SSI Bundle

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  • 1.The presentation is solely meant forAcademic purpose

2. Nothing to disclose 3. BEFORE AFTER 4. The very first requirement in ahospital/Physician/Surgeon is that itshould do the sick no harm 5. The Definition & epidemiology of Surgical siteinfections (SSIs) Pathogenesis of SSI Control of SSI New initiative 6. Mr. M underwentSSI?PPI 6 months back, 1. Yesnow presented with 2, Noa fever, swelling & 3. Ask CT surgeonspain at the surgical 4. Ill like to call thesite. professor 5. I am googling 7. Must have one of following within30 days post-op (1 year ifimplant): Purulent drainage Positive culture ( proper sample) Pain, inflammation, opening of wound neededTypes of SSI Incisional infections Superficial (skin, subcutaneous tissue) Deep (fascia, muscle) Organ space infections 8. The overall SSI was 20.09%In this retrospective study of Gen surg & GI surg the incidence was3.67% 9. Clinical Culturebased Outpatient follow-up Feedback Monitoring reduce SSI rates by 35-50% 10. Endogenous sources: Majority of cases Wound is a moist, devitalized, warmarea Directly proportional to inoculum,fewer organisms needed if foreignbody present Exogenous sources Hematogenous and lymphatic sources 11. Dorairajan Sureshkumar et al AIFIC 2013 Abstract 12. 1. Diab. mellitus/perioeperativehyperglycemia 2. Concurrent tobacco use 3. Obesity 4. Malnutrition 5. Low preoperative albumin 6. Remote infection at the time ofsurgery 7. Prolonged preoperative stay 8. Prior site irradiation 9. Concurrent steroid use 10. Colonization with S.aureus 13. 1. Shaving of site, the night prior to procedure 2. Use of razor for hair removal 3. Improper preoperative skin preparation 4. Improper antimicrobial prophylaxis (wrongdrug, dose & timing) 5. Failure to timely redose for prolongedprocedure 6. Inadequate OR ventilation 7. Increased OR traffic 8. Poor surgical technique (tissue trauma,poor hemeostasis) 9. Break in sterile technique, asepsis 10. Perioperative hypothermia & hypoxia 14. Preoperative Intraoperative &factors Postoperative factors Resolve Minimize dead space,malnutrition &devitalized tissue &obesity hematoma Consider supplemental O2 Discontinue Maintain Perioperativecigarette smoking normothermia Maximize diabetes Maintain hydration &control nutrition Minimize postoperativehyperglycemia (21 days Control infections at other sites (3 foldincrease) Stop smoking (31% to 5%) 30 days pre-op Same day hair removal just before surgery(3% vs 20%) Clipping or depilation only, avoid razors One study showed craniotomy without hairremoval had same infection rate 17. Rationale is that most patients get Staph aureusfrom their own nose Nasal swab screening and decolonization withmupirocin for 3 days reduced all site Staphinfections from 7.7% to 4% (NEJM 2002) If done ensure that the mupirocin course isfinished pre-op PCR screening followed by mupirocin nasalointment and chlorhexidine soap versus controls Rate of SSI 3.4% vs 7.2% (RR 0.42) Protection from deep space SSI even better (RR0.21) Bottom line: applicable for cardiac surgery,implant, immunosuppressed) N Engl J Med 2010;362:9 18. RCT compared chlorhexidine-alcohol vspovidone-iodine for clean contaminatedsurgery 9.1 vs 16.5% SSI rates respectively Unclear if povidone-iodine was allowed toevaporate N Engl J Med 2010;362:18 19. Numerous studies show an increased risk fornosocomial infections with blood transfusion(app. double) Avoid blood unless: Patient actively bleeding Hb3 hrsduration 23. Antibiotic resistance is increasing alarminglyand we are running out of antibiotics to treatpatients MRSA ESBL pan resistant Pseudomonas pan resistant Acinetobacter Every clean case that gets an antibiotic iscolonized by resistant organisms- thisspreads to other patients Study shows that broad spectrum antibioticuse predisposes to resistant infection later No preventive role after skin is closed 24. 2000 B.C Here, eat this root.(pre-antibiotic era) 1000 A.D That root is heathen,say this prayer 1940 A.D That potion is snakeoil, swallow this pill. 1985 A.D That pill is ineffective,take this new antibiotic 2012 A.D That antibiotic isplacebo.Here, eat this root orpray. (post antibiotic era) 25. Vancomycin or teicoplanin Can use single dose if outbreak of MRSA forhardware insertion eg prosthetic valve Aminoglycosides Cefoperazone-sulbactam Other third generation cephaloporins Piperacillin-tazobactam Meropenem or imipenem Linezolid 26. Background ResultsSummary In western countries despite extensiveThe results showed a significantly high level knowledge and guidelines on surgicalDuring the study period 1161 elective surgeries were performed. One hundred of adherence with guidelines concerning the antibiotic prophylaxis, implementation is percent compliance to all the three criteria was observed in 49.30% of cases. choice and timing of antibiotic. The infection often suboptimal. Only a minority ofCorrect antibiotic selection was done in 74.80% of surgeries, timing of the first control teams feed back lead to stopping of hospitals in a developing country like Indiadose was appropriate in 99.70% cases. The most frequent encountered antibiotic in 34.13% of times. Nearly 50 % of have an antibiotic policy and surgicaldeviation from the policy was unnecessary prolongation of prophylaxis inthe time all the three parameters were antibiotic prophylaxis guidelines. There is a 41.60% of cases. However in 34.13% of cases where prophylaxis was followed by the surgeons. need to study adherence to antibiotic prolonged, the surgeon accepted the infection control teams feed back to stop prophylaxis guidelines in India.antibiotic prophylaxis.ObjectiveConclusion To study the adherence to local hospitalOur study indicates the importance of surgical guidelines for antimicrobial prophylaxis inAdherence to Surgical Antibiotics Prophylaxis guidelines antibiotic guidelines and feed back by the surgery, and explore ways of improvinginfection control team in reducing unnecessary adherence.antibiotic usage in surgical practice. 100%80%ReferencesMaterials & Methods 60% 99.70%Adherence to local hospital guidelines for40% 74.80%surgical antimicrobialprophylaxis: a A prospective evaluation of the use of 58.40%multicentre audit in Dutch hospitals. JAC antimicrobial prophylaxis in patients 49.30% 49.30%20% (2003) 51 1389-1396 undergoing surgery at our hospital was carried out from July 2009 to March 2010. Three criteria were evaluated: 1. 0% Antibiotic choice 2. Timing of the First dose within 1 hour Followed guidelines for Antibiotics stopped within Followed guidelines forFollowed guidelines for antibiotic in relation to surgery and antibiotic selection 24 hours antibiotic selection andantibiotic selection and 3.Duration of administration. Thestopped within 24 hours stopped within 24 hours and first dose within 1 response to feedback provided by the % of cases hour infectioncontrolteamregarding duration was also evaluated,Sureshkumar et al ICAAC Boston 2010 27. Give antibiotics within one hour beforeincision and stop same day Avoid shaving, esp previous day Warm and oxygenate patient Tight intra-op and post-op glucose control Control your OR trafficHand hygiene before and after every patient contact 28. New watchwordtransition frombenchmarkingtozero tolerance 29. 1. Restrict hospital admission to 6-12 hours beforesurgery2. Do not shave/razor the surgical site 3. Use antibiotic as per surgical prophylaxisguidelines 4. Administer antibiotics 0-60 minutes beforeincision 5. Redose if surgery is prolonged more than threehours and stop when surgery is over.If interested enroll your name with us 30. ry 31. 2013 Operation O