Surgical Site Infections Flashcards
Wound classification: Clean
An uninfected operative wound in which no inflammation is encountered and respiratory, alimentary, genital or uninfected urinary tracts are not entered.
Wound classification: Clean Abx
Not indicated unless high-risk procedure
Wound classification: Clean-contaminated
Operative wounds in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.
Specifically operations involving the biliary tract, appendix, vagina and oropharynx.
Provided no evidence of infection or major break in technique is encountered.
Wound classification: Clean-contaminated Abx use
Prophylactic antibiotics indicated
Wound classification: Contaminated
Open, fresh, accidental wounds.
Operations with major breaks in sterile technique or gross spillage from GI tract and incisions in which acute, nonpurulent inflammation is encountered.
Wound classification: Contaminated Abx use
Prophylactic antibiotics indicated
Wound classification: Dirty
Old traumatic wounds with retained devitalized tissue and those that involve clinical infection or perforated viscera.
Wound classification: Dirty Abx use
Therapeutic antibiotics indicated
JS a 65 y/o male underwent a radical prostatectomy requiring entry into GU tract .
No prior infection noted and no major breaks in sterile technique noted.
How would you classify the wound? A.) Clean B.) Clean-contaminated C.) Contaminated D.) Dirty E.) Dirty-contaminated
B.) Clean-contaminated
Surgical site infection Microbiology most common pathogens?
Staphylococcus aureus 23%
Coagulase-negative staphylococci 17%
Which of the following pairs represents the most common pathogens in surgical site infections?
A.) Staphylococcus aureus and Coagulase-negative staphylococci
B.) Staphylococcus aureus and Acinetobacter spp.
C.) Serratia spp. and Proteus spp.
D.) Enterococcus and Pseudomonas spp.
E.) Streptococci and Klebsiella spp.
A.) Staphylococcus aureus and Coagulase-negative staphylococci
Factors affecting SSI
SSI Procedure related Operating Room related Antibiotic prophylaxis Patient related
Patient-related factors
Age Glucose control Obesity Smoking Immunosuppression Nutrition status Remote site(s) of infection/Previous hospitalization
Procedure-related factors
Hair removal
Skin preparation
Patient
Surgeon
Incision
Surgeon skill/technique
Oxygenation
Normothermia
Operating Room related factors
Ventilation
Traffic
Environmental surfaces
Surgical site prevention strategies pre-hospital
Preoperative bathing
Smoking cessation
Glucose control
MRSA screening
Bowel preparations
Surgical site prevention strategies hospital
Glucose control
Hair removal
Skin preparation
Surgical hand scrub
Surgical attire
Intraoperative normothermia
Wound protectors
Antibiotic sutures
Gloves/instruments
Wound closure
Topical antibiotics
Supplemental oxygen
Wound care
Which of the following statements is FALSE regarding factors associated with SSIs?
A.) Impaired glucose control increases risk of SSI
B.) Smoking augments the chance of acquiring a SSI
C.) Poor ventilation may result in contamination of wounds and SSIs
D.) Low OR traffic is associated with higher rates of SSIs
E.) Maintaining normothermia reduces SSIs
D.) Low OR traffic is associated with higher rates of SSIs
High operating room traffic is associated with higher rates of SSI’s
Principles of surgical prophylaxis
Antimicrobial agent(s) should:
- Prevent SSI
- Prevent SSI-related morbidity and mortality
- Reduce the duration and cost of health care
- Produce no adverse effects
- Have no adverse consequences for the microbial flora of the patient or hospital
When is cefazolin inappropriate?
Additional anaerobic coverage
-Colorectal surgery
Additional Gram-negative coverage
MRSA colonization
Severe beta-lactam allergy
Procedures requiring anaerobic coverage
Appendectomy for uncomplicated appendicitis
Small intestine with obstruction
Colorectal
Urologic - Clean-contaminated
Head and neck - Clean-contaminated
MRSA colonization
Considered for patients with known or high risk
High risk: recent hospitalization, nursing-home residents, hemodialysis patients
Screening and decolonization
Total joint replacement
Cardiac procedures
Decolonization should be completed close to date of surgery
Vancomycin should NOT be administered to MRSA-negative patient
Prophylaxis dosing weight
Ampicillin/sulbactam - 3g Aztreonam - 2g ****Cefazolin - 2g, 3g (≥120kg)**** Cefuroxime - 1.5g Cefotaxime - 1g Cefoxitin - 2g Ceftriaxone - 2g Ciprofloxacin - 400mg Clindamycin - 900mg Ertapenem - 1g ****Gentamicin - 5mg/kg (single dose)**** Levofloxacin - 500mg Metronidazole - 500mg ****Vancomycin - 15mg/kg****
Timing of initial dose
Deliver antibiotic to operative site prior to contamination
-Achieve sufficient tissue concentrations
One hour before incision
-2 hours for vancomycin and fluoroquinolones
If given after incision no appreciable effect on SSIs
Intraoperative redosing for prevention of surgical site infections
Redose if procedure exceeds two half-lives of antimicrobial
OR
Estimated blood loss of >1500 ml
Intraoperative redosing Ampicillin/sulbactam
2 hrs
Intraoperative redosing Aztreonam
4 hrs
Intraoperative redosing Cefazolin
4 hrs
Intraoperative redosing Cefuroxime
4 hrs
Intraoperative redosing Cefotaxime
3 hrs
Intraoperative redosing Cefoxitin
2 hrs
Intraoperative redosing Clindamycin
6 hrs
Duration of prophylaxis according to ASHP/SIS/SHEA
Should be less than 24 hours for most procedures
Duration of prophylaxis according to WHO
Surgical antibiotic prophylaxis administration should not be prolonged after completion of the operation
TJ is a 73 y/o female who will undergo elective colorectal surgery today at 1700. No active infection. TJ weighs 115 kg.
Allergies: NKDA
PMH: HTN
What prophylaxis would you recommend?
A.) Cefazolin 3 g B.) Cefazolin 2 g C.) Clindamycin 900 mg + gentamicin 5 mg/kg D.) Cefazolin 3 g + metronidazole 500 mg E.) Cefazolin 2 g + metronidazole 500 mg
E.) Cefazolin 2 g + metronidazole 500 mg
TJ is a 73 y/o female who will undergo elective colorectal surgery today at 1700. No active infection. TJ weighs 115 kg.
Allergies: NKDA
PMH: HTN
At what interval would you recommend redosing the cefazolin?
A.) 2 hours B.) 4 hours C.) 6 hours D.) 8 hours E.) No redosing necessary regardless of procedure duration
B.) 4 hours
TJ is a 73 y/o female who will undergo elective colorectal surgery today at 1700. No active infection. TJ weighs 115 kg.
Allergies: NKDA
PMH: HTN
What duration would you recommend (including intraoperative dosing)?
A.) One time pre-operative dose B.) 24 hours C.) 36 hours D.) 2 days E.) 4 days
A.) One time pre-operative dose
