Post Operative Infections: Risk Factors and Prevention Strategies Yasir Gashi MBBS,MD,FSSUM.

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Post Operative Infections:Risk Factors and Prevention Strategies

Yasir GashiMBBS,MD,FSSUM

Agenda

• Introduction • Pathophysiology • Patient related risk factors and its modification • Pre-operative aspects • Intar-operative aspects • Operating room • Use of antibiotics • Conclusions

Search principles

Filtering • Most recent • Direct conclusion for prevention • Guidelines • Evidence higher classes

• Level I (evidence from large, well-conducted, randomized, controlled clinical trials or a meta-analysis),

• Level II (evidence from small, well-conducted, randomized, controlled clinical trials),

• Level III (evidence from well-conducted cohort studies),• Level IV (evidence from well-conducted case-control studies),• Level V (evidence from uncontrolled studies that were not well

conducted),• Level VI (conflicting evidence that tends to favor the

recommendation), or• Level VII (expert opinion or data extrapolated from evidence for

general principles and other procedures).

• Level I (evidence from large, well-conducted, randomized, controlled clinical trials or a meta-analysis),

• Level II (evidence from small, well-conducted, randomized, controlled clinical trials),

• Level III (evidence from well-conducted cohort studies),• Level IV (evidence from well-conducted case-control studies),• Level V (evidence from uncontrolled studies that were not well

conducted),• Level VI (conflicting evidence that tends to favor the

recommendation), or• Level VII (expert opinion or data extrapolated from evidence for

general principles and other procedures).

Definition

• POIs or SSIsThe United States Centers for Disease Control and Prevention

“Infections occurring at or near the site of surgery within 30 days after operation or within 1 year if implant is in place”

Mangram AJ et al (1999) .Quidelines for prevention of SSIs. Epidemio;. 20:250-278 Mangram AJ et al (1999) .Quidelines for prevention of SSIs. Epidemio;. 20:250-278

Epidemiology

• Occurs in 1.5- 2 % of all Orthopedics procedures • Associated with 9% mortality

Astagneau P et al (2001). Mortality and Morbidity associated with SSIs: J Hosp infect 48:267-274

Pathophysiology • Most of the infections acquired peri-operatively• Source: Patients Theater staff • 40% is Staph A • MRSA is increasing • Poly microbial pathogens found in 1 third • 5% of them include MRSA

Weigelt et al (2010). SSIs causative pathogens and associated outcomes Am J of Infect control, 38: 112-120

Risk factors Patient related Surgical related Operating

room related

Non Modifiable Preop Pt Prepration No of people Ventilation and laminar air flow

Age / severity of illness Showering/ skin preparationSurgical incision and drapes/ skin prepration/ hair shaving

Modifiable Preop Surgeon Prepration

DMOBESITY

Surgical scrub / surgical attire

MALNUTRITION SMOKING

Intra-operative IMUNNOSUPRESSIVE DRUGS

Duration and techniques

room related

DMOBESITY

room related

DMOBESITY

room related

DMOBESITY

Risk factors related to patient

• Non modifiable • Modifiable

• Non modifiable: age and severity of the illness

• Modifiable

• Non modifiable • Modifiable Diabetes Mellitus : “Those with HBA1C less than 7 have twofold

lower infection rate than those with HBA1C more than 7”

Dronge et al 2006 long term diabetic control and post operative infectious complication Arch surgery 141: 375-380

• Non modifiable • Modifiable Obesity :

Incidence is increasing / one third in USA / 8 million are morbidly obese

> 300,000 death per yr100 million $ per yr

Finkelstien EA et al (2003) national medical spending attributable to overweight and obesity , how much and who’s paying ?

Obesity• Obese Pt has a higher rate of nosocomial SSIs• Those with BMI > 30 have almost double the risk

for SSIs . 0.05 % FOR NORMAL Pts BMI < 27 2.8 % FOR OBESE Pts4% FOR MORBIDLY OBESE Pts

Canturk Z et al Nosocomial infections and obesity in surgical Pts . Obes Res 2003

Obesity :Why at higher risk ??1. Hypoperfusion: ischaemia / necrosis /

suboptimal neutrophil oxadative killing 2. Tissue mass : capillaries ratio is high 3. Larger wound surface / high dose of bacteria/

larger dead space

Risk factors related to patientObesity :Why at higher risk ??4. Longer operation 5. High blood loss 6. Low tissue conc. of prophylactic antibiotics

The achieved therapeutic tissue conc. In obese Pts BMI 40-50: 48 %BMI 50-60: 28%BMI > 60 : 10%

Obesity :What to do ? 5 strategies Tight peri-operative glucose controlIncrease peri-operative O2 tension Larger dose of antibiotics – hit for the

maximum Go for MIS whenever feasibleDelay the operation if elective and wt

reduction is possible

Risk factors related to patientSmoking

• Pulmonary and cardiovascular complications, as well as wound infections are significantly more prevalent in smokers than in non-smokers (1,2)

1. Moller, A., Villebro, N., Pedersen, T. & Tonnensen, H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. The Lancet 2002; 359:114-117. 2. Ngaage, D., Martins, E., Orkell, E., Griffin, S., Cale, A., Cowen, M. & Guvenkik, L. The impact of the duration of mechanical ventilation on the respiratory outcome in smokers undergoing cardiac surgery. Cardiovasc Surg 2002; 10(4);345-350.

Smoking

• Cigarette smoking interferes with primary wound healing, possibly secondary to constriction of peripheral blood vessels, leading to tissue hypovolemia and hypoxia.

• Hoogendoorn Jm et al . Adverse effects of smoking on healing of bones and soft tissues. Unfallchirurg. 2002;105:76–81. [PubMed]

• 19. Belda Fj et al Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005;294:2035–2042. [PubMed]

Smoking

• RCT in 2003 demonstrated abstinence from smoking for as little as 4 weeks significantly reduces incisional wound infections.

Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003;238:1–5.

Alcohol

Risk factors related to patientMalnutrition

• Serum albumin < 3 is ae higher risk of SSIs • No enough evidence in the literiture

Risk factors related to patientImmunosuppressive drugs

• Unfortunately, no data are available from randomized, double-blind, controlled clinical trials.

Risk factors related to surgery

• Almost all are modifiable • Preoperative patient preparations :• Showering

• Showering1. RCT 1530 patients by wilhborg O 1987

“Showering with chlorohexidine siginficantly reduce the SSIs when compared to the group take no shower preoperatively “

Showering2. Meta analysis 2006“No significant difference between the 2 groups”

Webster J et al 2006 preoperative pathing or showering with skin antiseptics to prevent SSIs cochrane data base systemic review (2)

Showering

“Bathing may reduce the skin micro-organisms but not enough to prevent SSIs”

• Showering“in the evening and morning before surgery is better than single shower preoperatively”

Edmiston CE et al (2008). Preoperative shower revisited. J Am coll surg 207:233

• Nasal colonization :Reservoirs for staph aureus Mupirocin nasal ointment preoperatively ??It reduces the post operative infection in nasal

carriers .#

It can lead to resistance ##

20 % carriers

• In a 2008 Cochrane Database review, analysis of 8 randomized, controlled trials demonstrated that mupirocin significantly reduced the incidence of S aureus-associated SSIs.

van Rijen M, Bonten M, Wenzel R, Kluytmans J. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev. 2008;4 CD006216

• Hair :Do you want to remove hair from the incision site ?

Shave Don’t Shave

Risk factors related to surgery • Hair :Meta analysis Cochrane SR 2011 evidence class 1

“Shaving is associated with higher SSIs than no shaving - 9.5 Vs 5.8 %”

“Clipper are associated with lesss infection compared to razor”

Tanner J et al (2011) Preoperative hair removal to reduce surgical site infection . Cochrane Database systemic review (2)

Skin preparations:Which ? Povidone iodine Chlorohexidine – alcohol Alcohol

Skin preparations:Which ? Povidone iodine Use of povidone Iodine as skin antiseptic is

associated with lower rate of SSIs

Tschudin et al 2012 No risk of SSIs from residual bacteria after using povidone iodine in 1014 cases . Ann Surg 255:556-59

Skin preparations:Which ? Povidone iodine Use of povidone Iodine as skin antiseptic is

associated with lower rate of SSIs

Tschudin et al 2012 No risk of SSIs from residual bacteria after using povidone iodine in 1014 cases . Ann Surg 255:556-59

Skin preparations:Which ? Chlorohexidine and alcohol

Its superior to povidone iodine - in clean contaminated surgery

Darouiche et al . 2010 Chlorohexidine- alcohol versus povidone iodine for surgical site antisepsis . New Eng J of Med

Risk factors related to surgery Skin preparations:Which ? Chlorohexidine -alcohol Vs Iodine Vs alcohol

There is no evidence that any one is superior to another

Systemic review in 2004 , Edward P S et al preoperative skin antiseptic for prevention of SSIs in clean surgery . Cochrane dat base Sys Rev

Risk factors related to surgery surgical drapes

1. It should be imperable to liquid and viruses American society for testing material 1998

2. Disposable versus re-usable drapes : There is no

significant difference in SSIs RCT in 946 pts . Am J Surg 1996

Adhesive drapes: “ it doesn’t allow bacterial penetration and

prevent the skin bacteria from multiplying under the drapes”

French et al . The plastic surgical adhesive drape an evaluation of its efficacy as microbial barrier. Ann Surg

Adhesive drapes:

The benefit of adhesive drapes is still questionable

Meta analysis . Cochrane Sys Rev 2007

Pre-operative Preparation of Surgical Team

surgical hand scrub • Aims 1.Removal of transient micro-organisms.2.Removal of resident micro-organisms.3. Inhibit rebound growth of micro-organisms.

surgical hand scrub • Aims 1.Removal of transient micro-organisms.Soap and water 2. Removal of resident micro-organisms.Antiseptics 3.Inhibit rebound growth of micro-organisms.Antiseptics

surgical hand scrub • Options 1.Alcohol in concentration of 60-95% or alcohol

50-95% with chlorohexidine. 2.Povidone iodine .

surgical hand scrub • Options

1.Alcohol in concentration of 60-95% or alcohol 50-95% with chlorohexidine.

Both significantly lower the bacterial countCenters for disease control and prevention (2002) Guidelines for hand

hygiene in health care settings (report )

2. Povidone iodine .Significantly lower the bacterial count

surgical hand scrub • Which one is superior ?

The effect of chlorohexidine is more profound and longer lasting

Jarrah AO et al. interactive cardiovascular and thoracic Surg J 2011

surgical hand scrub • For how long ?

1. Scrubbing of 3-5 min should reduce bacterial count to acceptable level .

2. Longer duration of scrubbing is useless

Chen CF et al 2012 Effects of SSIs with waterless and handscrubing protocol on bacterial growth . Am j Infec Control

surgical attire • What ?

Surgical scrubs Masks Caps Gloves

surgical attire • why ?

Minimize the introduction of micro organisms from surgical team to patients

surgical attire • What ? Masks No scientific evidence that it prevent SSIs

Gloves Perforated gloves double the risk for SSIs

Pre-operative Preparation of Surgical Teamsurgical attire

If perforated and no prophylactic antibiotics used the risk increased to 4 times

Perforation is quite often 9% in Orthopaedics surgery

Majority of the perforation is not noticed during surgery

Double gloves is recommended

Misteli et al 2009 surgical glove perforation and risk for SSIs . Arch Surg AM J Surg

Intra-operative aspects

• Surgical duration

Prolonged duration of surgery ae increase risk of SSIs in arthroplasty

More contamination More bleeding Difficulties Wash out of the antibiotics Leong et al 2006 duration of operation as arisk factor for SSIs . J

hosp infec

Intra-operative aspects • Surgical technique Skin incisionTissue handling Wound closure DrainagePatients temp and tissue oxygenation

Intra-operative aspects • Surgical technique Skin incisionScalpel versus diathermy There is no evidence that use of diathermy

is ae increase risk of SSIsBut The National Institute for health and clinical

Excellence from UK does recommended avoidance of use of diathermy in making the skin incision( 2008) Report

Intra-operative aspects • Surgical technique Tissue damage and handling

Logic Difficult to quantify Irrigation remove debris but there is no

evidence that It decrease the risk of SSIs in clean surgery

Intra-operative aspects • Surgical technique Wound closure In 1000 patients the SSIs doesn’t differ among

suture material ( absorbable non absorbable mono or multi filament )

Gabrielli et al 2001 sutures and SSIs Plast Rec Surg

In contaminated wounds stapler is superior to sutures

Hochberg et al 2009 suture choice .Surg Clin North Am

Intra-operative aspects • Surgical technique Drainage :Haematoma may lead to infection

Tube connecting to outside may lead to infection

Intra-operative aspects • Surgical technique Drainage :Haematoma may lead to infection

Tube connecting to uotside may lead to infection

Intra-operative aspects • Surgical technique Drainage :Close Darin is not associate with SSIs in hip

fracture but this is also related to the duration

Chifton R et al (2007) closed suction surgical wound drainage Sys Rev of RCT. Knee J

Intra-operative aspects • Surgical technique Drainage :Close Darin is not associate with SSIs in hip

fracture but this is also related to the duration

Intra-operative aspects

Patients Temp, PO2 and Tissue Perf

Normo-thermia and supplemental oxygen are associated with lower SSIs compared to hypo/hyper-thermia and no oxygen

Kurz A et al 1996 Per-operative Normothermia N Eng J Med

Operating Room

• Ventilation and laminar flow • Number of people and traffic

Operating Room

• Ventilation and laminar flow The mechanism 1.Use of laminar air flow in orthopaedics is under

discussed Anderson D et al 2012 controversies in control

measures to prevent SSIs . www. Update.com

1.Laminar air flow reduce the SSIs Frieberg et al 1999 ultraclean laminar air flow AORN J

Operating Room

• Ventilation and laminar flow

Laminar air flow does not reduce SSIs

Brand et al (2008 ) operating room laminar air flow shows no protective effect on SSIs rate in Orth and abdominal surgery. Ann Surg

Operating Room

• Ventilation and laminar flow • Number of people and traffic

Number of people and traffic

• Dispersion of micro-organisms can occur by movements or talk.

• Number of persons and their movements are associated with higher number of bacterial contamination

• Its important to keep the number of staff as law as possible and minimize the needless talk

Lynch R et al 2009 measurement of foot traffic in OR .Implication for infection control Am J Med Qual

Antibiotics

• Why?• Which ?• When ?• For how long ?

Antibiotics

• Which ?

First option In case of allergy

Cefazoline (1-2g iv)

Clindamycin (600-900 mg)

Cefuraxime (1.5 g)

Vancomycin (1 g iv )The American Academy of Orthopaedic Surgeons (AAOS) recommendations

Antibiotics • When ?

Prophylactic antibiotics should be administered within one hour prior to skin incision

Additional intraoperative doses of antibiotic are advised if:1. The duration of the procedure exceeds one to two times the antibiotic’s half-life. 2. There is significant blood loss during the procedure.

The American Academy of Orthopaedic Surgeons (AAOS) recommendations

Antibiotics • When ?

Antibiotic Frequency of Administration

Cefazolin Every 2-5 hours

Cefuroxime Every 3-4 hours

Clindamycin Every 3-6 hours

Vancomycin Every 6-12 hours

Antibiotics

• For how long ?

Prophylactic antibiotics should be discontinued within 24 hours of the end of surgery.

Medical literature provides no evidence of benefit when they are continued past 24 hours

Conclusion

Although some areas are still controversial in prevention of SSIs, strong guidelines are available supporting some measures as tools for control and prevention of postoperative infections.

برغم وطني يا انت عزيزالمحن قساوة

Thank You

Post Operative Infections: Risk Factors and Prevention Strategies Yasir Gashi MBBS,MD,FSSUM.

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