Surgical site infections. J Scott Weese DVM DVSc DipACVIM

Transcription

1 Surgical site infections J Scott Weese DVM DVSc DipACVIM

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3 Adapted from Mandell et al 2005 Risk of SSI Microbial concentration and virulence X Tissue injury X Foreign material X Antimicrobial resistance General and local immunity X Perioperative antimicrobials

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5 KPC MRSA VRE MRSP FQRP MDR CMY-2 ESBL

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10 In the absence of a documented, logical infection control program, it s tough to argue that an infection was non-preventable

11 Take home message #1: Every clinics needs an infection control program

12 Infection Control Manual Central IC resource Cleaning and disinfection Training Bite/scratch protocols SSI surveillance and documentation Roles and responsibilities Make sure you document all that you do and make sure you DO all that you document

13 documentscompendia.html! Resources section!

14 Take home message #2: Someone needs to be in charge

15 Infection Control Practitioner Critical and underused infection control tool Central IC resource for the practice Information reporting Training (and documentation) Protocol development General resource for all things infection control Doesn t need to be a DVM or have special training

16 Take home message number 3: Surveillance isn t a bad word

17 Surveillance If you don t look, you don t find. If you don t find, you don t know. If you don t know, you can t intervene.

18 Do you know your endemic SSI rate? Do you have the data? Do you have a means to get the data? How good are the data? Would you be able to detect a change in SSI rate? Would you be able to intervene?

19 How to collect SSI data? Medical record review Recheck evaluation/suture removal visit Some may go to other clinics Infections may occur after suture removal Active telephone follow-up Time consuming What timeframe? Referral practices: information from referring veterinarians How good is routine communication?

20 OVC SSI Surveillance 30d SSIs identified in 28/946 (3.0%) patients! 25/847 (3.0%) dogs! 3/99 (3.0%) cats 1 yr followup Additional infection identified in 1/154 (0.65%)! TPLO 11/28 (39%) not documented in the medical record Turk et al, unpublished data

21 E. coli 5% Klebsiella 5% Enterococcus 10% Pasteurella 5% Strep. canis 5% MRSP 45% MSSP 10% MRSA 15%

22 Take home message #4: Think about your peri-operative antibiotic practices

23 Peri-operative Points It can t hurt is a fallacy Don t use antimicrobials in lieu of proper surgical and aseptic technique Starting after surgery is no more effective than not starting at all! Therapeutic levels at the time of first incision Induction or later (before first cut) Beta-lactams have short half-lives! Maintain therapeutic levels during entire surgery

24 TPLO s, Peri-op antimicrobials administered to 223/244 (99.6%) dogs Time from 1 st dose to incision min (mean + SD) Range: min >60 min 18% <30 min 25% Nazarali et al, unpublished data min 57%

25 87% received required intra-op dose on time Mean interval 95.1 min Risk factors for SSI Surgical time (P=0.03) Post-op antimicrobials (protective, P=0.01)

26 How Long? Little empirical evidence Still controversial in humans Once risk of contamination has passed (closure) and infection is not present, antimicrobial administration should typically stop Gross contamination Major procedures Invasive devices? TPLOs?

27 How Long? Little empirical evidence Still controversial in humans Once risk of contamination has passed (closure) and infection is not present, antimicrobial administration should typically stop Gross contamination Major procedures Invasive devices? TPLOs?

28 Take home message #5: Know your (actual) patient preparation methods

29 Patient Preparation Issues Clipping! Excessive attempts to remove hair! Poor technique! Poor equipment Scrubbing! Poor technique! Too aggressive! Confusing contact time with scrubbing time

30 Patient Prep Observation Contact times Soap: mean 82s, median 53s, range s Alcohol: mean 41s, median 30s, range 3-220s Reuse of gauze 60/62 (97%) alcohol applications 53/60 (88%) chlorhexidine/betadine applications Anderson et al, unpublished data

31 Patient Prep Observation Contact times Soap: mean 82s, median 53s, range s Alcohol: mean 41s, median 30s, range 3-220s Reuse of gauze 60/62 (97%) alcohol applications 53/60 (88%) chlorhexidine/betadine applications Anderson et al, unpublished data

32 Take home message #6: Surgical waterless hand sanitizers are good

33 Take home message #7: Know your sterilization and disinfection practices

34 Autoclave Quality Control External indicator tape Not reliable doesn t tell you about contents Indicator strips In every pack Biological indicators Confirm actual sterilization Performed periodically Documented: autoclave log

35 Flash Sterilization

36 Cold Sterilization

37 Take-home message #8: Look at your practice with a new set of eyes

38 Images from: / vetspecialists.co.uk

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42 MRSP Weak 3% Moderate 32% Strong 65%

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44 Take-home message #9: Biofilm - bad

45 How do we deal with biofilm? Prevent it from developing Infection prevention Judicious use of invasive devices/implants Implant materials with lower biofilm formation tendency Prompt diagnosis and proper treatment of infections Before biofilm gets established Removal of implants/debris New antimicrobials/combinations? Enzymes to dissolve biofilm?

46 Dispersin B Glycoside hydrolase enzyme produced by Aggregatibacter actinomycetecomitans Catalyzes hydrolysis of poly-nacetylglucosamine (PNAG) extracellular polysaccharide produced by various Gram positive bacteria and some Gram negatives

47 Take-home message #10: Culture your SSIs

48 Take-home messages :

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50 Surgical site infections do not indicate poor practice

51 Surgical site infections do not indicate poor practice Failing to take measures to prevent them does.

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55 The End

56 Number Tetracycline Doxycycline Minocycline < >16 Minimum inhibitory concentration (MIC) Breakpoint R: >16, I: 8, S< 4 ug/ml