![Page 1: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/1.jpg)
1
Surgical Site Infection
(SSI)
Y. Rongrungruang, MD
Department of Medicine
Faculty of Medicine Siriraj Hospital
Mahidol University
Comprehensive training in Infection Control
15-26 December 2014
Amari Airport Hotel
![Page 2: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/2.jpg)
Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
![Page 3: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/3.jpg)
Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
![Page 4: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/4.jpg)
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
![Page 5: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/5.jpg)
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
![Page 6: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/6.jpg)
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
![Page 7: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/7.jpg)
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
![Page 8: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/8.jpg)
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
Alexander JW, et al. Ann Surg 2011;253:1082–93
SS = surgical site
![Page 9: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/9.jpg)
Post-operative (immediate & late)
Hyperglycemia
Hypovolemia
Hypothermia
SS contamination post-op
Extra surgical site infections
Alexander JW, et al. Ann Surg 2011;253:1082–93
SSI risk factors & stage of operation
![Page 10: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/10.jpg)
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
![Page 11: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/11.jpg)
A 60 yr M patient presented with MSSA
bacteremia and septic arthritis Rt. Knee.
He also underwent TKR Rt. knee last 11
months.
Is this a PJI?
a. Yes, MSSA on top of prosthesis! b. Yes, this is < 1 yr post-op! c. No, this is > 90 days post-op!
![Page 12: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/12.jpg)
Focus
• Principles & Pathogenesis
• Surveillance & Definitions
• International guidelines
• Conclusions
![Page 13: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/13.jpg)
Site 2001 2006
LRTI 33.5 27.6
UTI 16.6 27.6
SSI 22.7 20.2
BSI 1.9 4.3
Common sites of HAI in surgical patients
Thailand 2001-2006 (%)
Danchaivijitr S, J Med Assoc Thai 2005 in 42 hospitals & national survey in 20 hospitals, 2006
![Page 14: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/14.jpg)
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
![Page 15: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/15.jpg)
Benchmarking our procedure-specific SSI
rates with those of resource-rich countries.
What ranking are we at?
a. About the same as those of them b. Variable between different SSI risk
categories c. At lower rankings
![Page 16: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/16.jpg)
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
![Page 17: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/17.jpg)
NNIS risk index category
Knight R, et al. Am J Surgery 182 (2001) 682–686
![Page 18: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/18.jpg)
![Page 19: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/19.jpg)
![Page 20: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/20.jpg)
![Page 21: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/21.jpg)
![Page 22: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/22.jpg)
![Page 23: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/23.jpg)
NNIS wound class / risk index & SSI
Knight R, et al. Am J Surgery 182 (2001) 682–686
![Page 24: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/24.jpg)
Which of the followings may be the most
widely used SSI definitions?
A. NHSN
B. NICE
C. ACS
![Page 25: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/25.jpg)
CDC, NHSN classification for surgical site infection
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 26: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/26.jpg)
![Page 27: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/27.jpg)
![Page 28: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/28.jpg)
![Page 29: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/29.jpg)
![Page 30: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/30.jpg)
![Page 31: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/31.jpg)
![Page 32: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/32.jpg)
![Page 33: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/33.jpg)
![Page 34: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/34.jpg)
![Page 35: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/35.jpg)
![Page 36: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/36.jpg)
![Page 37: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/37.jpg)
![Page 38: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/38.jpg)
Focus
• Principles & Pathogenesis
• Clinical aspects & Antimicrobial Rx
• Surveillance & Definitions
• International guidelines
• Conclusions
![Page 39: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/39.jpg)
Which of the followings may be the latest
SSI guideline & recommendation?
A. SHEA 2008
B. NICE 2008
C. SHEA 2014
![Page 40: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/40.jpg)
![Page 41: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/41.jpg)
![Page 42: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/42.jpg)
![Page 43: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/43.jpg)
Guideline summary: Pre-op
Type SHEA 2014 NICE 2008 SHEA 2008
Glucose control I-II NA AII
Obesity I NA AII
Smoking I NA AII
Immunosuppressive III NA CII
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
![Page 44: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/44.jpg)
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 45: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/45.jpg)
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 46: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/46.jpg)
Guideline summary: Peri-op
Category SHEA 2014 NICE 2008 SHEA 2008
Carrier decolonization II Not routinely Unresolved
Hair removal II Recommended AI
WHO checklist I NA NA
Skin preparation I Recommended AII
Normothermia I Recommended Unresolved
Supplemental oxygen I Recommended Unresolved
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
![Page 47: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/47.jpg)
S. aurues nasal carriage & SSI Herwaldt LA. Surgery 2003;134:S2-9
![Page 48: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/48.jpg)
Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362:9-17
![Page 49: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/49.jpg)
Preventing Surgical-Site Infections in Nasal Carriers of S. aureus Bode LG, Kluytmans JA, N Engl J Med 2010;362: 9-17
![Page 50: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/50.jpg)
Preoperative hair removal & SSI, Shaving vs Clipping Tanner J, Woodings D, Moncaster K. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3
![Page 51: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/51.jpg)
Time of clipping & SSI, day before vs on the day of surgery Tanner J, Woodings D, Moncaster K. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004122. DOI: 10.1002/14651858.CD004122.pub3
![Page 52: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/52.jpg)
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 53: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/53.jpg)
![Page 54: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/54.jpg)
54
![Page 55: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/55.jpg)
Chloroxylenol vs Iodophor/alcohol vs Chlorhexidine/alcohol
skin prep in foot & ankle surgery
Ostrander RV. J. Bone Joint Surg. Am. 2005;87:980-985
Chloroxylenol
Iodophor /alcohol
Chlorhexidine /alcohol
![Page 56: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/56.jpg)
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
![Page 57: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/57.jpg)
Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis
Darouiche RO, et al. N Engl J Med 2010;362:18-26.
![Page 58: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/58.jpg)
Spanish RCT of Perioperative Low vs High Oxygen Supplement Belda FJ, et al. JAMA. 2005;294:2035-2042
![Page 59: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/59.jpg)
Perioperative Normothermia vs hypothermia & SSI Kurz A, et al. N Engl J Med 1996;334:1209-15
![Page 60: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/60.jpg)
Guideline summary: operative
Type SHEA 2014 NICE 2008 CDC 1999
Surgeon skill &
technique
III NA AIII
Double glovings III Recommended AIII
Aseptic technique III Recommended AIII
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Mangram AJ, et al. Infect Control Hosp Epidemiol1999;20(4):250–78.
![Page 61: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/61.jpg)
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 62: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/62.jpg)
Chlorhexidine–Alcohol vs Povidone–Iodine Surgical Antisepsis
Darouiche RO, et al. N Engl J Med 2010;362:18-26.
![Page 63: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/63.jpg)
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 64: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/64.jpg)
Guideline summary: OR characters
Type SHEA 2014 NICE 2008 SHEA 2008
Ventilation III NA CI
Traffic III NA BII
Environment cleaning III NA BIII
Sterilization of devices II NA BI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
![Page 65: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/65.jpg)
Ventilation of Surgery & Crititcal care, Design parameter
ANSI/ASHRAE/ASHE Standard 170-2008, addendum
![Page 66: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/66.jpg)
Risk Factors for and Recommendations to Prevent SSI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
![Page 67: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/67.jpg)
Guideline summary: Surgical prophylaxis
Type SHEA 2014 NICE 2008 SHEA 2008
Timing < 30-60 min II Recommended AI
Antimicrobial of choices II Recommended AI
Duration of prophylaxis I NA AI
Marshall J, et al. Infect Control Hosp Epid 2014:35;753-71
NICE clinical guideline 74 guidance.nice.org.uk/cg74
Anderson DJ, et al. Infect Control Hosp Epidemiol 2008;29(suppl 1):S51–61.
![Page 68: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/68.jpg)
Antimicrobial prophylaxis in clean surgery
Knight R, et al. Am J Surgery 182 (2001) 682–686
![Page 69: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/69.jpg)
Timing of Antibiotic Prophylaxis & SSI following Total Hip Arthroplasty Van Kasteren ME, et al. Clin Infect Dis 2007 : 44
![Page 70: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/70.jpg)
![Page 71: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/71.jpg)
1 dose vs 7 doses of perioperative antimicrobial prophylaxis
in elective gastric cancer surgery.
Mohri Y, et al. Brit J Surgery 2007; 94: 683–688
![Page 72: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/72.jpg)
Prolonged ( > 48 h) surgical antimicrobial prophylaxis &
antimicrobial resistant organisms. Harbath S. circulation 2000;101;2916-2921
![Page 73: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/73.jpg)
Bone5: 7%–13%
Vancomycin Penetration
Sternal Bone1: 57%
Heart Valve4:
12%
CNS: <10%
Fat4: 14%
Muscle4: 9%
Epithelial lining fluid3:
18%
Lung tissue2: 17%–24%
1. Massias L et al. Antimicrob Agents Chemother. 1992;36:2539-2541; 2. Cruciani M et al. J Antimicrob Chemother.
1996;38:865-869. 3. Lamer C et al. Antimicrob Agents Chemother. 1993;37:281-286; 4. Daschner FD et al. J
Antimicrob Chemother. 1987;19:359-362; 5. Graziani AL et al. Antimicrob Agents Chemother. 1988;32:1320-1322.
![Page 74: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/74.jpg)
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
![Page 75: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/75.jpg)
Bratzler DW. Surgical Infection Prevention Guidelines Writer Workgroup The American Journal of Surgery 2005:189;395–404 Clinical Infect Diseases 2004;38:1706-15
![Page 76: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/76.jpg)
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)
![Page 77: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/77.jpg)
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
![Page 78: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/78.jpg)
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
![Page 79: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/79.jpg)
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
![Page 80: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/80.jpg)
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
![Page 81: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/81.jpg)
Preventing SSI : Antimicrobial choice & procedure
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
![Page 82: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/82.jpg)
Preventing SSI : Antimicrobial & dosing
Bratzler D, et al. Am J Health-Syst Pharm. 2013; 70:195-283
![Page 83: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/83.jpg)
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)
![Page 84: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/84.jpg)
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
![Page 85: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/85.jpg)
Establishing surgical prophylaxis ASP
• Assess the motivations
• Ensure accountability and leadership
• Set up structure and organization
• Define priorities, how to measure outcome
• Identify effective interventions
• Identify key measurements
• Educate and Train
• Communicate
![Page 86: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/86.jpg)
Surgical Antimicrobial Prophylaxis Form
![Page 87: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/87.jpg)
Given the evidence of ertapenem vs
comparator in preventing colorectal SSI,
general surgeons in your center considering
replace “cefoxitin” with “ertapenem” for colorectal surgical prophylaxis.
A. What’d be the evidence of erta vs cefox
against colorectal SSI?
B. Any drawback of using erta vs cefox?
C. What’d you recommend in this regard?
![Page 88: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/88.jpg)
Itani K, et al N Engl J Med 2006;355:2640-51
![Page 89: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/89.jpg)
Itani K, et al N Engl J Med 2006;355:2640-51
![Page 90: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/90.jpg)
In a urology unit, there is a growing
concern of ESBL-producing
Enterobacteriaceae SSI,
“cefazolin” switched to “fosfomycin” for invasive urological surgical prophylaxis.
A. What’d be the evidence of fosfo vs cefa
against SSI?
B. Any drawback of using fosfo vs cefa?
C. What’d you recommend in this regard?
![Page 91: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/91.jpg)
Ishisaka K, et al. J Infect Chemother (2007) 13:324–331
![Page 92: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/92.jpg)
Ishisaka K, et al. J Infect Chemother (2007) 13:324–331
![Page 93: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/93.jpg)
In your center with busy CVT services, the
unit staffs have been switching “cefazolin”
to “vancomycin” as a routine surgical
prophylaxis for CABG, given the concern of increasing incidence of MRSA SSI.
A. What’d be the evidence of vanco vs cefa
against MRSA SSI?
B. Any drawback of using vanco vs cefa?
C. What’d you recommend in this regard?
![Page 94: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/94.jpg)
A diabetic pt with high risk TKR
A 75-yr-old female patient with DM
• 2005 Dec : TKR rt. knee
• 2006 June : MSSA septic arthritis rt.knee, prosthesis removal & complete antimicrobial therapy
• 2006 November : scheduled for elective TKR rt. knee
![Page 95: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/95.jpg)
Investigation results
• Hct 36% WBC 8,000/mm3, PMN
70% L30%, plt 298,000/mm3
• ESR 24 mm/h
• FBS 120, HbA1C 6.5 %, BUN 24, Cr
1.5 mg/L, Chest X-ray & UA WNL
![Page 96: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/96.jpg)
Your choice of surgical prophylaxis?
A. Vancomycin
B. Cefazolin
C. Fosfomycin
![Page 97: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/97.jpg)
A diabetic pt with high risk TKR
• Nasal mupirocin & bodywash with 4%
chlorhexidine bath
• 2006 November : elective TKR rt. knee
with perioperative cefazolin x 48 hrs
• Good post-operative recovery up to 3
years of follow-up
![Page 98: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/98.jpg)
A diabetic pt with high risk TKR
• 2006 November: elective TKR rt. knee
• 2009 December readmission :acute
monoarthritis rt. knee
• Jt. fluid : WBC & PMN elevated
• Culture + for group A streptococci
![Page 99: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/99.jpg)
SSI
% (no/total)
Chlorhexidine 2.8 (5/185)
Povidone iodine 3.6 (7/195)
SSI reduction 23.4 (2/195)
Type of antiseptic & SSI in surgery unit
Jan – Nov 2007
![Page 100: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/100.jpg)
Hair removal technique & SSI in surgery unit
Jan – Nov 2007
Category SSI rate
% (no/total)
Shaving 4.1 (13/320)
Non-shaving 1.8 (2/111)
Risk reduction 53.4 (11/320)
![Page 101: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/101.jpg)
year 2550 2551 (11 mo)
total patients 7,877 6,602
SSI no. (%) 27 (3.4) 12 (1.8)
Annual SSI rate
![Page 102: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/102.jpg)
![Page 103: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/103.jpg)
![Page 104: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/104.jpg)
Thai periorbital flora & antiseptics
N = 51 (no of pt)
Type coag-
Staph
Dipthe
roids
Micro
cocci
Gr-rod
no Rx 43 20 9 7
CHG Rx 40 14 4 6
PID Rx 7 1 0 0
Rongrungruang Y, et al. J Med Assoc Thai 2005
![Page 105: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/105.jpg)
![Page 106: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/106.jpg)
Prophylactic antibiotics prescribing practices
Prescribing Practice N (%)
Number of Antibiotic (420 patients) 1 antibiotic > 2 antibiotics
301 (71.7) 119 (28.3)
Timing of Initiation of the First Antibiotic (420 patients)
Before Operation
- at OR prior to incision 253 (60.2)
- at Ward 49 (11.7)
After Incision in OR 72 (17.1)
After Operation 46 (11.0)
Timing of Antibiotic prior to incision (253 patients)
within 30 minutes 184 (72.7)
31 to 60 minutes 59 (23.3)
31 to 120 minutes 10 (4.0)
![Page 107: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/107.jpg)
Prophylactic antibiotics prescribing practices (cont.)
Type of Antibiotic (580 antibiotics & 420 patients)
Cefazolin 198 (47.1)
Cetriaxone 60 (14.3)
Metronidazole 48 (11.4)
Fosfomycin 47 (11.2)
Cefoxitin 36 (8.6)
Clindamycin 24 (5.7)
Ampicillin + Sulbactam 18 (4.3)
Ciprofloxacin 15 (3.6)
Cefotaxime 14 (3.3)
Cefepime 13 (3.1)
Amoxicillin + Clavulanate 12 (2.9)
Meropenem 11 (2.6)
Others 84 (20.0)
Duration of Antibiotic Prophylaxis in Before Operation Group (302 patients)
Single dose 47 (15.6)
1 day 6 (2.0)
2 days 81 (26.8)
> 2 days 168 (55.6)
Duration of Antibiotic Prophylaxis (420 patients)
Single dose 60 (14.3)
1 day 17 (4.0)
2 days 127 (30.2)
> 2 days 216 (51.4)
![Page 108: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/108.jpg)
Department/Devision
Type of Antibiotic
within 30 minutes
31-60 minutes
61-120 minutes
Total
Cardio/CVT cefazolin 18 6 2 26
maxipime=cefepime 3 0 0 3
clindamycin 1 1 0 2
fosfomycin 1 0 0 1
gentamicin 0 0 1 1
cefepime 1 0 0 1
Total 24 7 3 34
% 70.6 20.6 8.8 100.0
Timing of Antibiotic prior to incision (253 patients)
![Page 109: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/109.jpg)
Neuro fosfomycin 16 12 1 29
cefazolin 7 2 1 10
unasyn=ampi+sulbac 3 3
vancomycin 1 1
gentamicin 1 1
Total 26 16 2 44
% 59.1 36.4 4.5 100.0
Uro cetriaxone 11 1 12
cefoxin 1 1
cefotaxime 1 1
ciprofloxacin 1 1
Total 13 2 15
% 86.7 13.3 100.0
Vascular cefazolin 4 3 7
clindamycin 1 0 1
Total 5 3 8
% 62.5 37.5 100.0
Timing of Antibiotic prior to incision (253 patients)
Department/
Devision Type of Antibiotic
within 30
minutes
31-60
minutes
61-120
minutes Total
![Page 110: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/110.jpg)
Timing of Antibiotic prior to incision (253 patients)
Department/ Devision
Type of Antibiotic within 30 minutes
31-60 minutes
61-120 minutes
Total
H&Neck cefazolin 5 1 6
unasyn=ampi+sulbac 2 1 3 augmentin 1 1 2 cetriaxone 1 1
clindamycin 1 1 Total 9 4 13 % 69.2 30.8 100.0
Plastic cefazolin 1 1
unasyn=ampi+sulbac 1 1 Total 2 2 % 100.0 100.0
![Page 111: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/111.jpg)
Timing of Antibiotic prior to incision (253 patients)
Department/ Devision
Type of Antibiotic within 30 minutes
31-60 minutes 61-120 minutes
Total
Gen surg metronidazole or flagyl 15 1 2 18 cefazolin 10 3 13 cetriaxone 9 1 1 11 cefotaxime 4 1 5
unasyn=ampi+sulbac 1 2 3 ciprofloxacin 1 2 3 claforam=cefotaxime 1 1 1 3 ampicilin 1 1 gentamicin 1 1 claroxim 1 1 Total 44 11 4 59 % 74.6 18.6 6.8 100.0
Ortho cefazolin 33 13 2 48 clindamycin 3 1 4 zinnacef=cefuroxime 1 2 3 unasyn=ampi+sulbac 2 2 fosfomycin 1 1 2 cetriaxone 1 1 Total 40 18 2 60 % 66.7 30.0 3.3 100.0
![Page 112: Surgical Site Infection (SSI) - Ministry of Public Healthbamras.ddc.moph.go.th/userfiles/SSI_(2).pdf · Surgical Site Infection (SSI) ... SSI during pre-op, peri-op and post-operative](https://reader031.vdocuments.us/reader031/viewer/2022021615/5caf57ea88c993c5078b8ec0/html5/thumbnails/112.jpg)
Gynae cefoxin 12 12
cefoxitin 9 9 cefazolin 6 6 cetriaxone 2 2 clindamycin 1 1 metronidazole or flagyl 1 1 ampicillin 1 1 cefotaxime 1 1 Total 33 33 % 100.0 100.0
OB cefazolin 2 1 3 cefoxin 1 1 Total 3 1 4 % 75.0 25.0 100.0
ENT cefazolin 2 2 clindamycin 1 1 Total 2 1 3 % 66.7 33.3 100.0
Timing of Antibiotic prior to incision (253 patients)
Department/ Devision
Type of Antibiotic within 30 minutes
31-60 minutes
61-120 minutes
Total