Prevention of SSI

Question 1

Hypothermia

Answer 1

Mild Hypothermia (34-36C)
Incidence of SSI up from 5.8 to 18.8%
Benefits of Normothermia increase wound healing and decrease vasoconstriction.
Decrease super oxide radicals
Induced anti-inflammatory profile
Decreased collagen production

Question 2

Hyperoxia

Answer 2

Preservation of wound O2 tension
O2 radical by neutrophils
Develop collagen and epithelium
Decrease SSI with FiO2 0.8
Absolute risk reduction of 7%
Relative reduction of 45%

Question 3

Fluid Management

Answer 3

Euvolemia maintains perfusion
SubQ tissue hypovolemic
No significant change in SSI rate
Tissue O2 tension increase, but no effect
No effect colloid vs crystaloid

Question 4

Blood Glucose

Answer 4

Hyperglycemia increased morbitity/mortality:
Decreased leukocyte count
Deactivation of immunoglobulins
Functional Deficits in neutrophil function.

Question 5

Blood Transfusions

Answer 5

Post-op infection linked to blood products
Early studies used whole blood
Hemorrhage itself is a factor
SSI decreased with auto PRBC

Question 6

Nasopharynx Flora

Answer 6

Staph
Strep (mainly pneumoniae)
Moraxella Catarrhalis
Hemophilus

Question 7

Skin Flora

Answer 7

Staph epidermidis

Staph aureus

Question 8

Oropharynx Flora

Answer 8

Strep: Viridans, pyogenes, pneumoniae
Moraxella catarrhalis
Hemophilus

Question 9

Intestine Flora

Answer 9

Bacteroides fragilis
Strep
Enterococci

Question 10

Genital Tract (female)

Answer 10

Strep

Staph

Question 11

Bactericidal

Answer 11

Actively Kill Microorganisms

Question 12

Bacteriostatic

Answer 12

Slow growth of microorganisms

Question 13

Wound classes

Answer 13

Clean: Closed, elective
Clean-contaminated: GI,GU
Contaminated: Acute inflammation, penetrating trauma
Dirty: Preexisting infection, perf GI, trauma > 4hrs

Question 14

Cephalosporin Mechanism

Answer 14

Beta Lactam ring inhibits cell wall synthesis

Binds penicillin-binding proteins (PBPs)

Question 15

Clean Procedures

Answer 15

Cefazolin 1-2g IV

Question 16

Thoracic/Orthopedic

Answer 16

Cefuroxime 1.5g IV

Question 17

Bowel

Answer 17

Cefoxitin 1-2g IV
Cefazolin 1-2g + metronidazole 500mg
Ampicillin/sulbactam 3g

Question 18

PCN allergies

Answer 18

Vancomycin 1 g (10-15 mg/kg)
Clindamycin (600-900mg)
Gram Negative Coverage: Gentamicin, ciproflaxin, levoflaxin, aztreonam

Question 19

Vancomycin - MoA

Answer 19

Inhibits cell wall synthesis
Bactericidal against gram+
Time dependent killing..time above MIC for organism is more important
15mg/kg q12h

Question 20

Repeat Dosing

Answer 20

Cefazolin: 2-5hr
Cefoxitin: 2-3hr
Cefuroxime: 3-5hr
Ampicillin/sulbactam: 2-4
Nafcillin: 2hrs
Vancomycin: 6-12hr
Clindamycin: 3-6hr
Metronidazole: 6-8hr

Question 21

Neurosurgery

Answer 21

Organisms: S. aureus, S. Epidermidis
Recommendations: Cefazolin 1-2g, nafcillin 1-2g, vancomycin 1g

Question 22

Head and Neck

Answer 22

Organisms
Mouth: Streptococci, S. Epidermidis
Nose: Staph and strep
Recommendation: Cefazolin 1-3g, clindamycin 600-900mg+gentamycin 1.5mg/kg

Question 23

Cardiac Surgery

Answer 23

Organisms: S. aureus and coagulase-neg staph
gram - bacilli with saphenous vein
Cefuroxime
vancomycin and clindamycin

Question 24

Noncardiac thoracic surgery

Answer 24

Recommendation
cefazolin 1-2g
Cefuroxime 1.5g
Vancomycin 1g
Clindamycin 600-900mg

Question 25

Colorectal Surgery

Answer 25

``` Organisms: gram-neg bacilli, anaerobes, enterococci Recommendation: Neomycin+erythromycin Neomycin+metronidazole Cefazolin 1-2g + metronidazole 0.5g Cefoxitin or cefotetan 1-2g Ampicillin-sulbactam 3g ```

Question 26

Colorectal surgery with PCN allergy

Answer 26

``` Clindamycin and one of: gentamicin 1.5mg/kg ciproflaxin 400mg levofloxacin 750mg Moxifloxacin 400mg Metronidazole+aztreonam 1-2g +gentamicin other combo. ```

Question 27

Appendectomy

Answer 27

``` Organism: aerobic/anaerobic gram-neg enteric Recommend: Cefoxitin 1-2g Ampicillin-sulbactam 3g Cefazolin 1-2g and metronidazole 0.5g PCN allergic Clindamycin + gentamicin ```

Question 28

Esophageal and Gastroduodenal

Answer 28

Organisms: E. Coli, staph, strep, enterococci Recommendation: Cefazolin (1-2g)

Question 29

Orthopedics

Answer 29

Clean procedures do NOT need antibiotics | With hardware: cefazolin 1-2g, vancomycin 1g

Question 30

Cesarean Delivery

Answer 30

Cefazolin before incision

Question 31

Vancomycin Pearl

Answer 31

Redman syndrome: Pruritus, flushing, erythema of head and torso Arterial Hypotension

Question 32

Gentamicin peral

Answer 32

ototoxicity

Question 33

MRSA

Answer 33

Methicillin resistant staph aureus

Question 34

VRE

Answer 34

Vancomycin Resistant Enterococci

Question 35

C-diff

Answer 35

Clistridium Difficile