Treatment of Surgical Site Infection Meeting Quality Statement 6. Prof Peter Wilson University College London Hospitals

Transcription

1 Treatment of Surgical Site Infection Meeting Quality Statement 6 Prof Peter Wilson University College London Hospitals

2 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

3 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

4 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

5 Monitoring Impact Length of stay Antibiotics District nurse visits ICU, HDU, ward stay Local anaesthetic drainage General anaesthesia drainage Wound dressing

6 Pathogens Staphylococcus aureus Coagulase negative staphylococci Coryneforms Streptococcus group A Coliforms Pseudomonas spp. Anaerobes Candida spp.

7 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

8 Host factors Category of wound Presence of prosthesis or drain Prolonged surgery End of operation list Surgeon Aseptic technique Preoperative stay

9 Host factors Carriage of S. aureus Old age Chronic illness Steroid therapy Obesity Diabetes Mechanical breakdown of wound

10 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

11 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

12 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

13 Staphylococcus aureus Localised purulent infection Flucloxacillin, teicoplanin, vancomycin Drain any abscess Alginates, hydrocolloids, sugar paste Avoid packing of wound

14 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

15 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

16 Coliforms Necrotic wound - cleaning most important Alginates, sugar paste Mechanical debridement Correct leaking anastomosis Antibiotics less important - cefuroxime, ceftazidime, piptazobactam

17 Pseudomonas aeruginosa Abdominal wounds, burns or ulcers Cleaning or debridement of the wound Avoid topical antibiotics Hydrocolloids Enzyme treatments if necrotic Antibiotics rarely indicated

18 Anaerobes Usually mixed with coliforms Exposure to air - debridement important Alginates, sugar paste Correction of bowel leakage Metronidazole or clindamycin

19 Topical Do not treat bacterial colonisation Irrigants not tested in trials Sugar paste sterile, does not harm granulation tissue

20 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

21 Number of infections above expected 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 GENERAL ORTHOPAEDIC CARDIAC THORACIC GYNAECOLOGY C-SECTION VASCULAR NEUROSURGERY /01/ /05/ /09/ /02/ /06/ /11/ /03/2013 Dates

22 Preoperative nasal mupirocin ICHE 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

23 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

24 Conclusion Skin preparation, body temperature, glucose control, antibiotic prophylaxis In patient infection much more costly but outpatient infection more common