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SSI Evidence – a Surgeon’s Perspective

SSI Evidence – a Surgeon’s Perspective. E. Patchen Dellinger, MD University of Washington. Caring for the Critically Ill Patient. ABC = airway, breathing, circulation. Preventing Surgical Site Infections (SSI). ABC = airway, breathing, circulation = temperature, oxygen, fluids

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SSI Evidence – a Surgeon’s Perspective

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

  2. Caring for theCritically 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 AntibioticsQuestions • 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 4-12 24-48 3-5 • Other (mixed) GI 4-6 15-29 4-9 • Vascular 1- 4 7-17 10-17 • Cardiac 3-9 44-49 2-3 • Hysterectomy 1-16 18-38 3-6 • Craniotomy 0.5-3 4-12 9-29 • Spinal operation 2.2 5.9 27 • Total joint repl 0.5-1 2-9 12-100 • Brst & hernia ops 3.5 5.2 58

  6. Antibiotic ProphylaxisDemonstrated 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 AntibioticsQuestions • Which cases benefit? • Which drug should you use? • When should you start? • How much should you give? • How long should antibiotics be continued?

  8. Surgical Antibiotic ProphylaxisMy 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

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

  10. Prophylactic AntibioticsQuestions • Which cases benefit? • Which drug should you use? • When should you start? • How much should you give? • How long should antibiotics be continued?

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

  12. 10 10 10 10 5 5 5 5 0 0 0 0 -2 -2 0 0 2 2 4 4 6 6 Efficacy Of Prophylaxis Is Independent Of The Specific Antibiotic Penicillin, 40,000 U Erythromycin, 0.1 mg/Kg Control Control Staph + Penicillin Staph + Erythromycin Chloramphenicol, 0.1 mg/Kg Tetracycline, 0.1 mg/Kg Lesion Size, mm (24 Hours) Control Control Staph + Chloramphenicol Staph + Tetracycline Age of Lesion at Antibiotic Injection (Hours) Burke JF. Surgery. 1961;50:161.

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

  14. Prophylactic AntibioticsTiming - Cefazolin • Serum Levels (mg/L) • On CallAnesth • Incision 87 148 • 1 hour 37 57 • 2 hours 25 39 • DiPiro. Arch Surg 1985;120:829

  15. Prophylactic AntibioticsTiming – Cefazolin Muscle Levels • Incision • Wound closure • No Drug Dectectable On Call Anesth 9 7 38% 17 11 14% DiPiro JT et al. Arch Surg. 1985;120:829-832.

  16. Prophylactic AntibioticsAdministration in the O.R.Drugs Given I.V. Push over 5-10 Min • CefazolinDrug to incision 17 (7-29) minMuscle levels 76 (9-245) mg/kg • CefoxitinDrug to incision 22 (14-27) minMuscle levels 24 (13-45) mg/kg DiPiro. Arch Surg 1985;120:829DiPiro. Personal Communication

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

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

  19. Prophylactic AntibioticsQuestions • Which cases benefit? • Which drug should you use? • When should you start? • How much should you give? • How long should antibiotics be continued?

  20. Cardiac Surgery ProphylaxisEffect of Serum Levels Serum Levelat Wound Closure • None • Present Infection 3/11 2/175 P = .002 Goldmann. J ThoracCardiovasc Surg. 1977;73:470-479.

  21. Cardiac Surgery ProphylaxisEffect of Atrial Appendage Levels Cephalothin (mg/l) • Yes • No Infected 6 13 P = .02 Platt. Ann Intern Med. 1984;101:770-774.

  22. Prophylactic AntibioticsSize 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

  23. Gentamicin Levels andSSI Risk for Colectomy • Closing Gent • level (mg/L)D.M. (%)Stoma (%)Age • SSI1.3+1.0 29 50 59+14 • No SSI2.1+0.9 2 24 55+19 • p0.02 0.02 0.04 0.05 • Gent level < 0.5 at close had 80% SSI rate (p=0.003). Zelenitsky. Antimicrob Ag Chemother 2002;46:3026-30

  24. 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.

  25. New ASHP / IDSA / SHEA / SIS Antibiotic Prophylaxis Guidelines • Cefazolin < 80 kg 2 g> 120 kg 3 g • Vancomycin 15 mg/kg • Gentamicin 5 mg/kgdosing wgt = ideal wgt + 40% of excess wgt Bratzler. Surgical Infections2013;14:73-156

  26. Prophylactic AntibioticsQuestions • Which cases benefit? • Which drug should you use? • When should you start? • How much should you give? • How long should antibiotics be continued?

  27. Antibiotic ProphylaxisDuration • 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.

  28. Duration of ProphylaxisColorectal • Author Drug Duration Infection • Törnqvist 1981 doxycycline 1 dose 10% 3 days 19% • Juul 1987 amp/metronid 1 dose 6% 3 days 6%

  29. Duration of ProphylaxisJoint Replacement • Author Drug Duration Infection • Pollard 1979 cephaloridine 12 hours 1.4%(hips) flucloxacillin 14 days 1.3% • Heydemann 1986 cefazolin 1 dose 0(hips and knees) 24 hours 1% 48 hours 0 7 days 1.5%

  30. Duration of Prophylaxis:Infection and Antibiotic Resistance Risk in Cardiac Surgery • < 48 hr >48 hr OddsShort Long Ratio • Number 1502 1139 • SSI 131 (8.7%) 100(8.8%) 1.0 (0.8-1.3) • Acq Ab Res 6% 1.6 (1.1-2.6) Harbarth. Circulation 2000;101:2916

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

  32. Relative Benefit from Antibiotic Surgical Prophylaxis • OperationProphylaxis (%)Placebo (%)NNT* • Colon 4-12 24-48 3-5 • Other (mixed) GI 4-6 15-29 4-9 • Vascular 1-4 7-17 10-17 • Cardiac 3-9 44-49 2-3 • Hysterectomy 1-16 18-38 3-6 • Craniotomy 0.5-3 4-12 9-29 • Spinal operation 2.2 5.9 27 • Total joint repl 0.5-1 2-9 12-100 • Brst & hernia ops 3.5 5.2 58

  33. 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.

  34. Effect of Mechanical Bowel Prep on Colon Flora (log 10) • ColiformsBacteroidesClostridia • No Prep 4.5 – 7.5 7.9 – 9.5 1.8 – 3.6 • Prep 3.0 – 4.3 7.8 – 9.0 0.7 – 2.5 Nichols. Dis Col & Rect 1971; 14: 123-7

  35. 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

  36. Antibiotic and Mechanical Bowel Prep for Colectomy (18 hrs) • Any SSI • Placebo (56) 26 (43%) • Neo + Erythro (56) 5 (9%) • p=0.0001 Clarke. Ann Surg 1977; 186:251-9

  37. 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; 65:597-600

  38. 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

  39. Antibiotic and Mechanical Bowel Prep for Colectomy (18 - 48 hrs) • Bowel Prep +PlaceboOral Ab • 1974 43% 5% • 1977 43% 9% • 1978 42% 18% • 1979 41% 8%

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

  41. Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel Prep for Colectomy Parenteral only Parenteral + Oral p < 0.002 Lewis. Can J Surg 2002; 45: 173-80

  42. Parenteral Alone vs Parenteral and Oral Antibiotics – All with Bowel Prep for Colectomy – Meta-Analysis Parenteral only Parenteral + Oral Lewis. Can J Surg 2002; 45: 173-80

  43. MBP – yes / no?Antibiotics – oral / I.V. / both? SSI Rate N G Guenaga. Cochrane Database Syst Rev,2009(1):p.C001544 Nelson. Cochrane Database Syst Rev, 2009,(1): p.CD001181

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

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

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

  47. “Evidence Based” Bundle to Prevent SSI in Colorectal Surgery Anthony. Arch Surg 2010; 146: 263-9

  48. 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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