Surgical Site Infection

920,000 pts/23 million ops 14% adverse events in hospitals 18% (165,000) - disability > 6 months Crude rate 6 5 4 3 2 1 0 9 8 7 3% 4% 9% Clean Clean- Contam contam Double postop stay > $1.5 Billion in direct costs

Wenzel

NEJM

1992; 326:337-9

Surgical Site Infections in Presence or Absence of a Remote Infection 35 30 25 20 15 10 5 0 6% Elective no yes 15% 10% 25% Urgent 32% 7% 18% Emergency All

Ann surg

1964; 160

Relationship Between Wound Infection Reporting and Subsequent Infection Rates % 9 8 3 2 1 0 7 6 5 4 N=(1500) (1447) (1743) (1939)

Cruse

Canad Med Assoc J

1970; 102: 251

Pre Post Pre Post Hospital A Hospital B

10 9 8 2 1 0 7 6 5 4 3

Influence of Shaving on POW Infection Rates

9 10 8 3.5

PM - razor AM PM AM - clipper -

Alexander et al

Arch Sgy

1983

Timing of Prophylactic Antibiotics and Risk of Surgical Wound Infection Prospective cohort 2847 patients clean/clean-contaminated sgy Timing Early prep (364) Preop (1709) Periop (282) Postop (488) SWI 3.8% 0.6% 1.4% 3.3%

Classen et al

NEJM

1992; 326:281-6

Mupirocin study to prevent S. aureus POW infections - University of Iowa

Prospective, randomized, double-blind placebo controlled N=3966 patients at U of Iowa Preop carriage of S. aureus 891 (22%)

Perl et al IDSA 1999

Mupirocin vs Placebo in Preoperative Patients

Mupirocin (n=1933) Noso inf SSI 218 (11%) 152 (8%) S. aureus Nosoinf 45 (2.3%) S. aureus SSI 43 (2.2%) Placebo (n=1933) 220 (11%) 164 (9%) 55(2.99%) 46 (2.49%)

Perl et al

The MARS Study: 2% Mupirocin Preoperatively to Prevent S. aureus Infections 4030 patients (23% nasal carriers) 18% TCV Elim nasal carriage 80%



3 doses 93%



6 doses 100 80 18% nsgy 64% gen sry 60 40 8.3% 80.2% 20 0 plac mupir

Perl, Cullen, Wenzel et al

The MARS Study: 2% Mupirocin Preoperatively to Prevent S. aureus Infections 2 1 0 9 5 4 3 8 7 6

ALL PATIENTS CARRIERS

S. a inf S a SSI p=0.02

12 10 8 6 4 7.9 2 2.3 8.5 2.9 9.9 3.8* 11.6 7.6* 0 M (1933) P (1931) M (444) P (447)

Perl, Cullen, Wenzel et al

Surgical Technique: SSIs and Midline Incisional Hernias

Mean SSI 10%(0-27%) mean hernia 15% (5-26%) 1013 patients SSI predictors SL:WL ratio <4 - 22% hernia >4 - 9% hernia Hernia predictors age(y) obesity optime(h) deg.contam

reop OR .986

2.02

1.003

1.85

3.32

age (y) obesity wound inf sliwl<4 OR 1.022

2.45

2.5

2.98

Israelsson

Eur J Surg

1998;164:353

Perioperative Normothermia and the Incidence of Surgical Wound Infection Hypothesis: Hypothermia with vasoconstruction



pO 2 ,



phagocytosis, and



infection Plan: Randomized, double blind, controlled study of colorectal sgy pts Intervention: IV fluid warmers and forced warm air to up. body Standard: Bowel prep, preop ab Mean temp: 34.7 º C vs 36.6 º C

Kurz et al

NEJM

1996; 334:1209-15

Perioperative Normothermia and the Incidence of Surgical Wound Infection and Hospital Stay Colorectal surgery patients 20 18 16 6 4 2 0 14 12 10 8 p=0.009

6 19 Normo n=104 Hypoth n=96 13.5

13 12.5

12 11.5

p=0.01

11.8

13.5

11 10.5

Normo n=104 Hypoth n=96

Kurz et al

NEJM

1996; 334:1209-15

Supplemental Perioperative Oxygen and Rate of Surgical Wound Infection Hypothesis: oxidative killing is most imp defense vs POW infection Plan: randomize 500 pts undergoing colorectal sgy electively Intervention: 30% vs 80% inspired 0 2 via mask up + 2 h post op Standard: bowel prep, anesthesia, antibiotics core temp 36º C Pulse Ox: 97% vs 99% (p<0.001) Subcu Ox tension mmtg: 54 vs 73 (p=0.02)

Supplemental Perioperative Oxygen and Rate of Surgical Wounds Infection Mortality: 2.4% (30%) vs 0.4% (80%) p=0.13

12 10 8 6 4 2 0 11.2

5.2

30% n=250

oxygen

80% n=250

Greif et al

NEJM

2000; 342:161-7

Life Threatening Pelvic Sepsis After Stapled Hemorrhoidectomy 24 48 post-op hour 72

Lancet

2000; 355: 810

28 year old woman with post-op fever after liposuction

•

Buttocks and thigh liposuction

•

Disorientation

•

septic shock

•

buttock, thigh grey inter necrosis

• • •

f, ch, myalgia N, V, D op site pain, tender, minor erythrema

•

swelling broad-spectrum antibiotics

• • • • • •

Necrotic areas excised open incision drains ARDS dialysis

•

hypotension death 0 1 2 P o s t-op d a y 3 4 5

Anesth Plast Surg

2000; 24: 344-7

Necrotizing Fasciitis

Rare, rapidly progressing 30-60% mortality 38% (delay) vs 4% immed surgery S. pyogenes or anerobes/GNR Grey, edematous sq fat strips off fiscia c finger

Aesth Plastic Surg

2000; 24: 344-7

Ann Surg

1998; 64:397

Barriers to Effective Treatment of Necrotizing Soft Tissue Infections Delays in diagnosis Inadequate debridement Phys exam Work up Surgery • not “simple cellulitis”!

• more pronounced pain, toxicity • no undue delays with CT, MRI • surg exploration more efficient with frozen section • not ITS! But • repeated, excisional debridement

Urschel

Postgrad Med J

1999; 75:645-9

10 year old boy post op fever and rash

• closed reduction depressed nasal fx 1x1 cm 2 gelfoam support

0

• ER: f, n, v, abd pain 120/min mac rash face tr , abd gelfoam removed: no pus

1 2 3 post-op day 4 5

• discharged well

6

Early (



48 hours) Post-operative Infectious Diseases Emergencies Toxic Shock Syndrome

Streptococcus pyogenes

Clostridium species Necrotizing fasciitis

Necrotizing Soft Tissue Infections

Necrotizing fasciitis • Type I • Type II Polymicrobial Risk: DM gas in most Rx pen(vanc) anti-anerobe 3rd gen ceph gas ± S. aureus Risk: 50% gas TSS, varicella, NSAIDS, Pen +climdes rapid necrosis mult +/- IVIG tissue levels Gas gangrene

Urschel

Postgrad Med J

• C. perifringens

1999; 75:645-9

fulminant pen + clindes myonecrosis gas ? Hyperbaric O 2

Toxic Shock Syndrome

1978 - Described by Todd et al Lancet 1978; 2:1116-8 1980 - TSS + Tampon use NEJM 1980; 303:1429-42 Attack rate after nasal sgy 16,5/1000,000 + 10% mortality major (



4) J Infect Dis 1986; 153:356-9 minor (



3) fever, rash,



BP GI/m-sk/liver desquamation heme/cns involv

Otolaryn Head Neck Surg

1999; 120:569-70

Botryomycosis

Rare, indolent infection Pseudomycosis, suppurative Underlying immunodeficiency and/or tissue with poor healing ability Histo: organisms (granules) surrounded by neutrophils in fibrocellular stroma

Streptococcal TSS (T1, M-1) in 2 Patients Infected by a Colonized Surgeon Nasal carrier GAS 2 d post op gen rash bluish skin wound 85/50 125 37 8 GAS - wound 43 male Inguinal hernia repair 55 woman tetanus toxoid vaccine 73/39 105 38 6 erythema red, swollen arm

Rutishauser et al

Infection

1999; 27:259

Preventing Post-op Wound Infections

Pre-op advice

• • • • •

stop smoking!

optimize nutrition and weight seek hi-volume hospital/surgeon with rates reporting control comorbid cure remote inf.

Perioperatively Operativly Post-op

•

Avoid shaving

•

approp.antibiotics and timing

•

consider mupirocin in carriers

• •

Colon sgy: temp>36ºC 80% O 2 via mask

•

80% O 2

•

f 2 h D/c devices appropriately