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What is new in management of Surgical Infection PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "What is new in management of Surgical Infection" by Prof. Ravi Kant.

This medical PowerPoint presentation talks about advancements in the management of surgical infections in recent years.

Tags : Surgical Infection, Antibiotic Stewardship, Enhanced Recovery After Surgery (ERAS), Wound Management, Minimally Invasive Surgery, critical care medicine, critical care medicine PowerPoint presentation

Published on : Mar 31, 2023 | Views : 1441 | Downloads : 5

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Slide 1-

What is new in management of Surgical Infection Prof. Ravi Kant
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Contents: Introduction Types of surgical infections Definition of SSI Types SSI Recent management of SSI sepsis Peritonitis
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Soft tissue/wound Infictions. Third most reported nosocomial infections 16% of all reported nosocomial infections Most common surgical patient nosocomial infection (38%)
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2/3 involved surgical incision 1/3 deep structures accessed by incision Deaths in patients with nosocomial infections—77% related to infection. Soft tissue/wound Infictions. EWMA Journal 2005; 5(2): 11-15.
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Introduction < 1900= 70-80% mortality for wound infection >1900: Ignaz Semmelweis and Joseph Lister = antiseptic surgery
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Introduction Surgery, trauma, non-trauma local invasion can lead to bacterial insult. Once present, bacteria, initiate the host defense processes. Inflammatory mediators (kinins, histamine, etc.) PMN’s arrive, etc.
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Introduction Surgical infections surgical wound itself or in other systems in the patient. They can be initiated not only by “damage” to the host but also by changes in the host’s physiologic state.
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Infections Two main types Community-Acquired Hospital-Acquired
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Community-Acquired Skin/soft tissue Cellulitis: Group A strep Abcess/furuncle: Staph aureus Necrotizing: Mixed Hiradenitis suppurativa:Staph aureus Lymphangitis: Staph aureus
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Cellulitis
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Furuncle
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Necrotizing
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Hiradenitis
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Lymphangitis
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Breast Abscess
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Peri-rectal abscess
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Gas Gangrene
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Paronychia
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Diabetic foot infection
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Biliary Tract Usually result from obstruction Usual suspects: E. coli, Klebsiella, Enterococci Acute Cholecystitis GB empyema Ascending cholangitis
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Community-Acquired Viral Hepatitis HIV/AIDS Tetanus
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Hospital-Acquired Post-operative At the surgical site Systemic.
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Infected Vascular Graft Inguinal incision is independent risk factor Length of case and blood loss Prosthetic grafts 10%-20% S. Aureus
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Gas gangrene Beta hemolytic strept Clostridial perfringes (gram pos rods) rare 50% polymicrobial Rapid lysis of tissues with relatively little response from host Endotoxin
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Gas gangrene Aggressive debridement & antibiotics Repeat antibiotics
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Catheter Sepsis 80% of cases, colonized catheters had been inserted by inexperienced and experienced residents Key is to identify before sepsis develops Stapylococcus epidermis, S. Aureus, yeast
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Burn Infections Necrotic tissue readily colonized High bacteria counts are NOT a reliable indication of an infected burn Histological examination to determine invasiveness TX: debridement and antibiotics
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Hospital-Acquired Pulmonary Pneumonia Non-ventilator associated Ventilator associated Aspiration
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Hospital-Acquired Urinary Tract Diagnosis Usual suspects Pseudomonas, Serratia, other
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Hospital-Acquired Foreign-body associated Sites Catheters Lines Prosthetics/grafts
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Hospital-Acquired Wound infection & SSI.
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Surgical wounds are healing by 1) Primary intention 2) Secondary intention 3) Delayed primary intention
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Incidence of SSIs →closure/delayed closure of an infected wound [Gottrup, F. Wound healing and principles of wound closure. In: Holström H, Drzewieck KT (Eds). The Scandinavian Handbook of Plastic Surgery. Malmoe: Studenterliteraturen, 2005
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Definition of SSI The CDC : =< 30 days of surgery (or within a year in the case of implants) Mangram . Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999;
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classificationincisionalsurgical site infections Superficial Deep Organ/space
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superficial incisional surgical site infections < 30 days of procedure involve only the skin or subcutaneous tissue around the incision. Mangram . Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999
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Deep incisional surgical site infections < 30 days of procedure (or one year in the case of implants) are related to the procedure involve deep soft tissues, such as the fascia and muscles. Mangram . Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999
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ASEPSIS WOUND SCORING SYSTEM [ Wilson AP, Lancet 1986
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Southampton wound scoring system [Bailey IS, BMJ 1992; 304: 469-71
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Risk Factors Surgical factors Patient-specific factors local systemic
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Factors influencing SSIsPatient Risk Factors Local: High bacterial load Wound hematoma Necrotic tissue Foreign body Obesity Systemic: Advanced age Shock Diabetes Malnutrition Alcoholism Steroids Chemotherapy Immuno-compromise
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Factors influencing SSIs Antibiotics Prophylactic Therapeutic
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Factors influencing SSIs Surgical Risk Factors Type of procedure Degree of contamination Duration of operation Urgency of operation skin preparation operating room environment Antibiotic prophylaxis EWMA Journal 2005; 5(2): 11-15.
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Berard F, Gandon J, Ann Surg 1964
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Reduce hemoglobin A1c levels to <7% before operation Evidence Class II data References Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;
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Smoking cessation 30 d before operation Evidence Class II data References Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008
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Remove hair only if it will interfere with the operation; hair removal by clipping immediately before the operation or with depilatories; no pre- or perioperative shaving of surgical Evidence Class I data References Kjønniksen I. Preoperative hair removal– a systematic literature review. AORN J 2002
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Use an antiseptic surgical scrub or alcohol-based hand antiseptic for preoperative cleansing of the operative team members’ hands and forearms Evidence Class II data References Anderson DJ. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;
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Prepare the skin around the operative site with an appropriate antiseptic agent, including preparations based on alcohol, chlorhexidine, or iodine/iodophors Evidence Class II data References Anderson . Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;
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Administer prophylactic antibiotics for most clean-contaminated and contaminated procedures, and selected clean procedures use antibiotics appropriate for the potential pathogens Evidence Strong Class I data References Springer R. The Surgical care improvement project-focusing on infection control.Plast Surg Nurs 2007;
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Administer prophylactic antibiotics within1 h before incision (2 h for vancomycin and fluoroquinolones) Evidence Strong Class II data References Springer R. The Surgical care improvement project-focusing on infection control.Plast Surg Nurs 2007
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Use higher dosages of prophylactic antibioticsfor morbidly obese patients Evidence Limited Class II data References Springer R. The Surgical care improvement project-focusing on infection control.Plast Surg Nurs 2007
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Carefully handle tissue, eradicate dead space, and adhere to standard principles of asepsis Evidence Class III References Anderson DJ. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;
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Redose prophylactic antibiotics with short half-lives intraoperatively if operation is prolonged (for cefazolin if operation is >3 h) or if there is extensive blood loss Evidence Limited Class I, Class II data References Scher K. Studies on the duration of antibiotic administration for surgical prophylaxis Am Surg 1997
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Maintain intraoperative normothermiac Evidence Class I; some contradictory Class II data References Sessler DI, Akca O. Nonpharmacological prevention of surgical wound infections. Clin Infect Dis 2002
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Discontinue prophylactic antibiotics within 24 h after the procedure (48 h for cardiac surgery &liver transplant procedures) discontinue prophylactic antibiotics after skin closure Evidence Class I; meta-analyses support single dose regimens for prophylaxis References ASHP Therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 1999
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Maintain serum glucose levels <200 mg/dL on PO Evidence Class II data References Anderson DJ. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008
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Monitor wound for the development of SSI postoperative days 1 and 2d Evidence Class III data References Anderson DJ. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008
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opening the wound I&D . For most patients who have had their wounds opened and adequately drained, antibiotic therapy is unnecessary. Treatment of SSI Stevens DL. Prguidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005actice
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o use antibiotics only when there are significant systemic signs of infection (temperature higher than 38.5Cor heart rate greater than 100 beats/min) erythema extends more than 5 cm from the incision. Stevens DL. Prguidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005actice Treatment of SSI
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Sepsis Sepsis: Commonly called a "blood stream infection.“ The presence of bacteria (bacteremia) or other infectious organisms or their toxins in the blood (septicemia) or in other tissue of the body.
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Sepsis Sepsis may be associated with clinical symptoms of systemic (bodywide) illness, such as fever, chills, malaise , low blood pressure, and mental status changes. Sepsis can be a serious situation, a life threatening disease calling for urgent and comprehensive care.
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Sepsis, Septic shock Signs of: Increased C.O. Altered O2 SATURATION. Metabolic acidosis (usually) Can lead to ---Death.
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Sepsis Sepsis remains a major clinical problem for 21st century marginal improvement in the mortality antibiotics are cornerstone 10% improvement in mortality Mac Arthur RD et al.Adequacy of early empiric antibiotic treatment in severe sepsis experience from MONARCS trial . Clin Infect Dis 2004;38(2):284-88
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Cytokines Release TNF , IL1 IL6,10 Protease ,PG PAF Endothelial injury Coagulopathy Tissue factor Fibrin clot Inhibit activity Protein C Antithrombin III Suppress fibrinolysis
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The aim Sepsis is condition diagnosed on the bases of clinical & laboratory parameters increased level of inflammatory mediators reflects global dysregulation of immune response Examine the latest evidence for the use of immuno-modulating drugs obtained from human clinical trials
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immune response is multi-faceted Aim : Eliminate invading object Maintain homeostasis Limit tissue damage
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Sepsis And host response More than adequate or Inadequate.
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Inadequate Host response Stimulation by Levamisole Pro inflammatory Cytokine interferon y Anti- prostaglandins (immunosuppressive mediators
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IL-10 IL- 10 administration improves survival following endotoxin challenge Live candida - block IL-10- improves survival
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More than adequate host response Anti-inflammatory cyotkines like Interleukin 10 Agents to neutralise tumor necrsois factor or interlekin -1
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Severity assessment PAC- initially Ultra low frequency ossillations in CO/global end diastolic vol -severity high Lactate levels –good severity predictor Low exogenous clearance – very early predictor of mortality C reactive protein – high risk of organ failure/ too slow to monitor
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Management of Sepsis Hemodynamic, respiratory stability Source control in sepsis Early enteral feed/intensive insulin therapy stress ulcer prophylaxis, and deep vein thrombosis Daily hemodalysis – better survival
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Early goal-directed therapy (EGDT) Oximetric central venous catheters were placed to measure central venous pressure (CVP) & CvO2 500-mL aliquots of isotonic crystalloid were given by bolus infusion to achieve a central venous pressure greater than 8 mm Hg. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;
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Early goal-directed therapy (EGDT) Mean arterial pressure was maintained at 65 mm Hg or higher with vasopressors. If the CvO2 saturation was still less than 70%, blood was transfused to a hematocritof 30. If the CvO2 saturation was still less than 70%, dobutamine was started. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;
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Early goal-directed therapy (EGDT) Mortality was significantly lower among patients randomized to EGDT (48.2% versus 33.3%, P 5 .01). Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;
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Sepsis it is complex process and the goal of immune therapy is identifying critical point of response to modulate it
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TNF TNF is an important mediator of sepsis Serum level correlate with outcome Immunotherapy : - Antibodies - Blocking receptor Calandra T et al.Prognostic values of tumor necrosis factor/cachectin,interlukin-1,interferon-alpha and interferon gamma in the serum of patients with septic shock. J Infec Dis 1990;161:982-87
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Blockade of tumor necrosis factor Improves outcome in E. coli septicemia. But increased mortality with cecal ligation and puncture.
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TNF antibody NEROCEPT : reduction of mortality 1st 3 days - dose dependant INTERSEPT : -reduce progression of sepsis - rapid resolution of shock
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TNF antireciptor: Recombinant receptor : - dose dependant increase in mortality - deleterious effect in human clinical trial Fisher CJ et al.Treatment of septic shock with the tumot necrosis factor receptor.Fc fusion protein .N Engl J Med 1996;334:1697-702
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Most widely known and used immunotherapy Blunt & potent anti-inflammatory Action : Prevent complement activation inhibit nitrous oxide synthatase Decrease proinflammatory cytokines inhibit neutrophil aggregation stabilise lysosomal membrane Steroids
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1960-90S No advantage 1997 increase mortality with high dose Beneficial for patient with adrenal insufficiency Currently “ 2nd generation trials” : - low & physiological dose - long duration - vasopressor dependant pt - no difference among corticotrophic dependant or non dependant Minneci PC et al Meta analysis:the effect of steroids on survival & shock during sepsis depend on the dose. Ann Intern Med 2004;141:47-57
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Inhibit thrombin and factor Xa low during sepsis d/t - impaired synthesis - consumption by DIC - degradation by elastase Abraham E et al.Efficacy and safety of tifacogen in severe sepsis: randomised controlled trial .JAMA 2003;290:238-47
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APC action Anticoagulant Anti-inflammatory inhibit transcription NF-kB reducing pro-inflammatory cytokines APC inactivate Va,VIIa Low level in sepsis cytokine-induced down-regulation of thrombomodulin Esmon CT. Inflammation & thrombosis : mutual regulation by protein C. Immunologist 1998;6:84-89
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48hrs /reduces mortalityiv 24 ug/ kg/hr x 96hrs Recombinant APC “ Dotrecogin alfa” : - Significant reduction of mortality - faster resolution cardiovascular & respiratory dysfunction PROWESS ( protein c worldwide evaluation in severe sepsis) multicentre study,2001 APC
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Vasopressor/ Inotropics The Surviving Sepsis guidelines recommended dopamine or norepinephrine as first line agents. Vasopressin should be considered an important adjunct vasopressor. Epinephrine may be considered as a second line agent. Matthew C. Byrnes, MDa,b,*, GregJ. Beilman, MDa
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INTENSIVE GLUCOSEMANAGEMENT Current international recommendations have been made to maintain blood glucose levels lower than150 mg/dL. Maintenance of blood glucose between 80 and 110 mg/dL may carry a significant risk of hypoglycemia.
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All of the mentioned immunotherapeutic strategies worked in animal models of sepsis but not always converted into patient Comorbidity Extreme ages organ dysfunction genetic polymorphism site of infection
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cautious multi-centre studies ! - differences resources - availability of intensive care bed
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Only APC has been shown to improve outcome in septic patient low steroid dose also worthy , should not restricted to corticotrophin hypo-responsive patient Sprung CL et al.Influence of alterations in foregoing life sustaining treatment practices on a clinical sepsis trial.Critical Care Medicine 1997;25:383-7
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most effective management of septic patient remains recognition support of organ dysfunction antibiotics remain the cornerstone of management
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Administration of AT III is not recommended in sepsis : no significance difference in mortality increase risk of bleeding KyberSept trial “ randomised controlled clinical trial “
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Peritonitis
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Classification Primary peritonitis Secondary peritonitis Tertiary peritonitis
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Secondary peritonitis is the most common form for surgeons
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Intra-abdominal sepsis... Diversion Nutrition Fluid & Electrolytes ABG Antibiotics
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Diversion Small Bowel : ileostomy Large bowel : colostomy More important than antibiotics
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Nutrition Enteral or parenteral (TPN)
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Any Question?
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References Awad, S., Palacio, C., Subramanian, A., Byers, P., Abraham, P., Lewis, D., & Young, E. (2009). Implementation of a methicillin-resistant staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. The American Journal of Surgery, 198(5), 607-610. doi:10.1016/j.amjsurg.2009.07.010 Bratzler, D. (2006). The surgical infection prevention and surgical care improvement project: Promises and pitfalls. The American Surgeon. 72(11). 1010-1016. Retrieved from http://www.highbeam.com/The+American+Surgeon/publications.aspx Centers for Disease Control and Prevention. (2008). Surgical site infections, frequently asked questions. Retrieved from: http://www.cdc.gov/ncidod/dhqp/FAQ_SSI.html Centers for Medicare & Medicaid Services. (2008). Medicare and Medicaid move aggressively to encourage greater patient safety in hospitals and reduce never events. Retrieved from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=3219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
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References Chundamala, J., & Wright, J. (2007). The efficacy and risks of using povidone-iodine irrigation to prevent surgical site infection: An evidence-based review. Canadian Journal of Surgery. 50, 473-481. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/journals/505 Institute for Healthcare Improvement. (IHI). Surgical Site Infections. Retrieved from http://www.ihi.org/ihi/Topics/PatientSafety/SurgicalSiteInfections/SurgicalSiteInfectionsCaseForImprovement Joint Commission on Accreditation of Healthcare Organizations (JCAHO). 2004. Hospital National Patient Safety Goals. Retrieved from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/04_npsgs.htm Kable, A., Gibberd, R., & Spigelman, A. (2004). Complications after discharge for surgical patients. ANZ Journal of Surgery, 74, 92-97. doi:10.1046/j.1445-2197.2003.02922.x. Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., Jarvis, W. R., & The Hospital Infection Control Practices Advisory Committee. (1999). Guideline for prevention of surgical site infection. Infection Control and Hospital Epidemiology, 20, 247-278. Retrieved from http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/SSI.pdf
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References Peden, A. & Vaughan, J. (2006). American Journal of Infection Control. Hand Hygiene, 34(5), E60. Retrieved from http://www.ajicjournal.org/handhygiene Odom-Forren, J. (2006). Preventing surgical site infections. Nursing Management, 36, 58-64. Retrieved from http://journals.lww.com/nursingmanagement/Pages/issuelist.aspx Ramos, A., Asenslo, A., Munez, E., Torre-Cisneros, J., Montejo, M., Aguado, J.,… Cisneros, J. (2008). Incisional surgical site infection in kidney transplantation. Reconstructive Urology, 72, 119-123. doi:10.1016/j.urology.2007.11.030 Wynne, R., Botti, M., Stedman, H., Holsworth, L., Harinos, M., Flavell, O., & Manterfield, C. (2004, January). Effect of three wound dressings on infection, healing comfort, and cost in patients with sternotomy wounds. Chest Journal, 125, 43-49. Retrieved from http://intl.chestjournal.org