Andreas Voss

1

Andreas  Voss  iPrevent  

UMCN  &  CWZ  Nijmegen,  The  Netherlands  

Bratzler & Hunt, Clin Infect Dis 2006; 43:322-30.ccccc

To reduce preventable surgical morbidity and mortality by 25% by 2010

US national costs: $130-845 million/year

à saving = $ 32.5 to 212.5 million/year

Andreas Voss

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¤  80-­‐year-­‐old  male  receiving  a  knee  prosthesis  is  brought  to  the  OR  at  10:00  am  for  pre-­‐operaKve  preparaKon  and  anaesthesia.  

¤  Surgeons  requested  1  g  of  cefotaxim  to  be  given  as  prophylaxis.  Prophylaxis  was  given  by  anaesthesiologist  at  10:10  am.  

¤  OR  nurse  immediately  starts  with  “standard  prepara4on”  for  knee  surgery,  starts  disinfecKng  the  skin  at  10:30  am  and  the  first  incision  of  the  surgeons  is  set  at  10:42  am.  

¤  Due  to  unforeseen  complicaKons  the  surgery  takes  longer  than  expected  and  the  surgeon  orders  a  second  dose  of  the  anKbioKc,  that  is  given  at  12:40  am.  

¤  A9er  the  operaKon  the  surgeon  orders  2  further  deliveries  of  the  anKbioKc  for  7  pm  of  the  same  day  and  7  am  of  the  next  day.  

¤   1g  Cefotaxim  ²   dose?  ²   choice  of  ceph.  

¤   Standard  prep  for  knee  surgery  and  AB-­‐shot  at              10:10h,  first  incision  at  10:42h  

¤   Second  dose  12:42h  

¤   A[er  2  extra  doses  

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40-75% inappropriateness in single hospitals ¤  US (Everitt et al., Infect Control Hosp Epid 1990; Silver et al., Am J Surg 1996;

Gorecki et al.,World J Surg 1999). ¤  Canada (Girotti et al., CJS 1990; Zoutman et al., Can J Surg 1999) ¤  UK (Griffiths et al., J Hosp Infect 1986) ¤  France (Bailly et al, J Hosp Inf 2001) ¤  Italy (Mozillo et al., Eur J Epidemiol 1988; Motola et al., J Chemother 1998) ¤  Belgium (Sasse et al., J Antimicrob Chemother 1998) ¤  The Netherlands (Gyssens et al., J Antimicrob Chemother 1996) ¤  Switzerland (Parret et al., Schweiz med Wschr 1993) ¤  Israel (Finkelstein et al., Isr J Med Sci 1996) ¤  Australia (Johnston et al., Austr Clin Rev 1992)

¤ Lichtenstein-procedure (open inguinal hernia repair with mesh): -less SSI in patients with antibiotics compared to placebo Taylor EW et al. Br J Surg. 2004 Yerdel MA et al. Ann Surg 2001

Platt R et al. N Engl J Med 1990

-no difference in SSI between patients with prophylaxis (1.6%) and placebo (1.8%). Aufenacker TJ et al. Ann Surg 2004

   

¤ Clean  ² ElecKve,  non-­‐traumaKc,  non-­‐infected  ² Hip  replacement,  catheter/device  implantaKon  

¤ Clean-­‐contaminated  ² Open  GI-­‐tract,  urogenital-­‐tract,  or  airways  ² GI-­‐surgery,  hysterectomy,  open  fracture,  CABG  

¤ Contaminated  ² TraumaKc  wound  <  6h,  leakage  from  GI  tract,  infected  urine  or  bile  

¤ Dirty/infected    ² Infected,  pus,  fecal  contaminaKon,  necroKc  Kssue  

Woundclassification

Cruse & Ford(n=63000)

SENIC(n=59000)

Olson & Lee(n=36500)

Culver et al(n=85000)

Clean 1,5 2,9 1,3 2,1

Clean-contaminated 7,7 3,9 2,4 3,3

Contaminated 15,2 8,5 7,9 6,4

Dirty 40,0 12,6 - 7,1

Clean surgery NO except - implant surgery - high intrinsic risk for SSI

Clean contaminated procedures YES Dirty surgery = needs THERAPY

Clean contaminated and contaminated, risk of wound infection > 5-30 %

¤ Colorectal surgery [Baum, 1981] ¤ Appendectomy [Gorbach, 1991] ¤ Esophageal surgery ¤ Gastroduodenal surgery, high risk ¤ Small bowel ¤ Biliary system, high risk ¤ Gynaecological surgery [Hemsell, 1991] ¤ Head and neck surgery [Shapiro, 1991]

www.sign.ac.uk/guidelines

Andreas Voss

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Colo-rectal appendectomy

vaginal hysterectomy

infected UT

Abd/thoracic trauma open #

1. First generation cephalosporins 2. Second generation cephalosporins 3. Third generation cephalosporins 4. Glycopeptides 5. Penicillin and betalactamase inhibitor 6. Clindamycin (allergy?)

¤ High  efficacy  

¤ Low  toxicity  à  “No”  side  effects  

¤ As  narrow  spectrum  as  possible  

¤ On-­‐Kme  administraKon  possible!  

¤ Low  costs  

¤ Different  from  AB  used  for  treatment  

¤ Optimal dose is not exactly known

¤ For most drugs, therapeutic dose is used

¤ Half-life of the drug needs to be considered

¤ Increase the dose for obese patients

Forse RA et al. Surgery 1989;106:750-6

Nightingale & Quintiliani, Pharmacotherapy 1991;11:6S-13S

Andreas Voss

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Surgery Type Antimicrobial recommendations

Hip or knee arthroplasty

Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin*

Beta-lactam allergy: " Vancomycin or clindamycin

Cardiac or vascular

Preferred: Cefazolin or cefuroxime If patient high risk for MRSA: Vancomycin*

Beta-lactam allergy: " Vancomycin or clindamycin

Bratzler DW, Hunt DR. Clin Infect Dis. 2006

Surgery Type Antimicrobial recommendations

Hysterectomy " Cefotetan, cefazolin, cefoxitin, cefuroxime, or ampicillin-sulbactam

Beta-lactam allergy: " Clindamycin + gentamicin or fluoroquinolone* or aztreonam " Metronidazole + gentamicin or fluoroquinolone* " Clindamycin monotherapy

Colorectal † " Neomycin + erythromycin base; neomycin + metronidazole " Cefotetan, cefoxitin, cefazolin + metronidazole, or ampicillin-sulbactam

Beta-lactam allergy: " Clindamycin + gentamicin or fluoroquinolone* or aztreonam " Metronidazole + gentamicin or fluoroquinolone*

Bratzler DW, Hunt DR. Clin Infect Dis. 2006

-24 to –2h = early - 2h = preop 0 to +3h = peri-op >3h = post-op

3.8% RR 6.7

0.6% RR 1.0

1.4% RR 2.4

3.3% RR 5.8

NEJM 1992;326:281-6

Stone Ann Surg 1976;184:443-452

SSI

Administration < 120 minutes before: RR 0.5 Administration 2 or more hours before: RR 5.3

Andreas Voss

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… administration of the first dose within one hour… …optimal timing …is 30 minutes prior to incision…

¤ Guideline:  <120  minutes  before  ² Could  be  -­‐120        or      -­‐60        or      -­‐30        or      -­‐1  ² Do  you  believe  that  all  of  the  above  is  correct?    

¤ Need  to  agree  on  a  range  e.g.    ² -­‐45  to  -­‐15        or  ² -­‐90  to  -­‐30  

¤ Depends  on:  ² AnKbioKc  choice      (penetraKon,  top  concentraKon,  HLT)  

² IndicaKon    (need  to  be  present  in  Kssue,    equilibrium  between  compartments)  

90 to15 minutes before incision – or - stop of blood-flow

McDonald Aust NZ J Surg 1998;68:388

Favo

rs si

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dose

Fa

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dose

Andreas Voss

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¤ Most  studies  have  confirmed  efficacy  of  ≤12  hrs  of  prophylacKc  anKbioKcs  

¤ Many  studies  have  shown  efficacy  of  a  single  dose  

¤ Whenever  compared,  the  shorter  course  has  been  as  effecKve  as  the  longer  course  and  results  in  less  anKbioKc  resistance  

¤ Overview  Status  quo  ¤ IndicaKon  ¤ Choice  of  anKbioKc    ¤ Timing  ¤ DuraKon  ¤ Quality  control  

¤ ProporKon  of  paKents  who  have  their  anKbioKc  dose  iniKated  within  1  hour  before  surgical  incision  (2  hours  for  vancomycin  or  fluoroquinolones)  

¤ ProporKon  of  paKents  who  receive  prophylacKc  anKbioKcs  consistent  with  current  recommendaKons  (published  guidelines)  

¤ ProporKon  of  paKents  whose  prophylacKc  anKbioKcs  were  disconKnued  within  24  hours  of  surgery  end  Kme  (48  hours  for  cardiac  surgery)  

¤ ProporKon  of  paKents  who  have  their  anKbioKc  dose  iniKated  within  1  hour  before  surgical  incision*  

* Or any other time/time range your quality improvement team agreed on

12.44 13.09

Andreas Voss

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00:07

00:14

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00:28

00:36

00:43

00:50

00:57Timing as agreed on ¤ Install  quality  improvement  team  

² MDs,  nurses  and  OR  management,  surgeon  (chair),  anesthesiologist,  ward  staff,  QM,  IC,  pharmacist    

¤ Why  is  prophylaxis  not  given  on  Kme?  ² Process,  structure,  logisKcs,  responsibiliKes    

¤ Consensus  on  how  to  do  it  ² Agree  on  Kme  range  ² Describe  a  realisKc    process  (SOP)  ² Assign  responsibiliKes  

00:00

00:07

00:14

00:21

00:28

00:36

00:43

00:50

00:57Timing as agreed on v  Antibiotic has to be in the tissue at time of

incision or stop of blood-flow

v  Time period = end infusion until incision

v  Could be start of infusion as long as extra time is added and everyone in the hospital knows the rules

v  2nd shot after 2-3 halftimes (3-4 h)

v  2nd shot senseless during stop blood-flow

v  No prophylaxis after 24 hours