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Reducing Infections in Surgical Practice
Fred A Sweet, MD
Rockford Spine Center
Illinois, USA
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Introduction: How bacteria get in
The Host Skin PREP
The Surgeon Prophylactic Antibiotics
The Procedure Local Antibiotics
The STAFF Post op care
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The HOSTDiabetes (HgbA1c)
smoking
obesity
protein stores
Immune compromise (Rheumatoid meds etc)
renal failure, Liver failure etc
MRSA colonization- screening effective???
Decolonization help???
Mupirocin ?? Chorhexidine??
Hygiene
CONTAMINATION and WOUND HEALING
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The Surgeon
Experience
Surgical technique
Hygiene
Dermatitis (eczema, dandruff)
Double glove
Change Gloves after drape?
Hand Prep- Chlorhexidine residual?
MRSA Colonization????
Decolonization???
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The Procedure
Size of incision
Duration of procedure
Blood loss
Tissue disruption
Implants
Microscope
Staff scrubbing in and out for breaks, set ups
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The Staff
Number of OR STAFF (talking, in and out of room)
Experience and sterile technique
scrub -chlorhexidine residual?
double glove
Hair nets??? Vs hoods??
MRSA colonization??Decolonization of staff???
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Skin PREP
Chlorhexidine vs Iodine
Duraprep
Alcohol
Ioban
combination prep with adherent drape
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Antibiotic ProphylaxisAre we using the right agent for the procedure?
57% of staph resistant to Cefazolin
IV VANCO no better than Cefazolin
Ceftaroline or linezolid for MRSA prophylaxis??
Redosing for longer procedures?
Combination IV Antibiotics?
Cefazolin + Gent = 80-85% coverage
Cefazolin +Vancomycin IV ????
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Antibiotic Prophylaxis
Role of Local Antimicrobials (not FDA APROVED)
Vancomycin Powder- empiric, dose uncertain
Gentamicin Powder – dose by weight
Dilute Betadine Lavage ???
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Post op CARE
Reduce wound contamination
non occlusive dressings
Skin closure –staples or nylon sutures?
Wound vacs??? (negative pressure therapy)
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Study Design
Institutional Biologic Resource committee approval
120 adult male Sprague-Dawley Rats (440gms)
PTFE vascular graft - subcutaneous
106 Staph. Aureus (MSSA) innoculum
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Study Design
Preop Intravenous
20 rats Vancomycin (15mg/kg)
20 rats Cefazolin (15mg/kg)
Intrawound
20 rats Vancomycin (15mg/kg)
20 rats Cefazolin (15mg/kg)
20 rats Tobramicin ( 5mg/kg)
20 rats 0.35% betadine x 3 min
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Surgical Procedure
Anesthesia
IP ketamine + diazepam
Lidocaine + Meloxicam
Skin prep
Isopropyl Alcohol + Betadine prep
Iodine adhesive drape
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Surgical Procedure1 cm2 PTFE vascular graft
sub-muscular thoracic spine
200ul 108 CFU Staph Aureus inncoculum
Antibiotic powder or betadine wash
Wound closure with Nylon suture
Ad lib food and water x 7 days
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Bacteriologic Evaluation
Animals sacrificed POD 7
Vascular graft recovered sterile technique
Cultured 5% Sheep Blood Agar Plate x 5 days
All positive cultures detected in 24 hrs
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Bacteriologic Evaluation
Negative cultures Positive cultures
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Results
Intravenous Infection
Vancomycin 100%
Cefazolin 100%
Intrawound
Vancomycin 20% *P < 0.05%
Tobramicin 20% *P < 0.05%
Cefazolin 85%
Betadine 100%
*Independent Sample T-tests.
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Discussion
Intrawound Vanc & Tobra more effective than IV or other local agents
Results corroborate clinical and animal studies
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Discussion
IV antibiotic prophylaxis depends on tissue concentrations for effect
Local antibiotics reach much higher local concentrations than IV
Reducing IV prophylaxis might reduce prevalence of resistant organisms???
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Limitations
7 day incubation – miss chronic infection?
Results cannot extrapolate to other bacteria or other hosts ( human)
Further clinical studies warranted
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References
Classen, Evans, Pestotnik et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med. 1992;326 (5):281-286
Brown, Cipriano, Moric et al. Dilute Betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty. 2012 Jan; 27-30
Sweet, Roh, Sliva. Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions: Efficacy, drug levels, and patient outcomes. Spine 2011 Nov 15; 36 (24): 2084-2088
Zevala, Chuntarapas, Kelly et all. Intrawound vancomycin powder eradicates surgical wound contamination: in vivo Rabbit study. J Bone Joint Surg AM. 2014;96:46-51
O’Neill , Smith, Abtahi et al. Reduce surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J. 2011 Jul; 11(7):641-6
Molinari Kahera, Molinari. Prophylactic Intraoperative powder vancomycin in postoperative deep spinal wound infection: 1,512 consecutive surgical cases over 6-year period. Eur Spine J. 2012 Jun; 21(Suppl 4): S476-82. Epub 2011