Treatment of Surgical Site Infection Meeting Quality Statement 6

Prof Peter Wilson

University College London Hospitals

TEG Quality Standard 6

Treatment and effective antibiotic prescribing: People with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

Monitoring progress against the standard

Surgical site infection

Substantial burden on health care

Hospital stay doubled: £65 million/year in UK

Surgical site infection used as a performance indicator

League tables but rates very dependent on post discharge follow up

Monitoring compliance

Evidence of antibiotic treatment covering the likely pathogens chosen on local resistance and clinical sample results

Measure number appropriate choice / total surgical site infections

Surveillance nurse, antimicrobial stewardship round, medical liaison

Monitoring Impact

Length of stay

Antibiotics

District nurse visits

ICU, HDU, ward stay

Local anaesthetic drainage

General anaesthesia drainage

Wound dressing

Pathogens

Staphylococcus aureus

Coagulase negative staphylococci

Coryneforms

Streptococcus group A

Coliforms

Pseudomonas spp.

Anaerobes

Candida spp.

Effect of pathogens

Each species of pathogen has a different effect on wound infection

Host susceptibility important

Assessment of the wound important in diagnosis, treatment and audit

Treatment of infection determined by the likely pathogen

Host factors

Category of wound

Presence of prosthesis or drain

Prolonged surgery

End of operation list

Surgeon

Aseptic technique

Preoperative stay

Host factors

Carriage of S. aureus

Old age

Chronic illness

Steroid therapy

Obesity

Diabetes

Mechanical breakdown of wound

Oct –Dec 2012 UCLH

In 737/931 (79%) of operations surveyed patients were contacted at one month

26% ASEPSIS >10 (abnormal wound)

8.8% ASEPSIS >20 (infection)

6.8% CDC defined wound infection

54% of infections detected post discharge only

Antibiotics

Prophylaxis 1 dose or 24h – no benefit beyond 4 h post surgery

Increasing ESBL so meropenem usage doubling every year

High dose short duration

Quickly isolate patients with diarrhoea

Treatment

Dressings – keep the wound clean

Topical application – sugar paste, irrigation, vacuum dressing

Surgical drainage of pus

Debridement

Antibiotics

Take care with urgency of treatment

Staphylococcus aureus

Localised purulent infection

Flucloxacillin, teicoplanin, vancomycin

Drain any abscess

Alginates, hydrocolloids, sugar paste

Avoid packing of wound

Streptococcus group A

Spreading cellulitis - little pus

Necrotizing fasciitis: urgent surgical debridement + high dose penicillin

Cellulitis: benzyl penicillin or clindamycin

All wounds covered and kept dry

Coagulase negative staphylococci

Can be similar to S. aureus infection

Remove any prosthetic material or sutures if possible

Teicoplanin or vancomycin

Rifampicin may penetrate biofilm

Alginates, hydrocolloids, sugar paste

Coliforms

Necrotic wound - cleaning most important

Alginates, sugar paste

Mechanical debridement

Correct leaking anastomosis

Antibiotics less important - cefuroxime, ceftazidime, piptazobactam

Pseudomonas aeruginosa

Abdominal wounds, burns or ulcers

Cleaning or debridement of the wound

Avoid topical antibiotics

Hydrocolloids

Enzyme treatments if necrotic

Antibiotics rarely indicated

Anaerobes

Usually mixed with coliforms

Exposure to air - debridement important

Alginates, sugar paste

Correction of bowel leakage

Metronidazole or clindamycin

Topical

Do not treat bacterial colonisation

Irrigants not tested in trials

Sugar paste sterile, does not harm granulation tissue

SSI Prevention Care Bundle

MRSA screening & decontamination

2% chlorhexidine

Antibiotic prophylaxis

Hair removal not shaving

Glucose control

Maintain body temperature

Optimise closure methods

Wound charts

Cumulative observed minus expected infection graph (VLAD) by specialty.

Specialty average risk between 01/05/00 and 30/04/05. Definition of infection: ASEPSIS > 20

Operation date between 01/01/05 and 30/09/11

-150

-100

-50

0

50

100

150

01/01/2005 16/05/2006 28/09/2007 09/02/2009 24/06/2010 06/11/2011 20/03/2013

Dates

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GENERAL ORTHOPAEDIC CARDIAC THORACIC GYNAECOLOGY C-SECTION VASCULAR NEUROSURGERY

Preoperative nasal mupirocin

ICHE 2012 33 152

Two stage revision surgery for infected joint costs $100,000

Culture $96, mupirocin 5 day $6

26% S aureus carriage, screening 85%

Empirical treatment with mupirocin and no screening cheapest

Screen vs treat all both cost effective vs no treatment

Remember If Streptococcus pyogenes suspected:

no pus, spreading infection, act very quickly, get a Gram stain of discharge

Staphylococcal infections must be drained of pus

Pseudomonal infections are often colonization and do not need antibiotic treatment

Conclusion

Skin preparation, body temperature, glucose control, antibiotic prophylaxis

In patient infection much more costly but outpatient infection more common