Surgical Site Infections.ppt

Surgical Site Infections.ppt

1. Surgical Site Infections
–Role of Cefuroxime

2. SSIs: Magnitude of the
Problem
Surgical site infections:
•are the third most prevalent HCAI in hospital inpatients
•are present in 1% of hospital inpatients surveyed (2011)
•account for 1.4% of overall HCAI incidence in England
•developed in 10% of large bowel operation cases*
•are largely preventable.

3. Surgical Wound Classification
•Class 1 –Clean
–Uninfected operative wound, no inflammation
•Class II –Clean-Contaminated
–Alimentary tract (and others), under controlled conditions without
unusual contamination
•Class III –Contaminated
–Major breaks in sterile technique, eg, gross spillage from the
gastrointestinal tract
–Incisions encountering acute inflammation
•Class IV –Dirty-Infected
–Old traumatic wounds with dead tissue, infection, perforated
viscera
Mangram AJ et al. Am J Infect Control. 1999;27:97–134.

4. Risk Factors for SSI: The Patient
•Age
•Nutritional status
•Diabetes
•Nicotine use
•Obesity
•Coexistent infection
•Colonization
•Altered immune response
•Long preoperative stay

5. Risk Factors for SSI: Pre-and Intraoperative
•Inappropriate use of antimicrobial prophylaxis
•Infection at remote site not treated prior to surgery
•Shaving the site vs. clipping
•Long duration of surgery
•Improper skin preparation
•Improper surgical team hand antisepsis
•Environment of the room (ventilation, sterilization)
•Surgical attire and drapes
•Asepsis
•Surgical technique: hemostasis, sterile field

6. CDC recommendation to
prevent SSIs

7. Prevention Strategies: Core
Preoperative Measures
Administer antimicrobial prophylaxis in accordance with
evidence based standards and guidelines
–Administer within 1 hour prior to incision*
•2hr for vancomycin and fluoroquinolones
–Select appropriate agents on basis of
•Surgical procedure
•Most common SSI pathogens for the procedure
•Published recommendations
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality
Measures. Surg Infect 2008;9(6):579-84.

8. •Remote infections-whenever possible:
–Identify and treat before elective operation
–Postpone operation until infection has resolved
•Do not remove hair at the operative site unless it will interfere
with the operation; do not use razors
–If necessary, remove by clipping or by use of a depilatory
agent
Prevention Strategies: Core
Preoperative Measures

9. •Skin Prep
–Use appropriate antiseptic agent and technique for skin
preparation
•Maintain immediate postoperative normothermia*
•Colorectal surgery patients
–Mechanically prepare the colon (Enemas, cathartic agents)
–Administer non-absorbable oral antimicrobial agents in
divided doses on the day before the operation
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP): Evolution of National Quality
Measures. Surg Infect 2008;9(6):579-84.
Prevention Strategies: Core
Preoperative Measures

10. •Operating Room (OR) Traffic
–Keep OR doors closed during surgery except as
needed for passage of equipment, personnel, and
the patient
Prevention Strategies: Core
Intra-operative Measures

11. •Surgical Wound Dressing
–Protect primary closure incisions with sterile dressing for 24-
48 hrs post-op
•Control blood glucose level during the immediate post-
operative period (cardiac)*
–Measure blood glucose level at 6AM on POD#1 and #2 with
procedure day = POD#0
–Maintain post-op blood glucose level at <200mg/dL
*Fry DE. Surgical Site Infections and the Surgical Care Improvement Project (SCIP):
Evolution of Nationaluality Measures. Surg Infect 2008;9(6):579-84.
Prevention Strategies: Core
Postoperative Measures

12. Antibiotic Prophylaxis (NICE)
–Give antibiotic prophylaxis before:
-clean surgery for the placement of a prosthesis or
implant
-clean-contaminated surgery
-contaminated surgery
–Do not routinely use for clean non-prosthetic
uncomplicated surgery
–Use local antibiotic formulary and consider adverse
effects
–Consider prophylaxis on starting anaesthesia, or
earlier for operations using a tourniquet

13. Other Recommendation Sources
•American Society of Health-System Pharmacists
•Infectious Diseases Society of America
•The Hospital Infection Control Practices Advisory
Committee
•Medical Letter
•Surgical Infection Society
•Sanford Guide to Antimicrobial Therapy 2003
Bratzler DW. Available at:
http://www.medqic.org/scip/pdf/spkrnotesSIP_to_SCIP_101205.ppt. Accessed May
26, 2006.

14. Antimicrobial Requirements
•Active against most likely aerobes and anaerobes
1,2
•Appropriate dosage and timing for adequate
concentration at wound site
1,2
•Generally well tolerated
1
•Administer for shortest effective period to minimize
adverse effects, cost, and resistance
1
1.American Society of Health-System Pharmacists. Am J Health-Syst Pharm
1999;56:1839–1888.
2.Song et al. Br J Surg 1998;85:1232–1241.

15. Common Principles
Ideally, an antimicrobial agent for surgical prophylaxis should
1. Prevent SSI,
2. Prevent ssi-related morbidity and mortality,
3. Reduce the duration and cost of health care (when the costs
associated with the management of SSI are considered, the
cost-effectiveness of prophylaxis becomes evident),
4. Produce no adverse effects, and
5. Have no adverse consequences for the microbial flora of the
patient or the hospital

16. Ideal antimicrobial agent
1.To achieve these goals, an antimicrobial agent should be
1.Active against the pathogens most likely to
contaminate the surgical site,
2.Given in an appropriate dosage and at time that
ensures adequate serum and tissue concentrations
during the period of potential contamination,
3.Safe, and
4.Administered for the shortest effective period to
minimize adverse effects, the development of
resistance, and costs.

17. CefuroximeisasecondgenerationCephalosporin,
highlystabletomostß-lactamases,bothPenicillinases
andCephalosporinasesofgrampositiveandgram
negativebacteria
Description

18. Aerobic Gram-Positive Microorganisms:
Staphylococcus aureus
Streptococcus pneumoniae
Streptococcus pyogenes
Aerobic Gram-Negative Microorganisms:
Escherichia coli
Haemophilus influenzae (including beta-lactamase–producing
strains)
Haemophilus parainfluenzae
Klebsiella pneumoniae
Moraxella catarrhalis (including beta-lactamase–producing strains)
Neisseria gonorrhoeae (including beta-lactamase-producing strains
Spirochetes:
Borrelia burgdorferi
Sensitive Organisms

19. Cefuroximeissubsequentlydistributedthroughoutthe
extracellularfluids.Theaxetilmoietyismetabolizedto
acetaldehydeandaceticacid.
Absorptionofthetabletisgreaterwhentakenafterfood
(absolutebioavailabilityofCefuroximeAxetiltabletsincreases
from37%to52%).
Cefuroximeisexcretedunchangedintheurine;inadults,
approximately50%oftheadministereddoseisrecoveredinthe
urinewithin12hours.
Pharmacokinetics

20. Tissue concentration during preoperative use
After giving 1.5 gm injection of cefuroxime 40 mins before surgical
incision achieved the concentration of antibiotics 14 times higher than
MICs of S. Aureus and S. Epidermis and 7 times higher than MICs of E.
coli.

21. Antibiotic prophylaxis for hysterectomy, a prospective
cohort study: cefuroxime, metronidazole, or both?
•Studywasconductedinfifty-threehospitalsinFinland.
Atotalof5279womenundergoinghysterectomyfor
benignindicationswereselectedandgiveneither
cefuroximeormetronidazoleorboth.
•Inthisstudy,cefuroximeappearedtobeeffectivein
prophylaxisagainstinfections.Metronidazoleappeared
tobeineffective,withnoadditionalrisk-reductive
effectwhencombinedwithcefuroxime.

22. Suitability of cefuroxime for perioperative antibiotic
prophylaxis in maxillofacial surgical procedures
•Serumandtissuesamplesweretaken,todeterminethe
intraoperativecefuroximeconcentration,from40
patientswhohadbeengiven1.5gcefuroximei.v.during
maxillofacialsurgery.
•Maximumserumlevelsaveraging80mg/lwere
measuredwithin30minofadministration.Average
levelsof1–3mg/kgwerestillmeasurableafter4h.No
postoperativewoundinfectionwasseenunder
prophylaxiswithcefuroxime.
•Cefuroximeissuitableforperioperativeprophylaxis
duringmaxillofacialsurgicalproceduresbecauseofits
favourablekineticsandbroadspectrumofaction.

23. Cefuroxime as antibiotic prophylaxis in CABG
surgery
•Todeterminetheefficacyofcefuroximeasa
prophylacticagentagainstinfection.
•The study enrolled 1232 adult patients (age )16
years who underwent isolated CABG surgery with
the use of extracorporeal circulation within two
periods.
•All these surgical procedures were performed by
the same three surgical teams. General anesthesia
was provided by the same three teams according to
a set protocol.

24. Results

25. Advantages:
Broad-spectrumantibiotic-Cefuroximehasbactericidalactivity
againstawiderangeofcommonpathogens,includingmanybeta-
lactamaseproducingstrains.Ithasgoodstabilitytobacterialbeta-
lactamase,andconsequentlyisactiveagainstmanyampicillin-
resistantoramoxicillin-resistantstrains.
Widetissuedistribution-Widelydistributedinthebodyintomost
tissuesandfluidsincludinggallbladder,liver,kidney,bone,uterus,
ovary,sputum,bile,andperitoneal,pleural,andsynovialfluids
Mostactivecephalosporinforbeta-lactamase-producing
Haemophilusinfluenzae,organismthatcausesrespiratorytract
infectionssuchasotitismedia,bronchitisandsinusitis.
Cefuroxime "pros" and "cons”

26. Lessgastrointestinalsideeffects-Cefuroximeaxetilproduces
fewergastrointestinalsideeffectsthansomeotherwidelyused
antibiotics(e.g.Augmentin,cefixime).
Safeforuseinchildren-Safetyandeffectivenessofcefuroxime
axetilhavebeenestablishedforchildrenaged3monthsto12years.
PregnancycategoryB.
Easeofuse-twicedailydosing.
AvailableinoralandI.V.formulations.
Cefuroxime "pros" and "cons”