คุณดาวกิา โหแน่ (คุณใหม่กว่า) อายุ 35 ปี เป็นเบาหวาน, HbA1C 7.4 gm/L, ไม่สูบบุหร่ี, น า้หนักตัว 65 กก., BMI 31 kg/m2,

ได้รับการผ่าตัด mammoplasty, ก่อนผ่าตัดแพทย์ส่ัง shave หน้าอกถึงรักแร้, skin paint ด้วย betadine และให้ cefazolin 1 gm

IV drip on call to OR, การผ่าตัดเสร็จส้ินภายใน 20 นาที หลงัผ่าตัดให้ cefezolin 1 gm q 8 h x 3 วนั

เปลีย่นเป็น dicloxacillin (500) 1 x 4 pc x 5 วนัและให้กลบับ้านได้

คุณดาวกิา โหแน่ (คุณใหม่กว่า) อายุ 35 ปี เป็นเบาหวาน HbA1C 7.4 gm/L, ไม่สูบบุหร่ี, น า้หนักตวั 65 กก., BMI 31 kg/m2, ได้รับการผ่าตดั mammoplasty กลบับ้านไป 14 วนั วนันีม้าพบแพทย์เน่ืองจากแผลผ่าตดับวมแดงมหีนอง

เพาะเช้ือขึน้ Methicillin-sensitive S. aureus

ก. ปัจจัยเส่ียงใดบ้างที่น่าจะเกีย่วข้องกบัการติดเช้ือข้างต้น

ข. Intervention ใดบ้างที่อาจลดความเส่ียงการติดเช้ือข้างต้น

Focus

• Principles & Pathogenesis

• Surveillance & Definitions

• International guidelines

• Conclusions

Principles of SSI

• Patients undergoing surgery at risk of

SSI during pre-op, peri-op and post-

operative periods

• Acquisition of SSI organisms may be

via colonization/contamination/extra-

surgical site ID

Outcomes associated with SSI • 2–11 times higher risk of death

among patients with SSI

• 70% of deaths in patients with SSI

are directly attributable to SSI

• 60% of SSIs estimated preventable

by evidence-based guidelines

Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71

Principles of SSI & prevention

• SSI risk more effectively reduced during

pre & peri-op > post-op periods, esp in

elective surgery

• Target to reduce SSI < 0.5% in clean, 1% in

clean contaminated, 2% in highly

contaminated wounds*

*Alexander JW, et al. Ann Surg 2011;253:1082–1093

Modifiable Non modifiable

Smoking Age

Hyperglycemia Co-morbidities

Obesity (BMI, PBF) History of radiation

Skin colonization History of SSTI

Extra SS infections

SSI risk factors & stage, Pre-operative

Alexander JW, et al. Ann Surg 2011;253:1082–93

SS = surgical site

Peri-operative

Hyperglycemia Blood transfusion

SS contamination peri-op Skin injury s/p razor

OR air contamination Hypothermia

Glove perforation Hypotension

Drain & SS colonization Oxygen desaturation

SSI risk factors & stage of operation


SS = surgical site

Post-operative (immediate & late)

Hyperglycemia

Hypovolemia

Hypothermia

SS contamination post-op

Extra surgical site infections


SSI risk factors & stage of operation

Types (mean) Songkla Thailand USA

Extra cost

(bahts)

43,658 5,192

(ATB

only)

120,000

Extra LOS

(days)

23.5 12.7 7.5

SSI : extra Cost & LOS

Kasatpibal N, J Med Assoc Thai 2005; 88(8): 1083-91

Focus




• Conclusions

Type of wound Thailand USA

Clean 1.5 2.1

Clean-contam 3.4 3.3

Contam 6.7 6.4

Dirty 7.8 7.1

SSI rates (%) by wound class

Danchaivijitr S, J Med Assoc Thai 2005 Knight R, et al. Am J Surgery 182 (2001) 682–686

Category NNIS 0 NNIS 1 NNIS 2

CABG 0/1.0 2.2/1.7 3.7/2.5

craniotomy 0.9/0.7 1.7/1.9 2.4/3.8

hernia repair 0.8/0.2 2.1/0.2 4.5/0.0

USA vs Thailand 2004 , SSI rate (%) by

surgical procedures & risk index category

Am J Infect Control 2004;32:470-85 J Med Assoc Thai 2005; 88 (Suppl 10): S75-82

NNIS risk index category

Knight R, et al. Am J Surgery 182 (2001) 682–686

A 60 yr M patient developed MSSA septic

arthritis Rt. Knee. Total knee replacement

Rt. knee was performed 11 months earlier.

Is this a PJI?

a. Yes, MSSA with prosthesis b. Yes, this is < 1 yr post-op c. No, this is > 90 days post-op

CDC, NHSN classification for surgical site infection


Focus


• Clinical aspects & Antimicrobial Rx



• Conclusions

Guideline summary: Pre-op

Type SHEA 2014 NICE 2008 SHEA 2008

Glucose control I-II NA AII

Smoking I NA AII

Obesity I NA AII

Immunosuppressive III NA CII

Periop infection Rx II Recommended AII


NICE clinical guideline 74 guidance.nice.org.uk/cg74

Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.

Guideline summary: Pre-op

Category Recommendations

Glucose

control

For DM , reduce hemoglobin A1c < 7% before

surgery (I)

Obesity Increase dosing of prophylactic antimicrobial agent

for morbidly obese patients (I)

Smoking Encourage smoking cessation within 30 days (I)

Pre-op ID

outside

surgical

site

Identify and treat infections (eg, urinary tract

infection) remote to the surgical site prior to elective

surgery, do not routinely treat colonization or

contamination (II)



Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61

Guideline summary: Peri-op

Category SHEA 2014 NICE 2008 SHEA 2008

Clipping for hair removal II Recommended AI

Skin preparation I Recommended AII

Normothermia I Recommended Unresolved

Supplemental oxygen I Recommended Unresolved




Guideline summary: Peri-op


Hair removal If necessary, remove hair outside OR using clippers or a depilatory agent (II)

Skin prep Use alcohol-containing skin paint if not contraindicated.

Unclear which combo with alcohol: alcohol + CHG >

betadine, alcohol + iodine > betadine (I)

Normothermia Maintain normothermia (temp > 35.5°C ) (I)

Oxygen

supplement

Optimize tissue oxygenation with supplemental oxygen

& adequate fluid during and immediately following

surgery esp patient on ventilator (I)




Category Povidone-iodine

(n=250)

CHG/Alc

(n=250)

95% CI

class II-III,

no (%)

167 (65.2) 164 (65.6) 0.91

operative

time, hr

1.43 (0.4-3) 1.45 (0.45-3) 0.93

SSI, no (%) 8 (3.2) 5 (2) 1.6 (1.4-1.8)

Peri-operative antiseptic & SSI in abd surgery

Paocharoen V, J Med Assoc Thai 2009;92:898-902

Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis

Darouiche RO, et al. N Engl J Med 2010;362:18-26.

Guideline summary: intraoperative

Type SHEA 2014 NICE 2008 CDC 1999

Surgeon skill &

technique

III NA AIII

Double glovings III Recommended AIII

Aseptic technique III Recommended AIII



Mangram AJ, et al. Infect Control Hosp Epidemiol1999;20(4):250–78.

Guideline summary: OR characters


Ventilation III NA CI

Traffic III NA BII

Environment cleaning III NA BIII

Sterilization of devices II NA BI




OR ventilation & air filtration

Standards compliance

Design Condition

Clean room class : ISO 7 (10,000)

Room pressure : > +7.5 Pa

Fresh air intake : > 4 ACH

Air circulation : 20-25 ACH

Temperature : 20 – 24 C

Relative humidity : 30-60 %RH

Principles of surgical prophylaxis

• Aimed to reduce burden of specific

organism at risk of inoculating surgical site

• Reduced effectiveness associated with

emerging antimicrobial resistance

• Surgical prophylaxis needs to be “adequate”

as well as antimicrobial therapy

47

Considerations in Antibiotic Dosing PK/PD Markers

48

Vancomycin Pharmacokinetics in Cardiac

Surgery With or Without Cardiopulmonary Bypass

Vancomycin concentration/ time curves, Values expressed as median, Cotogni P. Ann Pharmacother 2013;47:455-63

Preventing SSI : Antimicrobial & dosing

Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283

Guideline summary: Surgical prophylaxis


Timing < 30-60 min II Recommended AI

Antimicrobial of choices II Recommended AI

Duration of prophylaxis I NA AI




Surgical prophylaxis: Timing


Timing Administration within 1 hour before incision.

< 1 hour is effective, some studies show superior

efficacy for between 0 and 30 min prior to incision

compared with between 30 and 60 min

Two hours for the vancomycin and

fluoroquinolones

Antimicrobials infused prior to inflation of

tourniquets in procedures using “bloodless”

techniques: data insufficient


Surgical prophylaxis: choice & duration


Choice &

duration of

prophylaxis

Select appropriate agents on the basis of the

surgical procedure, the most common pathogens

causing SSIs for a specific procedure, and

published recommendations

Discontinue agent within 24 hours after surgery

No evidence of efficacy after closure, but

increased resistance & Clostridium difficile


Guidelines developed jointly by the American Society

of Health-System Pharmacists (ASHP), the Infectious Diseases

Society of America (IDSA), the Surgical Infection Society (SIS),

and the Society for Healthcare Epidemiology of America (SHEA)

Preventing SSI : Antimicrobial choice & procedure


Types Vancomycin

n = 452

Cefazolin

n = 433

p value

Overall SSI

no (%)

43 (9.5) 39 (9.0) NS

MRSA 8 (1.8) 15 (3.5) NS

MSSA 17 (3.7) 6 (1.3) 0.04*

Choice of surgical prophylaxis : covering

antimicrobial resistance or sensitive? n (%)

Finkelstein R. J Thorac Cardiovasc Surg 2002;123:326-32

Preventing SSI : Antimicrobial choice & procedure


Surgical Antimicrobial

Therapy & Prophylaxis

• Readministration may be warranted for

prolonged or excessive bleeding,

extensive burns, cardiopulmonary bypass

• Readministration may not be warranted

in patients in whom the half-life of the

agent may be prolonged (e.g., patients

with renal insufficiency or failure)

Guideline summary: Post-op


Glucose

control

For DM , The recommendation of maintaining

postoperative blood glucose less than 200 mg/dL at 6

am on postoperative days 1 and 2 is being replaced

Blood glucose during post-op for cardiac surgery (I)

and noncardiac surgery (II) (180 mg/dL or lower) in

the time frame of 18–24 hours after anesthesia end

time




Guideline summary: special approach

Category SHEA 2014 NICE 2008 SHEA 2008

Carrier decolonization II Not routinely Unresolved

Perform antiseptic wound

lavage

II NA NA

Perform an SSI risk

assessment

III NA NA




Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362: 9-17

Preoperative Decontamination on SSI in

Elective Orthopedic Surgery & Hardware

Bebko SP. JAMA Surg. 2015;150(5):390-5

SSI Bundle among Patients Undergoing

Cardiac, Hip, or Knee Surgery

Schweizer ML, Herwaldt LA. JAMA 2015;313(21):2162-71

Conclusions

• Selected SSI interventions may be

effectively implemented in selected settings

• Overuse of surgical prophylaxis may be

comparable to those of antimicrobial Rx,

but highly manageable

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