Study on surgical site infection Ajita Mehta, Shireen Samson, Shweta Ghag, Sudeep Shah, Camilla Rodrigues, F. D. Dastur   Infection Control Committee, P. D. Hinduja National Hospital & Medical Research Center, Mahim, Mumbai

INTRODUCTION contaminated cases Wound infection in clean & clean -  1 - 5 % worldwide  Cause of morbidity, cost, hospital stay  Index of quality care  Surgeons may be wary of wound infections Irrational antibiotic policy: Prolonged duration, Peculiar combinations, Overkill, Leads to drug resistance (major problem)

Infection Rate – year 2003 Month Overall Infected Pulmonary urinary tract Clean Rate Vascular infection infection (%) cases (%) (%) (%) /1000days Jan 2.3 4.9 1.5 1.0 Feb 2.6 4.7 2.5 2.8 Mar 2.2 6.8 2.0 2.6 Apr 2.3 4.6 2.0 0.5 May 1.7 3.7 19 3.4 1.0 Jun 2.2 6.4 32 1.3 2.7 Jul 2.0 2.7 15 2.0 0.8 Aug 2.0 4.2 26.7 3.1 1.2 Oct 2.2 4.8 24 2.0 2.0 Nov 1.8 4.1 19 2.3 2.0 Dec 1.9 5.9 23 2.1 1.3

Objectives Current rate of Surgical Site infections b) Assess role of rational antibiotic policy

Material & Methods Prospective & Consecutive cases Clean & clean contaminated surgery cases (no contamination of the operative field by uncontrolled spillage of visceral contents) No breach in asepsis e.g. hernia, arthroplasty CABG, Cholecystectomy

Specialities included: Exclusions :  Endoscopy  Laparoscopic surgery  Urological & Gynaec procedures Specialities included:  General & Oncosurgery,  Orthopedics,  Cardiac surgery

* Patient recruitment * Assessment  From theatre list DAILY  Day 1/2 visit – proforma entry, contact no.  Day 8th visit Rounds- staff nurse information  Information from resident doctor Microbiology review Day 30th phone call to patients

RESULTS Duration of study: 7 months (Nov’03 to May’ 04) Total number of cases studied: 1000 Speciality No.of cases Infected Percentage General Surgery 303 1 0.3% Ortho 469 4 0.8% CVTS 228 7 3.0% Total : 1000 12 1.2%

Surgeon Total Infected Antibiotic cases (Days) ORTH(469) A 196 3 (1.5%) Cefazolin (3 doses) B 56 Cefuroxime (3 doses) C 132 1(0.7%) Cefazolin (5 doses) D 36 - Cefazolin (3 doses) E 46 - Cefazolin (3doses)

Surgeon Total Infected Antibiotic Cases (Days) CVTS (228) A 49 2 (4.0%) Amox-clav/Amikacin/Tobramycin(5) B 69 2 (2.8%) Cefuroxime/Amikacin (3-5) C 72 1 (1.3%) Cefpirome (3) D 27 2 (7.4%) Cefpirome (5-7) E 10 - Cefuroxime (2-3) F 1 - Cefepime (2-3)

Surgeon Total Infected Antibiotic Cases (Days) General Surgery (303) Surgeon Total Infected Antibiotic Cases (Days) A 109 - Cefuroxime (3 dose) 5 days oral B 81 - Ceftriaxome (2 dose) C 13 - Cefuroxime (3 dose) D 32 (3.1%) Cefazolin (3-5 dose) E 13 - Cefuroxime (3 dose) F 20 - Cefazolin (3 dose)

Surgeon Total Infected Antibiotic Cases (Days) G 22 - Cefotaxime/ceftazidime H 8 - Cefazolin (3 dose) I 2 - Cefotaxime(3doses) J 1 - Augmentin (3 dose) K 1 - Cefuroxime (3 dose) L 1 - Amp/Amikacin (3 dose)

* Following hospital guidelines -- 5 /550 * Not following guidelines (Higher antibiotics) -- 7/450 * No significant difference in the above 2 but, - it increases the antibiotic resistance, - it increases cost to the patient due to higher antibiotic, - preserve higher antibiotics for serious cases

How is this study better than current available information? • Accurate inclusion of all cases (denominator) from OT list • Accurate assessment of wound infection (numerator) by survey & phone call

CONCLUSION Infection rate is the same irrespective of antibiotics used  The rate of infections is low in this study

RECOMMENDATIONS Rational hospital antibiotic policy should be followed by all: Single dose of cefuroxime / cefazolin in clean cases 3 doses in clean contaminated cases.

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