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Neil S. Silverman, MD

Center for Fetal Medicine & Women's Ultrasound

Los Angeles, CA Clinical Professor, Obstetrics/Gynecology

David Geffen School of Medicine at UCLA

September 7, 2011

Objectives

Review magnitude and impact of surgical site infections

Discuss traditional and current approaches to surgical prophylaxis for cesareans Antibiotic dosing considerations: obesity

New guidelines for SBE prophylaxis

Role of pre-op skin preps

Impact of "new" organisms: MRSA

Nomenclature of SSI

Impact of SSI Diagnosed After Hospital Discharge

SSI Cases (N=89) (1.9% of cohort of 4571 procedures) Median total $1,240 (445-4,594) costs (range) Mean total costs $5,155 No SSI Controls (N=178) $300 (146-795) $1,733

Controls matched on surgery type, age, duration of procedure. 2.3% underwent gynecologic procedures. Emerging Infectious Diseases 2003;9:196-203

SSI Rates from the Literature In the Antibiotic Prophylaxis Era

Procedure

Csection

Range of SSI*

5-30% PPE, 0-12% wound 0.9-38% (~4-8%) 2.8-23% (~5-10%)

Vag hyst

Abd hyst or mixed

Abd surgery, mixed 3.9-13%

Colorectal 4.4-22% (most ~ 10%)

*Includes wound infection and intra-abdominal infections/abscess (does not include UTI, pneumonia)

Pathogens in Ob/Gyn Infections

Postpartum endometritis Peptostrep, Bacteroides, G vag, enterococci, GBS, enteric Gram negative rods Wound infection 25-50% Staph aureus, coag negative Staph 50-75% vaginal flora Post hysterectomy Bacteroides, Peptostrep, G. vag, enterococci, enteric GNR

Selected references: J Repro Med 1993;38:843-8, Obstet Gynecol 1991;77:287-92, J Repro Med 1990;35:322-8, Obstet Gynecol 1988;72:559-64, BJOG 2001;108:143-8, AJOG 1979;133:602-10.

Surgical Prophylaxis

Antimicrobial prophylaxis can decrease the incidence of

post-operative infection - This benefit balanced against risks of: . Toxic and allergic reactions . Emergence of resistant bacteria . Drug interactions

Prophylaxis generally recommended:

Procedures with high infection rates Implantation of prosthetic material Consequences of infection would be especially serious

Choice of Prophylactic Agent: Guidelines

As a rule, an effective prophylactic regimen should have

activity against the most likely infecting organisms, but does not need to eradicate every potential pathogen

The operation should be associated with endogenous

bacterial contamination

Prophylactic antibiotic should be present in the wound at

some time during the operation

More is not better: short course therapy should be used

Prophylactic Antibiotics: Timing and Dosing

With most antibiotics, a single dose given 30 minutes or less before the

skin incision provides adequate tissue concentrations through surgery Short half-life drugs: Ampicillin Cefoxitin/cefotetan Long half-life drugs: cefazolin doxycycline metronidazole If surgery is prolonged (>4 hours), major blood loss occurs, or a short-halflife antibiotic is used, an additional dose is advisable during the procedure

Postoperative dosing of antibiotics gives no additional benefit

as "prophylaxis"

History of Cesarean Prophylaxis

Prior to 2000, research had focused on and demonstrated

the overall benefit of prophylactic antibiotics in reducing post-cesarean infectious morbidity, compared to no prophylaxis

In these studies, "prophylaxis" occurred after the surgical

incision, after cord clamping Concerns/theoretical risks regarding neonatal impact of pre-delivery antibiotics

From early 2000's onward, more studies addressed the

concept of bringing the timing of cesarean prophylaxis more in line with other surgical prophylaxis regimens

Benefits of Cesarean Prophylaxis: Recent Reviews

Dinsmoor MJ, et al. Obstet Gynecol, 2009

MFMU Network data: 9432 women who had pre-labor c/s 6006 women (64%) received perioperative antibiotic prophylaxis

Prophylaxis rates of PP endometritis from 2.6 % to 2.0% (OR 0.4; 0.3-0.6) Rate of wound infection also : 1% to 0.5% (OR 0.5; 0.28 ­ 0.86) Significance remained when selecting out pts with ROM pre-c/s Baseline rates of infection extremely low

Smaill FM, Gyte GML. Cochrane Database, 2010

Meta-analysis of 86 studies involving > 13,000 women

Antibiotic prophylaxis for c/s decreased infectious risks

Wound infx 61% (77 studies), endometritis 62% (79 studies), febrile morbidity 55% (50 studies), serious maternal infx 69% (31 studies)

Findings similar whether c/s was elective or not, or whether antibiotics given

before or after cord clamping

Earlier Pre-Incision C/S Prophylaxis Studies

Cunningham FG, et al. Obstet Gynecol, 1983.

Nonrandomized; 642 women at "high risk of infection" at time of c/s

305 pts got abx: 3 "perioperative" doses (PCN/gent or cefamandole) 255 pts got 1st dose 10-90 minutes before cord clamping 50 pts got 1st dose within 90 minutes of cord clamping

No difference between groups in rates of infection

Fejgin MD, et al. Int J Gynaecol, 1993.

Nonrandomized; data on pts given abx pre-op collected prospectively

(n=241), post-cord clamping data retrospective/historical (n = 194)

Post-cord clamping group had higher mean BMI and longer op time

No differences in "febrile morbidity" or endometritis, but higher rates of

wound infection in group receiving abx after cord claping

Randomized Cesarean Prophylaxis Trials

1. Wax JR, et al. J Maternal Fetal Med, 1997 (n = 90) Cefazolin, no difference for all outcomes 2. Thigpen B, et al. Am J Obstet Gynecol, 2005 (n = 302) Cefazolin Decrease in overall infectious morbidity with pre-op, but not in the specific single outcomes of endometritis or wound infection 3. Sullivan SA, et al. Am J Obstet Gynecol, 2007 (n = 357) Cefazolin 15-60 minutes before surgery 80% decrease in endometritis (OR 0.2; CI 0.05-0.9) 60% decrease in SSI (OR 0.42; CI 0.1 -1.3) 65% decrease in total infectious morbidity (OR 0.35; CI 0.14-0.82) No increased risks of neonatal sepsis, sepsis workup, length of stay

Only #2 stated that GBS prophylaxis similar for both groups Only #3 included both laboring and nonlaboring pts (other 2 laboring only)

Summary of postcesarean infectious morbidity observed Outcome Study group (n = 175)

2 (1%)

Control group (n = 182)

10 (5%)

Relative risk 95% CI

0.2 (0.2 to 0.94)

Adjusted OR 95% CI

0.22 (0.05 to 0.9)

Endomyometritis

Wound infections

5 (3%)

10 (5%)

0.52 (0.18 to 1.5)

0.4 (0.1 to 1.3)

Total infectious morbidity

8 (4.5%)

21 (11.5%)

0.4 (0.18 to 0.87) 0.35 (0.14 to 0.8)

Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Sullivan SA, et al. American Journal of Obstetrics & Gynecology. 196(5):455.e1-5, 2007 May.

Reviews and Protocol-Evaluation Studies

Costantine MM, et al. Am J Obstet Gynecol 2008

Meta-analysis of 3 prior RCTs (n = 749; excluded 2 non-randomized)

Confirmed decreases in both endometritis and overall infectious morbidity,

with trend toward lower risk of wound infection with pre-incision antibiotics

Pre-op antibiotics had no effect on neonatal outcomes

Kaimal AJ, et al. Am J Obstet Gynecol 2008

Retrospective cohort study @ UCSF, before and after prophylaxis policy

change to pre-incisional antibiotics (n = 1316)

For all cesareans, overall infectious morbidity outcome variable decreased

significantly with pre-op (6.4% 2.5%; p = 0.002)

No statistical difference for elective/non-labor cesareans, with lower

overall baseline SSI rate (2.7%)

Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Costantine MM, et al. American Journal of Obstetrics & Gynecology. 199(3):301.e1-6, 2008 Sep.

Timing of Perioperative Antibiotics for Cesarean Delivery

Endometritis

Total Infectious Morbidity

Study Sullivan et al Wax et al Thigpen et al

Risk ratio (95% CI)

0.21 (0.05, 0.94) 0.84 (0.05, 12.97) 0.53 (0.27, 1.03)

Study Sullivan et al Wax et al Thigpen et al

Risk ratio (95% CI)

0.21 (0.05, 0.94) 0.84 (0.05, 12.97) 0.53 (0.27, 1.03)

Overal (95% CI)

0.47 (0.26, 0.85)

Overall (95% CI)

0.47 (0.26, 0.85)

.05

.5

1

5

10 15

.05

5

1

5 10 15

Favors preoperative

Favors cord clamping Favors preoperative Favors cord clamping

Wound infection

Study Sullivan et al Wax et al Thigpen et al Risk ratio (95% CI) 0.52 (0.18, 1.49) 0.42 (0.04, 4.45) 0.73 (0.26, 2.05)

Overall (95% CI)

0.60 (0.30, 1.21) Constantine. Timing of perioperative antibiotics for Cesarean delivery. Am J Obstet Gynecol 2008

.05

5

1

5

10 15

Favors preoperative

Favors cord clamping

Protocol-Change and Cesarean Prophylaxis

Review of all cesareans before and after cesarean prophylaxis

protocol change to pre-incisional at a single large center (Magee-Women's): n = 9010

Mean BMI and rates of labor before c/s (58%) similar between groups

Significantly lower rates for both endometritis

(2.2% vs 3.9%) and wound infection (2.5% vs 3.6%) in the preincisional antibiotics group Differences in infection rates stayed the same in adjusted odds ratio

Adjustment for chorioamnionitis, trial of labor, gest age, maternal

age/race, resident teaching service

Owens SM, et al. Obstet Gynecol 2009; 114: 573-9

From: Owens SM, et al. Obstet Gynecol 2009; 114: 573-9

Postpartum endometritis by 3-month intervals. Group 1: July 2002-Nov 2004, after umbilical-cord clamping. Group 2: June 2005-August 2007, before skin incision. Each bar represents consecutive 3-month period. From: Owens SM, et al. Obstet Gynecol 2009

Emerging Concepts in Cesarean Prophylaxis?

Systematic review of pre-incisional prophylaxis and extended ­

spectrum regimens after cord-clamping Argument to support extended-spectrum antibiotics (azithromycin, metronidazole) focuses on ureaplasma and/or anaerobic coverage Evidence to suggest extended-spectrum antibiotics comes from single center

Authors acknowledge need for head-to-head comparisons of 2

regimens pre-op (cefazolin vs azithromycin) Impact of cefazolin pre-op appears to be comparable to azithromycin after cord clamping (with cefazolin after clamping inferior to both

Tita AT , et al. Obstet Gynecol 2009; 113: 675-82.

Extended-Spectrum Prophylaxis to be Studied

Cesarean Section Optimal Antibiotic Prophylaxis (C/SOAP) study,

registered with ClinicalTrialsFeeds,org (PI: Alan Tita, UAB) Trial to evaluate comparative effectiveness and safety of cefazolin alone vs cefazolin + azithromycin pre-op

Randomized placebo-controlled trial Enrolling only women with unscheduled/non-elective c/s Labor and/or at least 4 hours of ROM

24 weeks' gestation

Primary outcome measure: endometritis and/or wound infection

and/or other post-cesarean infection up to 4 weeks after delivery

Start date January 2011 (to January 2014); est. enrollment 2000

Current Cesarean Prophylaxis Recommendations

Reinforces role of antimicrobial prophylaxis for cesarean

delivery to reduce postoperative maternal infectious morbidity

Preoperatively administered antimicrobial prophylaxis has no

deleterious effects on mother or newborn

Policy also endorsed by AAP

Prophylaxis should be given for all cesareans unless patient

already receiving appropriate antibiotics for another indication

Pre-delivery (intrapartum) GBS prophylaxis will only be adequate

for surgical prophylaxis if patient happens to be receiving cefazolin

Prophylaxis should be given within 60 minutes of incision

ACOG, Committee Opinion #465, September 2010

Antibiotic Dosing and Obesity

Obesity presents a challenge to antibiotic doing and levels, in addition to

being an independent risk factor for infection

Actual body weight (compared to ideal) has been shown to be more

appropriate for dose calculation for vancomycin and aminoglycosides

(Hall RG, Am J Med 2008)

Increases in both volume of distribution and drug clearance for

cephalosporins demonstrated in obese patients

Resulting lower levels seen in bone, fat, and other tissues compared to non-

obese pts with similar dosing (Pai MP, Pharmacotherapy 2007)

Consider higher dosing of cefazolin for pre-operative cesarean

prophylaxis if BMI > 30 vs BW > 100 kg? (2 gm vs 1 gm ?)

2-gm dose for obese bariatric pts shown to give comparable serum levels to

1-gm dose in non-obese pts (Forse RA, Surgery 1989)

Ob/Gyn SSI

Antimicrobial Prophylaxis

Obesity ­ >220# (100 kg) or BMI > 35

Double dose of cefazolin

Time (minutes)

Group A (control) C (1 gm IV) D (2 gm IV) Incision 13.5 + 6.3 12.7 + 7.8 15.7 + 8.2 Closure 98.1 + 25.2 123.9 + 20.8 116.5 + 22.8

Serum level (g/ml)

Incision 110.5 + 18.9 65.2 + 15.0* 127.8 + 16.3 Closure 44.5 + 7.4 23.5 + 5.1* 46.2 + 9.9

Adipose tissue level (g/gm)

Incision 6.0 + 1.3 4.0 + 2.3 7.3 + 3.1 Closure 4.1 + 0.8 2.4 + 1.0 4.1 + 1.1

*Significantly (p < 0.001) different from control group A by ANOVAR Significantly (p <0.01) different from control group A by ANOVAR

Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989;106:750-7

Effect of Maternal Obesity on Tissue Concentrations of Prophylactic Cefazolin during Cesarean Delivery

14 Cefazolin Concentration (mcg/g) 12 10 8 6 4 2

<30

30-40 BMI Category

40+

Chan, et al. AJOG, 2011

Obesity and Surgical Prophylaxis

Based on available data, ACOG currently recommends

considering higher dose than 1-gm cefazolin for BMI > 30 or weight > 100 kg As data evolve, 2-gm dose may not be sufficient for tissue levels and may need to be adjusted upward for morbidly obese patients

WHO class III obesity, BMI > 40-45

ACOG PB # 120, June 2011

SBE Prophylaxis: Rationale

Infective endocarditis (IE) is associated with significant morbidity

and mortality

Experimental studies have suggested that endothelial damage

leads to platelet and fibrin deposition and formation of nonbacterial thrombotic endocardial lesions

With bacteremia, organisms may adhere to these lesions and

multiply in them, leading to an infective vegetation

Valvular and congenital abnormalities, esp. those associated with

high-velocity jets, can trigger this damage cascade

Since 1955, the AHA has made recommendations for prevention

of IE with with antimicrobial prophylaxis before specific dental, GI, and GU procedures in patients at risk

SBE Prophylaxis: Major Changes in Updated Recommendations (2008)

On review of current literature, only an extremely small number of

cases of IE may be prevented by antibiotic prophylaxis for dental procedures even if such therapy were 100% effective

IE prophylaxis for dental procedures is reasonable only for patients

with highest risk cardiac conditions

Prophylaxis not recommended solely on the basis of an increased

lifetime risk of acquisition of IE

Administration of antibiotics solely to prevent endocarditis is not recommended for patients who

undergo a GI or GU procedure

Nishimura RA, et al. Circulation 2008

Rationale for Updated SBE Recommendations

IE more likely to result from frequent exposure to random bacteremia associated with daily activities than from bacteremia caused by dental, GI, or GU procedure Prophylaxis may prevent an exceedingly small of cases of IE (if any) in individuals who undergo such

procedures

The risk of antibiotic-associated adverse events exceeds the benefit (if any) from prophylactic

antibiotic therapy

What Warrants Prophylaxis?

Prophylaxis should be given only to high-risk patients before

dental procedures that involve manipulation of either gingival tissue or the periapical region of the teeth or perforation of oral mucosa No longer recommended for respiratory tract procedures unless in a high risk patient AND involves incision of mucosa (tonsillectomy/adenoidectomy)

No prophylaxis : Bronchoscopy, endoscopy, colonoscopy, TEE

In high-risk pts undergoing elective cystoscopy or other urinary

tract manipulation, who are infected or colonized with enterococci, it is reasonable to eradicate enterococci from urine before procedure

Also reasonable if these pts have a GI or GU infection, to give

antibiotics to prevent wound infection or sepsis

Who are "High Risk" Patients?

Patients with prosthetic cardiac valves or prosthetic material

used for valve repair Patients with past history of infective endocarditis Patients with cardiac valvulopathy after cardiac transplantation Specific cardiac lesions (CHD)

Unrepaired cyanotic CHD: includes palliative shunts/conduits

Completely repaired CHD using prosthetic material or device,

during first 6 months after procedure Repaired CHD with residual defects at site of or adjacent to a prosthetic patch or device

AHA Committee Statement

Committee recognizes that decades of previous

recommendations with most forms of valvular heart disease (VHD) and other conditions have been abruptly changed by these recommendations Clinicians should be able to discuss rationale for new changes with their patients, including lack of scientific evidence to demonstrate a proven benefit for prophylaxis In select circumstances, some clinicians may still feel more comfortable using prophylaxis: in those settings, it should be determined that the antibiotic risks are low Over time, acceptance of the new guidelines is anticipated among both providers and patients

Guidelines don't always agree: the problems with guideline committees

5 months after ACC/AHA Guideline Update published, a

separate committee report issued by a (separate) ACC/AHA Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease

Warnes CA, et al. J Am Coll Cardiology 2008; 52: 143-263

Essentially reaffirmed recommendations from Nishimura

document, however, in Section 1.8:

Although endocarditis is a recognized risk for maternal morbidity and mortality, endocarditis prophylaxis around the time of delivery is not universally recommended for patients with structural heart disease, because some believe that the risk of bacteremia is low. Others routinely administer antibiotics because it is not known in advance whether or not instrumentation will be required. Thus, there is no consensus on this point (117). Antibiotics should be considered for those at highest risk of an adverse outcome and, when appropriate, given as the membranes rupture. Intravenous amoxicillin and gentamicin should be considered for women with high-risk anatomy or previous history of endocarditis.

SBE Guidelines: Attempting to resolve the issue

Even when SBE prophylaxis is earlier guidelines was

indicated, it was single-agent, single-dose, not amp/gent How was "at the time of membrane rupture" decided: would this require multiple doses of aminoglycoside? Why was the possible need for "instrumentation" considered? Single reference : retrospective study of 96 pregnancies in 44 women with CHD from 1994 Presbitero P, et al. Circulation 1994

1 death 2 months after delivery in a woman with repaired

tetralogy, 2 pts with peripartum SBE (3% of pregnancies) Authors suggest abx "as soon as labor begins"

Conference call attempt

Resulting ACOG PB Statement (June 2011)

Only cardiac conditions with highest risk of adverse

outcomes require prophylaxis, and this is primarily for pts undergoing invasive dental procedures However, because of potential for significant morbidity and mortality, based on expert opinion and a limited retrospective study of women with congenital heart disease, AHA and ACC recommend use of prophylactic abx be considered for vaginal delivery in pts with highest risk of adverse outcomes for endocarditis: cyanotic cardiac disease, prosthetic valves, or both "...antibiotic regimens for endocarditis prophylaxis can be administered as close to 30-60 minutes before anticipated time of delivery as is feasible

SSIs and Skin Prep

Background: SSIs occur in 300-500K patients in U.S. per year

despite povidone-iodine skin cleansing pre-op

Improvement in skin antisepsis could decrease SSIs since skin in major

source of pathogens

CDC recommends 2% chlorhexidine-based prep be used to cleanse

vascular catheter insertion sites (Kirkland KB, Inf Cont Hosp Epid, 2002)

No current CDC recommendations as to which antiseptics should

be used for pre-op skin preps

No prior randomized studies examining effect of one antiseptic

skin prep against another to prevent SSIs

Skin Prep Study and SSI Rates

Randomized clinical trial of chlorhexidine-alcohol vs povidone-

iodine for skin prep at 6 university-affiliated hospitals in United States (n = 849)

Primary endpoint: any SSI within 30 days after surgery

Chlorhexidine-alcohol had significantly lower SSI rates for:

Any SSI (60% ) Superficial incisional infection (50% ) Deep incisional infection (67% ) No difference for sepsis or organ-space infection

No cases of fire or chemical burns in OR

Darouiche RO, et al. N Engl J Med 2010; 362: 18-26

Table 2. Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-TreatPopulation) Type of Infection

Chlorhexidine-Alcohol Povidone-lodine (N=409) (N=440) no. (%)

39 (9.5) 17 (4.2) 71 (16.1) 38 (8.6)

Relative Risk (95% CI)

0.59 (0.41-0.85) 0.48 (0.28-0.84)

P Value

Any surgical-site infection Superficial incisional infection

0.004 0.008

Deep incisional infection

Organ-space infection Sepsis from surgical-site infection

4 (1.0)

18 (4.4) 11 (2.7)

13 (3.0)

20 (4.5) 19 (4.3)

0.33 (0.11-1.01)

0.97 (0.52-1.80) 0.62 (0.30-1.29)

0.05

>0.99 0.26

Darouiche RO, et al. NEJM 2010

MRSA and SSIs

Over past 10-15 years, MRSA infections have changed from

hospital-acquired infections in ill patients to infections in otherwise healthy patients, including pregnant women

Epidemiologic studies suggest MRSA colonization rates in

healthy pregnant women near term to be 2% (R-V swabs) to 10% (nasal swabs

(Creech CB, Am J Infect Control, 2010; Beigi R, Inf Dis Ob Gyn, 2008)

Annual economic impact of MRSA infection in U.S. obstetric

populations projected to be $ 8.0-8.7 million

Prevalence of MRSA, incidence of mastitis, rate of c/s are all key driving

factors in estimations

(Beigi RH, Obstet Gynecol 2009)

How to Address MRSA?

Recent retrospective institutional review (E. Va. Med School)

showed that institution of a pre-incision antibiotic policy for c/s decreased incidence of infectious morbidity from 21% to 8.5% ( p < 0.001) (Thurman AR, AJIC 2010)

However, in MRSA wound infections proportionally

MRSA most common organism isolated from SSIs (53%)

Survey of health-care providers (Mascitti KB, AJIC 2010) 70% preferred TMP-SMX for directed treatment of MRSA skin and soft-tissue infections For recurrent infections, 88% reported at least 1 topical decolonization protocol

Topical mupirocin Antiseptic body wash Bleach baths

Can SSIs be Prevented in S. aureus Carriers?

Study of decolonization procedures on hospitalized pts found to

have (+) nasal swabs (rapid PCR) for S. aureus

1251 subjects drawn from 6771 screened on admission All strains were methicillin-sensitive

Colonized pts (medical and surgical) randomized to receive nasal

mupirocin and chlorhexidine wash (or placebo) for at least 4 days

Rate of S. aureus infection lower for all patients in treatment

group (3.4% vs 7.7%; RR = 0.42, CI 0.23 ­ 0.75)

Effect of mupirocin-chlorhexidine treatment was greatest for

reducing deep SSI (79% )

Bode LGM, et al. N Engl J Med 2010; 362: 9-17

Table 2. Relative Risk of Hospital-Acquired Staphylococcus aureus Infectionand Characteristics of Infections (Intention-to-Treat Analysis).

Variable MupirocinChlorhexidine (N = 504)

no. (%)

Placebo (N=413) 32 (7.7) 25 (6.1) 6 (1.5) 1 (0.2) 16 (4.4) 13 (3.5) 2 (0.5) 0 1 (0.2) 0

Relative Risk (95% CI) 0.42(0.23-0.75) 0.39(0.20-0.77) 0.55(0.16-1.92)

S. aureus infection Source of infection Endogenous Exogenous Unknown Localization of infection Deep surgical site Superficial surgical site Lower respiratory tract Urinary tract Bacteremia Soft tissue

17 (3.4) 12 (2.4) 4 (0.8) 1 (0.2) 4 (0.9) 7 (1.6) 2(0.4) 1 (0.2) 1 (0.2) 2 (0.4)

0.21 (0.07-0.62) 0.45 (0.18-1.11) 0.82 (0.12-5.78)

Bode LGM, et al. NEJM 2010

MRSA and Decolonization: Issues

While intranasal or topical "decolonization" protocols have been

studied as a means to prevent recurrent skin and soft tissue infections (SSTIs) among MRSA carriers, overall efficacy and optimal dosing or duration for such regimens remains uncertain

IDSA Guidelines: Liu C, Clin Infect Dis, 1/11

No definitive data for post-op infections in MRSA carriers With CA-MRSA carriers, recent study showed nasal mupirocin

decreased colonization but NOT 1st-time SSTIs

Ellis MW, Antimicrob Agents Chemother 2007

Concerns about high levels of mupirocin resistance in some

community settings

Diep BA, Ann Intern Med 2008

Addressing MRSA: Practical Considerations

CA-MRSA-colonized individuals may be chronically colonized and

at risk for clinical infection No data to support routine screening of all patients

No indication of which culture site is most sensitive or accurate for

OB patients

Even if pre-op MRSA decolonization (at least 5 days) were shown

to be of benefit, it would be of limited impact in OB patients, where most of surgeries (c/s) are unscheduled If history of MRSA colonization and surgery (planned or not):

No data to guide altering surgical prophylaxis, but could consider

adding single dose of MRSA-active antibiotic (e.g. vancomycin) to standard pre-incision regimen (ACOG PB, June 2011)

Summary: Decreasing Cesarean SSIs

Clipping, not shaving, incision site, as close to timing of surgery

as possible (ACOG, Guidelines for Perinatal Care, 10th edition)

Consideration of chlorhexidine-alcohol as pre-op skin prep PRE-OPERATIVE antibiotic prophylaxis: 1 dose within 60 minutes

of incision

First-generation cephalosporin (cefazolin) as 1st choice

Consideration to adding pre-operative MRSA prophylaxis to

standard antibiotics pre-incision for known MRSA carriers

Universal screening not recommended at present

Discuss institutional policies

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