 Control glucose Good teamwork

110 Slide Set and References available by request Send request to


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