SCIP Infection Module

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SCIP Infection Module

• E. Patchen Dellinger

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Prophylactic Antibiotics

• Antibiotics given for the purpose of preventing
  infection when infection is not present but the
  risk of postoperative infection is present

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Relative Benefit from Antibiotic Surgical
Prophylaxis

• Operation Prophylaxis () Placebo () NNT
• Colon 4-12 24-48 3-5
• Other (mixed) GI 4-6 15-29 4-9
• Vascular 1-4 7-17 10-17
• Cardiac 3-9 44-49 2-3
• Hysterectomy 1-16 18-38 3-6
• Craniotomy 0.5-3 4-12 9-29
• Total joint repl 0.5-1 2-9 12-100
• Brst hernia ops 3.5 5.2 58

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Prophylactic AntibioticsQuestions

• Which cases benefit?
• Which drug should you use?
• When should you start?
• How much should you give?
• How long should antibiotics be continued?

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CMS Surgical Infection Prevention Target
Procedures

• Coronary artery bypass grafting
• Open chest cardiac operations
• Colon operations
• Hip or knee arthroplasty
• Abdominal or vaginal hysterectomy
• Vascular operations
• Aneurysm repair
• Thromboendarterectomy
• Vein Bypass

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SCIP Infection 1

• Prophylactic antibiotic received within one hour
  prior to surgical incision (two hours allowed for
  vancomycin or quinolone)

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Decisive Period For Development Of Wound Infection
Lesion Size, (mm)
Lesion Age (hrs)
Burke. In Hunt, ed. Wound Healing and Wound
Infection, New York Appleton, 1980242.
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Efficacy Of Prophylaxis Is Independent Of The
Specific Antibiotic
Penicillin, 40,000 U
Erythromycin, 0.1 mg/Kg
Control
Control
Staph Penicillin
Staph Erythromycin
Chloramphenicol, 0.1 mg/Kg
Tetracycline, 0.1 mg/Kg
Lesion Size, mm (24 Hours)
Control
Control
Staph Chloramphenicol
Staph Tetracycline
Age of Lesion at Antibiotic Injection (Hours)
Burke JF. Surgery. 196150161.
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Timing of Antibiotic ProphylaxisGI Operations
Stone HH et al. Ann Surg. 1976184443-452.
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Perioperative Prophylactic AntibioticsTiming of
Administration
14/369
15/441
1/41
1/47
Infections ()
1/81
2/180
5/699
5/1009
Hours From Incision
Classen. NEJM. 1992328281.
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Prophylactic AntibioticsTiming - Cefazolin

• Serum Levels (mg/L)
• On Call Anesth
• Incision 87 148
• 2 hours 37 57
• 3 hours 25 39
• DiPiro. Arch Surg
  1985120829

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Prophylactic AntibioticsTiming Cefazolin
Muscle Levels
On Call
Anesth
9 7
17 11

• Incision
• Wound closure

DiPiro JT et al. Arch Surg. 1985120829-832.
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Prophylactic AntibioticsAdministration in the
O.R.Drugs Given I.V. Push over 5-10 Min

• CefazolinDrug to incision 17 (7-29) minMuscle
  levels 76 (9-245) mg/kg
• CefoxitinDrug to incision 22 (14-27) minMuscle
  levels 24 (13-45) mg/kg

DiPiro. Arch Surg 1985120829DiPiro. Personal
Communication
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Prophylactic AntibioticsQuestions

• When do we start?

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Antibiotic Timing Related to Incision
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
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Prophylactic AntibioticsFactors Influencing
Administration
Welch. Clin Perform Qual Health Care 19986168
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Prophylactic Antibiotic Use Patterns, Changes
1988-1998




pre-op nurse responsible, check list standing
order in O.R. remove standing order replace
standing order
Burke. Clin Infect Dis 2001 33 (suppl 2)S78
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Prophylactic Antibiotic Use Patterns, Changes
1988-1998

• Prophylaxis gt 24 hrs30 6
• Average number of proph doses10 4
• Inflation adjusted antibiotic cost38 reduction
• Antibiotic-associated adverse events64 reduction

Burke. Clin Infect Dis 2001 33 (suppl 2)S78
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SCIP Infection 2

• Prophylactic antibiotic selection for surgical
  patients

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Recently Updated Antibiotic Recommendations
For the purposes of national performance
measurement a case will pass the antibiotic
selection performance measure if vancomycin is
used for prophylaxis (in the absence of a
documented beta-lactam allergy) if there is
physician documentation of the rationale for
vancomycin use (effective for July 2006
discharges).
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Recently Updated Antibiotic Recommendations
(continued)
Ciprofloxacin, levofloxacin, gatifloxacin, or
moxifloxacin (effective for July 2006
discharges). For the purposes of national
performance measurement, a case will pass the
antibiotic selection indicator if the patient
receives oral prophylaxis alone, parenteral
prophylaxis alone, or oral prophylaxis combined
with parenteral prophylaxis.
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SCIP Infection 3

• Prophylactic antibiotics discontinued within 24
  hours after surgery end time (48 hours for
  cardiac patients)

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Discontinuation of Antibiotics
Patients were excluded from the denominator of
this performance measure if there was any
documentation of an infection during surgery or
in the first 48 hours after surgery.
Bratzler DW, Houck PM, et al. Arch Surg.
2005140174-182.
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Antibiotic ProphylaxisDuration

• Most studies have confirmed efficacy of ?12 hrs.
• Many studies have shown efficacy of a single
  dose.
• Whenever compared, the shorter course has been as
  effective as the longer course.

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Duration of ProphylaxisCardiac

• Author Drug Duration Infection
• Conte 1972 cephalothin 1 dose 10 4 days 9
• Goldmann 1977 cephalothin 2 days 4 6
  days 6
• Austin 1980 cephalothin 2 doses 11 3
  days 9
• Geroulanos 1986 cefuroxime 2 days 1.1 cefazolin
  4 days 2.5

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Duration of ProphylaxisInfection and Antibiotic
Resistance Risk in Cardiac Surgery

• lt 48 hr gt48 hr Odds Short Long Ratio
• Number 1502 1139
• SSI 131 (8.7) 100(8.8) 1.0 (0.8-1.3)
• Acq Ab Res 6 1.6 (1.1-2.6)

Harbarth. Circulation 20001012916
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Duration of ProphylaxisJoint Replacement

• Author Drug Duration Infection
• Pollard 1979 cephaloridine 12 hours 1.4(hips) f
  lucloxacillin 14 days 1.3
• Heydemann 1986 cefazolin 1 dose 0(hips and
  knees) 24 hours 1 48 hours 0 7 days 1.5

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Single vs Multiple Dose Surgical Prophylaxis
Systematic Review
Favors multiple dose
Favors single dose
McDonald. Aust NZ J Surg 199868388
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Duration of Antibiotic ProphylaxisWhat is Best
for Our Patients?

• Antibiotic prophylaxis is one of many methods for
  reducing the incidence of SSI
• There is a lack of evidence that antibiotics
  given after the end of the operation prevent
  SSIs
• There is evidence that increased use of
  antibiotics promotes antibiotic resistance

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• Duration of prophylactic antibiotic
  administration should not exceed the 24-hour
  post-operative period.
• Prophylactic antibiotics should be discontinued
  within 24 hours of the end of surgery.
• Medical literature does not support the
  continuation of antibiotics until all drains or
  catheters are removed and provides no evidence of
  benefit when they are continued past 24 hours.

http//www.aaos.org/wordhtml/papers/advistmt/1027.
htm
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SCIP Infection 4

• Cardiac surgery patients with controlled 6 a.m.
  postoperative serum glucose

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Diabetes, Glucose Control, and SSIsAfter Median
Sternotomy
Latham. ICHE 2001 22 607-12
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Hyperglycemia and Risk of SSI after Cardiac
Operations

• Hyperglycemia - doubled risk of SSI
• Hyperglycemic 48 of diabetics 12 of
  nondiabetics 30 of all patients
• 47 of hyperglycemic episodes were in nondiabetics

Latham. Inf Contr Hosp Epidemiol.
200122607 Dellinger. Inf Contr Hosp Epidemiol.
200122604
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Deep Sternal SSI and Glucose
Zerr. Ann Thorac Surg 199763356
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Glucose Control and Deep Sternal Wound Infections
Furnary et al. Ann Thorac Surg 199967352
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Glucose Control and Mortality after CABG in 3554
Diabetics
Furnary. J Thorac Cardiovasc Surg 20031251007
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SCIP Infection 5

• Postoperative wound infection diagnosed during
  index hospitalization(OUTCOME)

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This One is Difficult!

• The purpose of the process measures is to lower
  SSI rates, if we dont survey we wont know if
  theyre working
• There is not agreement regarding the most
  effective and efficient methods for SSI
  surveillance
• More than half of all SSI are detected after
  hospital discharge

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SCIP Infection 6

• Surgery patients with appropriate hair removal

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Influence of Shaving on SSI

• No Hair Group Removal Depilatory Shaved
• Number 155 153 246
• Infection rate 0.6 0.6 5.6

Seropian. Am J Surg 1971 121 251
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Shaving, Clipping and SSI
Cruse. Arch Surg 1973 107 206
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Hair Removal Techniques and SSI
Alexander. Arch Surg 1983 118 347
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Shaving vs ClippingCardiac Surgery

• Number Infected ()
• Shaved 990 13 (1.3)
• Clipped 990 4 (0.4)
• p lt 0.03

Ko. Ann Thorac surg 199253301
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SCIP Infection 7

• Colorectal surgery patients with immediate
  postoperative normothermia

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Temperature and Tissue O2 tension

• Subcut temp increase 4 C
• Subcut O2 tension increase 40 torr
• Linear correlation between temperature and O2
  tension
• Threefold increase in local perfusion

Rabkin. Arch Surg 1987122221
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Wound Oxygen Tension SSI
14
25
33
24
15
19
Observed-Expected SSI Rate
40-49
50-59
60-69
70-79
80-89
90-129
Maximum wound pO2
Hopf. Arch Surg 1997132997
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Temperature and SSI Following Colectomy

• Mechanical bowel prep
• Parenteral antibiotics at induction x 4 d
• Standard anesthetic-isoflurane
• Randomized after inductionTgt36.5 º or Tgt34.5 º
• Supplemental O2 in PACU x 3h
• Aggressive fluid resuscitation

Kurz. NEJM 19963341209
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Temperature and SSI Following Colectomy

• Normo (104) Hypo (96) P
• Transfused pts 23 34 .054
• Units transfused .41 .81.2 .01
• Vasoconstr-O.R. 6 77 lt.001
• Vasoconst-PACU 21 81 lt.001

Kurz. NEJM 19963341209
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Temperature and SSI Following Colectomy

• Normo (104) Hypo (96) P
• SSI 6 18 .009
• Collagen dep 328 254 .04
• Time to eat 5.6d 6.5d lt.006

Kurz. NEJM 19963341209
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Local Warming and SSI after Clean Operations

• Elective hernia repair
• Varicose vein operation
• Breast operation, incision gt 3cm
• Pre-op warming gt 30 min Whole body forced air -
  systemic Incision site radiant heat - local

Melling. Lancet 2001358876
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Local Warming and SSI after Clean Operations

• Local Systemic Control
• SSI 5 (4) 8 (6) 19 (14)
• Post-op antibiotics 9 (7) 9 (7) 22 (16)
• Hematoma 4 (3) 2 (1) 5 (4)
• Seroma 7 (5) 4 (3) 9 (7)

p lt 0.01
Melling. Lancet 2001358876
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Temperature and Surgical Site Infections

• Hypothermia reduces tissue oxygen tension by
  vasoconstriction
• Hypothermia reduces leukocyte superoxide
  production
• Hypothermia increases bleeding and transfusion
  requirement
• Hypothermia increases duration of hospital stay
  even in uninfected patients

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Can We Prevent SSIs in the Operating Room?

• Oxygenation
• Temperature
• Fluid Management
• Antibiotics
• Glucose
• Shaving
• ?Other
• The period of maximum influence on SSI risk
  begins and ends in the operating room.