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Preventing Surgical Site Infections for Gastrointestinal Surgery

Learn about SSIs, risk factors, prevention methods, and the latest trends in gastrointestinal surgery wound care presented by Dr. CHIA Chi Fung from Queen Elizabeth Hospital at a Surgical Grand Round in January 2017.

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Preventing Surgical Site Infections for Gastrointestinal Surgery

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  1. Preventing Surgical Site Infections for Gastrointestinal Surgery Dr CHIA Chi Fung (Queen Elizabeth Hospital) Joint Hospital Surgical Grand Round Jan 2017

  2. Wound matters • M/70, Newly found Ca rectumHx of lap R hemicolectomy for Ca caecumAPR + Total colectomy + End-ileostomy done • Post-op discharge from laparotomy wound on D7Wound C/ST: Proteus, E Coli, PseudomonasProlonged hospital stay for wound care till D23

  3. Wound matters • F/83, Strangulated incisional herniaHx of LAR for Ca rectumSmall bowel resection and defect repair done • Gapping with purulent discharge on D6Wound swab: Klebsiella, EnterococcusCT: Inflammatory change at wound Subcutaneous collection at abdominal wallGiven TPN, daily dressings Meropenem, vancomycin

  4. Surgical Site Infections (SSI) • Procedure-related infection at or near incision • Within 30 days (or within 90 days if prosthetic material) • Translates to morbidity, hospital stay, cost and mortality • Microbiology: • Skin flora • Endogenous flora of involved viscus / mucosa

  5. Risk Factors • Age • Underlying Illness • Obesity • Smoking • Wound Classification • Clean: up to 3% • Clean-contaminated: up to 8% • Contaminated: up to 15% • Dirty: up to 40%

  6. How to prevent SSIs? • Pre-op preparation • Nutrition, S aureus decontamination, Bathing • Bowel Preparation • Peri-op care • Oxygenation, Perfusion • Sterile environment, Hand decontamination • Skin preparation • Antibiotics on induction and impregnated sutures • Wound protectors • Wound irrigation

  7. Bowel Preparation • Polyethylene glycol, Sodium phosphate • Good or bad? •  Intraluminal faecal mass   Bacterial load • ?? Liquefies faeces   Intra-op spillage

  8. Bowel Preparation • Yes or No? NICE 2008: ✗ IDSA 2014: ? to combine with oral antibiotics WHO 2016: ✓ with oral antibiotics • If only bowel prep, worse than none • Meta-analysis 13 RCTs: OR 1.31 (95%CI 1.00-1.72) • Benefits other than SSI not taken into account

  9. Oral Antibiotics with bowel prep • Better than bowel prep alone • Meta-analysis 11 RCTs: OR 0.56 (95%CI 0.37-0.83) • What type? What dose? • No conclusive evidence • High intraluminal concentrations, poor absorption • Against facultative Gram-ve & anaerobic bacteria • E.g. Neomycin + Metronidazole • ? Oral antibiotics alone ? Side effect profile

  10. Surgical Site Preparation • What to use? NICE 2013: Iodine or Chlorhexidine IDSA 2014: Alcohol-containing WHO 2016: Alcohol-based chlorhexidine • Limitation • Small effect size ~ 4 fewer in 100 • ? Cost-effective

  11. Wound Protector • Minimize wound-edge contamination • Yes or No? NICE 2013: ✓ abdominal IDSA 2014: ✓ GI & biliary WHO 2016: ✓ abdominal • Lower risk of SSI • ~ 10 fewer in 100 • Very low quality evidence • May not be cost-effective

  12. Wound Irrigation • Physical removal + Dilution + Local antibacterial effect • How? Syringe pressure? Pulsed irrigation? • What? Saline? Povidine-iodine? Antibiotics?

  13. Wound Irrigation • Yes or No? NICE 2008: ✗ IDSA 2014: ✓ povidine-iodine WHO 2016: ✓ povidine-iodine • Remains debate • Mainly based on old evidence or evidence from non-GI surgeries • ? Wound irritation

  14. What’s the trend? • Oral antibiotics goes with bowel prep • Alcohol-based chlorhexidine for skin prep • Consider use of wound protectors • Wound irrigation with povidone-iodine

  15. To know more • Thanks

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