Complications in Pelvic Floor Surgery: Peri operative infective complications

Transcription

1 IUGA W19: 4 September 2012 Workshop notes Complications in Pelvic Floor Surgery: Peri operative infective complications A/Professor Mary O Reilly MBBS FRACP MPH Eastern Health; Faculty of Medicine, Nursing and Health Sciences, Monash University; Cabrini Health; Melbourne, Victoria, Australia. Introduction While infective complications from pelvic surgery are uncommon, they can be difficult to diagnose and manage. This session will cover perioperative infective complications associated with pelvic floor surgery including prevention, diagnosis and management in addition to an update on some of the newer multi-resistant organisms which may complicate surgery and the new and old agents now used to treat them. The discussion will also include preventing and managing the complications of the antimicrobial agents used to prevent surgical infections Topics to be covered include: Post operative sepsis Post operative haematoma The role of antibiotic irrigations Prevention including bundles and surgical antimicrobial prophylaxis Problematic Bugs Clostridium difficile Recurrent UTI ESBL gram negatives including Indian metallo-betalactamases CA- MRSA Community Acquired MRSA

2 1. An ID physicians approach to postoperative fever?infection Most common Urinary tract infection % HAI, Chest infection, IV site infection Surgical complications are less common Surgical site infection, Intra-abdominal sepsis Haematoma (Remember drug fevers) Question: Is it infection or haematoma or infected haematoma? 1.1 Haematoma Clinical Febrile but often look well despite spiking temperatures of o C No rigors May have persistent fever from time of surgery May be febrile for 7-10 days depending on size of clot Investigations: Blood cultures - negative Initial elevated WCC Elevated CRP: can be in the hundreds Imaging : Ultrasound, CT: absence of features suggesting abscess e.g. no air fluid levels, no complex echoes Management Supportive If uncertain, broad spectrum antibiotics aiming to cease when cultures are negative and diagnosis clear(er) No role for prophylactic antibiotics Risk of selection of resistant organisms Complications including antibiotic related diarrhoea Other complications including IV related infections Confuses the picture and may lead to a long unnecessary course of antimicrobials

3 1.2 Infected haematoma Clinical: associated wound infection or cellulitis, secondary fever if patient rigors, they have an infection Investigation Ultrasound, CT: complex echoes, gas, fluid levels Aspirate polymorphs, positive cultures Positive blood cultures Management Drain if possible o Ultrasound, CT drainage o?open IV/oral antimicrobials as for pelvic sepsis see below May require 2-6 weeks therapy if a large undrained collection 1.3 Pelvic sepsis Clinical: +/- Wound infection or cellulitis, Secondary fever Purulent discharge if patient rigors, they have an infection (if rapidly progressing cellulitis, crepitus, necrosis, local pain out of keeping with clinical signs consider necrotising fasciitis) Investigation Ultrasound, CT: complex echoes, gas, fluid levels Aspirate polymorphs, positive cultures Positive blood cultures

4 Management pelvis sepsis (excluding necrotising fasciitis) Drain if possible o Ultrasound, CT drainage o?open IV/oral antimicrobials as for pelvic sepsis see below ~7 days related to progress (May require 2-6 weeks therapy if a large undrained collection, follow clinically and CRP) Antimicrobial therapy for pelvic post operative sepsis Empiric treatment related to local antibiograms and local guidelines and individual patient Likely organisms Gut Staph Resistant organisms May be low virulence organisms with mesh in situ Risk of yeast infections Previous bacteriology Consider Health service MRO rates Other factors Antimicrobial Stewardship C.difficile rates ESBL rates Toxicity e.g. gentamicin Cost Agents refer to local guidelines and stewardship programs e.g Therapeutic Guidelines Australia; National Antibiotic Guidelines Malaysia, Singapore, ECCMID; local European Guidelines NHS; Local Trust guidelines; SCIP, Scotland; HICPAC (USA); IDSA:;2009 American College of Obstetricians and Gynecologists (ACOG) Australia:

5 Empiric Ampicillin, gentamicin (or 3 rd generation cephalosporin), metronidazole (minimise gentamicin use) Ticarcillin clavulanate, Piperacillin tazobactam if prolonged 3 rd generation cephalosporins plus metronidazole Quinolones plus metronidazole not recommended, reserve agents Carbapenems reserve agent Vancomycin for high prevalence MRSA Others (based on public domain guidelines) Malaysia cefotaxime or ampicillin beta lactamase inhibitor, or ciprofloxacin metronidazole Europe betalactam betalactamase inhibitors UK focus on minimising 3 rd generation cephalosporins, increased gentamicin use US broader cover including carbapenems, quinolones Duration of therapy It depends! Organism and site? associated bacteremia E.g. staph aureus bacteremia recommended 2 weeks IV then 4 week oral enterococcal bacteremia recommended 2 weeks IV Gram negative bacteremia: treat until better, May be all oral therapy or short term IV followed by oral?collection drained, partially drained or undrained?mesh?vascular involvement (very rare) (Other patient factors: prosthetic devices e.g. valve replacements; immune-suppression etc) Role of Antibiotic irrigations for management of sepsis Risks: Local reactions Hypersensitivity Induction of resistance

6 2. Prevention of peri-operative infections: Prevention of peri-operative infective complications Bundles including Antibiotic prophylaxis HICPAC, USA: NHS, UK; NHS Scotland; Australia; Antimicrobial choice: Refer to local guidelines related to procedure, risk, individual and local antibiograms 2.1 General Principles: HICPAC 2009 Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines Administer within 1 hour prior to incision *2hr for Vancomycin and fluoroquinolones Select appropriate agents on basis of surgical procedure Most common SSI pathogens for the procedure Published recommendations Remote infections-whenever possible: Identify and treat before elective operation Postpone operation until infection has resolved Do not remove hair at the operative site unless it will interfere with the operation; do not use razors If necessary, remove by clipping or by use of a depilatory agent Redose antibiotic at the 3 hr interval in procedures with duration >3hrs (* See exceptions to this recommendation in*engelmanr, et al. The Society of Thoracic Surgeons Practice Guideline Series:AntibioticProphylaxis in CardicaSurgery, Part II:AntibioticChoice. Ann Thor Surg2007;83: Adjust antimicrobial prophylaxis dose for obese patients (BMI >30) *Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol2008;29 (Suppl1):S51-S Role of antimicrobial prophylaxis in mesh surgery unproven, but common practice. [ All women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence should receive a single dose of first-generation cephalosporin. (III-B) Society O &G Canada 2012] [Harmanli et al Int Urogynecol J 2012 Antibiotic prophylaxis in mid urethral slings: no benefit]

7 2.3 Gynaecological Antimicrobial prophylaxis (if indicated) Regional differences: EXAMPLES only: please see your local guidelines for recommendations for your region Hysterectomy Australia Therapeutic Guidelines Antibiotic Version (Local health service variations) Cephazolin 1g (2g if >80kg) and metronidazole 500 mg or cefoxitin 1g Malaysia National Antibiotic Guidelines Cefuroxime 1.5 G IV; alternative amoxicillin clavulanate UK Co-amoxiclav1.2g IV given at induction Cefuroxime 1.5g IV plus Metronidazole 500mg IV given at induction NHS Scotland Avoid cephalosporins, clindamycin, quinolones and co-amoxiclav wherever possible Take into account local resistance patterns e.g. >95% of MRSA isolated in Tayside are sensitive to gentamicin De-colonisation therapy prior to surgery when MRSA positive when recommended in Infection Control Policies Canada USA IDSA Cephalosporins single dose cefazolin 1-2 G or cefoxitin or cefazolin Ampicillin sulbactam for endocarditis prophylaxis In patients with beta-lactam allergy, options include clindamycin plus gentamicin or quinolone Consider the individual Allergies Renal and liver function MRO s Recent hospitalisations Recent therapy

8 General Principles for antimicrobial prophylaxis In general one dose, usually IV In general commencing up to 1 hour prior to procedure not during or after the procedure! No role for a few days of oral before (may induce resistance) No evidence for extra doses post operatively Don t use broader spectrum than recommended Difficult to treat post op if complications Call a friend! (ID physician or Microbiologist) If complex individual prophylaxis issues should be discussed with Microbiology or Infectious Diseases pre-operatively and recorded in medical notes NHS Scotland 2.4 Wound Infections If percutaneous surgery i.e. transabdominal or laparoscopic ensure no active skin lesions o Local or remote (CDC 1A) If exfoliating skin condition e.g. psoriasis, eczema; optimise preoperatively especially if inserting mesh Decolonisation MRSA carriers o In general not undertaken for Gynaecological surgery o Regional differences Questionable role of preoperative shower in gynaecological surgery? Hair removal (Cochrane 2006) o Avoid if possible o If required clipping not shaving o As close to surgery as practible IV antimicrobial prophylaxis if relevant Skin antisepsis as per guidelines o Chlorhexidine alcohol superior to povidone iodine in clean/contaminated surgery CDC: no preference Darouiche 2010: chlorhexidine superior Ref.Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, Webb AL, Carrick MM, Miller HJ, Awad SS, Crosby CT, Mosier MC, Alsharif A, Berger DH 2.5 Vaginal preparation Controversial Povidone iodine Chlorhexidine potentially toxic Sterile saline

9 2.6 Prevention of procedural associated UTI See Bundles Investigate for and treat bacteriuria pre op (close to surgery) o If recurrent UTI give pt a MSU slip ~ 5 days pre-operatively o Ensure results followed up and actioned Remove urinary catheter as soon as possible Routine surgical single dose perioperative prophylaxis may reduce UTI 3. Recurrent UTI s 3.1 Avoid chasing the cultures 3.2 Non antimicrobial therapies Topical Estrogen Role of cranberry juice 3.3 Antimicrobial agents Beneficial (Cochrane review) 6 month trial As narrow spectrum as possible Trimethoprim, Cephalexin Avoid Cotrimoxazole due to potential side effects Induces MRO s

10 4. Problematic Bugs 4.1 Clostridium difficile Hyper-virulent strain Drivers: Management Antimicrobial use Prophylaxis or therapy Cephalosporins and quinolones highest risk Prevention Minimise antimicrobial use: Antimicrobial Stewardship In general one dose for prophylaxis is adequate Choice of antimicrobial Cephalosporins higher risk than broad spectrum penicillins or aminoglycosides Early investigation and treatment as per local guidelines Cease antibiotics if possible Oral Metronidazole or oral Vancomycin first line Nasogastric, rectal Vancomycin if unable to tolerate oral Role of probiotics under investigation 4.2 Resistant gram negatives Extended spectrum beta lactamases (ESBL) gram negative organisms e.g. E.coli and Klebsiella other plasmid-mediated beta-lactamase-1 (bladha-1). Resistant to common agents including 3 rd generation cephalosporins e.g. ceftriaxone, cefotaxime May be quinolone resistant Usually susceptible to carbapenems Common in India and Asia and travellers to endemic areas New Delhi metallobeta lactamases (e.g blandm-1). Originally described in E. coli now more widespread including in V. cholerae, Resistant to common agents including 3 rd generation cephalosporins e.g. ceftriaxone, cefotaxime and carbapenems e.g. meropenem Usually no oral agent therefore require prolonged intravenous therapy Infection Control implications

11 Treatment Options: Limited, all IV, all expensive, IV Colistin IV Tigecycline (not for pseudomonas) Consider Hospital in the Home if available Prevention Antimicrobial Stewardship Infection Control in health care facilities 4.3 Community Acquired MRSA Ca MRSA, (formerly Non-multiresistant MRSA [nm MRSA]) MRSA resistant to Methicillin(Oxacillin, flucloxacillin) but often sensitive to clindamycin, doxycycline or Cotrimoxazole in addition to vancomycin Often community rather than hospital associated High virulence. Associated with recurrent boils and severe pneumonia.