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Resistenze batteriche e terapia delle infezioni postoperatorie F Fausto de Lalla,Vicenza.

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Presentation on theme: "Resistenze batteriche e terapia delle infezioni postoperatorie F Fausto de Lalla,Vicenza."— Presentation transcript:

1 Resistenze batteriche e terapia delle infezioni postoperatorie F Fausto de Lalla,Vicenza

2 Postoperative infection 2006 F Despite the great advances in surgical technique and antibiotic prophylaxis, and ongoing research in this field, wound infection remains a considerable cause of morbidity and mortality among surgical patients

3 Antibiotic Resistance The knowledge of sensitivity patterns of the most likely etiological agents of postoperative infections is pivotal for the success of both The knowledge of sensitivity patterns of the most likely etiological agents of postoperative infections is pivotal for the success of both - perioperative prophylaxis, and - perioperative prophylaxis, and - empiric treatment of SSIs - empiric treatment of SSIs

4 TRADITIONAL CLASSIFICATION F Clean surgery F Clean-contaminated surgery F Contaminated surgery F Dirty surgery

5 Pathogens Causing Surgical Site Infections Are different, in respect to the surgical procedure and the site of infection. Are different, in respect to the surgical procedure and the site of infection. Infections following: Infections following: - CLEAN SURGICAL PROCEDURES - CLEAN SURGICAL PROCEDURES (with or without implantation of vascular grafts or prosthetic devices) (with or without implantation of vascular grafts or prosthetic devices) - SUPERFICIAL,INCISIONAL SSIs (i.e. simple infection of the surgical incision, involving only skin and subcutaneous tissue) : - SUPERFICIAL,INCISIONAL SSIs (i.e. simple infection of the surgical incision, involving only skin and subcutaneous tissue) : are most often caused by are most often caused by Staph. aureus or coag. negative staphylococci Staph. aureus or coag. negative staphylococci (patients skin flora, surgical team, exogenous environment) (patients skin flora, surgical team, exogenous environment)

6 Pathogens Causing Surgical Site Infections Deep and organ space infections following Deep and organ space infections following CLEAN- CONTAMINATED SURGERY : CLEAN- CONTAMINATED SURGERY : - are more often polymicrobial infections - are more often polymicrobial infections - are caused by the normal endogenous microflora of the structure which has been transected - are caused by the normal endogenous microflora of the structure which has been transected

7 Most Likely SSI Pathogens according to Operation Type Operation Likely pathogens Operation Likely pathogens F Appendectomy - gram-negativi bacilli + anaerobes colorectal (B.fragilis) colorectal (B.fragilis) F Gastroduodenal - gram-negativi bacilli oropharingeal anarobes; streptococci anarobes; streptococci F Biliary tract - gram-negativi bacilli±Enterococcus spp F OB/GYN. - gram-negativi bacilli + anaerobes (B. fragilis)± enterococcus spp; streptococc fragilis)± enterococcus spp; streptococc F Urologic - gram-negative bacilli F Head and neck - oropharingeal anarobes ± gram- negative bacilli; streptococci;

8 Eziologia delle infezioni postoperatorie - Resistenze -gram positivi -gram positivi - gram negativi - gram negativi - microrganismi in situazioni particolari particolari

9 Emerging Gram-positive Micro- organisms in Postoperative Infections F MR staphylococci F VR enterococci

10 Surgical Infection with Antibiotic-resistant Microorganisms Surgical patients with infections by Surgical patients with infections by MR staphylococci or VRE have: MR staphylococci or VRE have: a significantly higher mortality rate a significantly higher mortality rate longer hospitalization longer hospitalization longer treatment before the discharge longer treatment before the discharge than patients with infections by MS staphylococci or glycopeptide sensitive enterococci than patients with infections by MS staphylococci or glycopeptide sensitive enterococci Nichols RL, Am J Med 1998; Gleason et al, Arch Surg 1999; Mekontso DA, et al. CID 2001; Edmond MB, et al. CID 1996 Nichols RL, Am J Med 1998; Gleason et al, Arch Surg 1999; Mekontso DA, et al. CID 2001; Edmond MB, et al. CID 1996

11 Significance of Enterococci in Surgical Infections F Enterococcal bacteremia carries a serious prognosis F Patients with intra-abdominal infection and an initial isolation of enterococci have a significant higher treatment failure rate * F VRE infections, and particularly VRE bacteremia, are associated with high morbidity and mortality** * Burnett RJ, Dellinger EP, et al. Surgery 1995 ** Edmond MB, et al. CID 1996

12 Microbiologia delle peritoniti secondaria(comunitaria) e postoperatoria (ospedaliera) microrganismo comunitaria (%) ospedaliera(%) p microrganismo comunitaria (%) ospedaliera(%) p - Enterococchi 5 21 0,001 - E. coli 36 19 0,005 - Enterobacter spp. 3 12 0,05 - Bacteroides spp 10 7 NS - Klebsiella spp 7 7 NS - S.aureus 1 6 0,05 - S.coagulasi neg. 1 5 0,05 - Streptococcus spp 14 4 0,005 - Pseudomonas spp 2 6 NS - Roehrborn A. CID 2001;33:1513-9

13 VRE: isolamenti per materiale ANNO MATERIALE N° ISOLAMENTI 2001Feci24 Urine7 Ferita chir. 3 Sangue2 Liquor1 Drenaggio bil. 1 2002Feci85 Urine3 Piaga decubito Bile11

14 MR Staphylococci in Surgical Site Infections (S.Bortolo Hospital) Dept. S.aureus Coag. Neg. staph. MR/ tot S.aureus (%) MR/ tot. CNS (%) MR/ tot S.aureus (%) MR/ tot. CNS (%) - Neurosurg. 35/39 (89.7) 18/26 (69.2) - Cardiosurg. 11/18 (61.1) 11/15 (73.3) - Orthoped. 32/58 (55.2) 12/18 (66.7) TOTAL 78/115 (67.8) 41/59 (69.5) de Lalla F. J Hosp Infect 2002

15 MR Staphylococci in Surgical Site Infections in Italy Ancona and Pesaro Hospitals (676 patients) * Ancona and Pesaro Hospitals (676 patients) * - MR S. aureus/total S.aureus = 104/191 (54%) - MR S. aureus/total S.aureus = 104/191 (54%) - MR CNS/total CNS = 71/138 (51%) - MR CNS/total CNS = 71/138 (51%) S.Bortolo Hospital,Vicenza ** S.Bortolo Hospital,Vicenza ** - MR S. aureus/total S.aureus = 78/115 (67.8%) - MR S. aureus/total S.aureus = 78/115 (67.8%) - MR CNS/total CNS = 41/59 (69.5) - MR CNS/total CNS = 41/59 (69.5) 86 orthopedic centers (2,013 isolates from 86 orthopedic centers (2,013 isolates from SSIs following TH or TK arthroplasties) *** SSIs following TH or TK arthroplasties) *** - MR S. aureus/total S.aureus = 212/463 (46%) - MR S. aureus/total S.aureus = 212/463 (46%) - MR CNS/total CNS = 156/304 (51%) - MR CNS/total CNS = 156/304 (51%) * Giacometti A et al. J Clin Microbiol 2000; de Lalla et al,J Hosp Infect 2002;*** Mini E et al, J Chemother 2001

16 Implications of Resistance for Selection of Antibiotics in Surgery (1) TREATMENT OF ESTABLISHED TREATMENT OF ESTABLISHED INFECTIONS: INFECTIONS: 1) SSIs following clean surgery : - the high frequency of MR staphylococci as - the high frequency of MR staphylococci as causative agents should be kept in mind, causative agents should be kept in mind, AND AND - glycopetides should be administered in the empiric treatment of the most serious of these infections (e.g. prosthetic infections) - glycopetides should be administered in the empiric treatment of the most serious of these infections (e.g. prosthetic infections)

17 PERIOPERATIVE PROPHYLAXIS : PERIOPERATIVE PROPHYLAXIS : - The administration of glycopeptides as prophylactic agents in clean prosthetic major surgery is suggested by some Authors ( at least for those cardiovascular and orthopedic Depts. in which the prevalence of MR staphylococci is considerably high ) - prophylactic glycopeptides are extensively used in clinical practice

18 If the proportion of postoperative S. aureus i nfection caused by MRSA (in major vascular and orthopedic surgical prostheses) were to rise to 20%, we would probably advise using vancomycin or teicoplanin as prophylactic agents in both of these areas. If the proportion of postoperative S. aureus i nfection caused by MRSA (in major vascular and orthopedic surgical prostheses) were to rise to 20%, we would probably advise using vancomycin or teicoplanin as prophylactic agents in both of these areas. Adam P Fraise, J Antimicrob Chemother 1998; 42:287-289 Adam P Fraise, J Antimicrob Chemother 1998; 42:287-289

19 Antibiotic of choice in clean surgery prophylaxis Vancomycin may be the agent of choice in certain clinical circumstances,such as a cluster of MRSA mediastinitis or incision infection due to MR coag.neg staphylococci. A threshold has not been scientifically defined that can support the decision to use vancomycin. The decision should involve local considerations. CDC Guidelines CDC Guidelines

20 Clinical consequences and cost of limiting use of vancomycin for perioperative prophylaxis:example of coronary artery bypass surgery (CABS) * - -to compare clinical results and cost-effectiveness of no prophylaxis, cefazolin and vancomycin in CABS - -Decision-analytic models - -Vancomycin resulted in 7% fewer surgical infections and 1% lower all-cause mortality and saved $ 117 per procedure,compared with cefazolin. - -Cefazolin resulted in substantially fewer infections and deaths and lower costs than no prophylaxis - -Data on vancomycins impact on resistance are needed to quantify……..the future long term-consequences to society - * Zanetti,Goldie, Platt, Emerg Infect Dis 2001;820-7

21 Glycopeptides Are No More Effective than ß-Lactam Agents for Prevention of Surgical Site Infection after Cardiac Surgery: a Meta-analysis (Bolon et al,CID 2004) F 7 trials published between 1988-2002 on 5,761 subjects F Glycopeptide : vancomycin (4 studies) or teicoplanin (3 trials) F Comparators: cefazolin (3),cefuroxime (1),ceftriaxone (1),fluc+tobra (1) F Prevalence of MRSA: low (6 trials), high (1 study) F Blinded: No (5 trials), yes (2studies) RESULTS : neither agent proved to be superior for prevention of occurrence of SSI (primary outcome at 30 days !!) RESULTS : neither agent proved to be superior for prevention of occurrence of SSI (primary outcome at 30 days !!) In subanalyses: In subanalyses: - ß-lactams were superior to glycopeptides for prevention of chest SSIs, and - ß-lactams were superior to glycopeptides for prevention of chest SSIs, and - glycopetides were superior for prevention of SSIs caused by MR gram + bacteria. - glycopetides were superior for prevention of SSIs caused by MR gram + bacteria.

22 Implications of Resistance for Selection of Antibiotics in Surgery (2) F during treatment with 3rd gen cephalosporins enterococcal superinfection can occurs enterococcal superinfection can occurs F the use of 3rd gen ceph.s is an important risk factor for VRE colonization and infection in surgical patients * F in the hospitals with high rates of VRE, limitation of 3rd gen ceph.s use, with an increase of penicillins - LI combinations, is followed by a significant decrease in the VRE infection ** F Dahms RA et al, Arch Surg 1998; ** May AK, Shock 2000 F Dahms RA et al, Arch Surg 1998; ** May AK, Shock 2000

23 Implications of Resistance for Selection of Antibiotics in Surgery (3) - The particular role of Enterococcus spp. as an etiological agent of tertiary peritonitis (hospital acquired peritonitis) should be kept in mind (use of extended spectrum penicillins and penicillin- LIs combinations in the treatment of abdominal and pelvic surgical infections) - Postoperative infections in patients who have been hospitalized for a prolonged period prior to surgery, and/or have received prior antibiotic treatment are more likely to involve antibiotic resistant Gram negative bacilli(ESBL producing Klebsiella pneumoniae, E.coli, C.freundi, E.cloacae, S. marcescens …..).: the possible administration of carbapenems should be kept in mind


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