Le Infezioni in Cardiochirurgia - asl2.liguria.it · UTI Cardiochirurgia: Prof. De Bellis P. Dott....
Transcript of Le Infezioni in Cardiochirurgia - asl2.liguria.it · UTI Cardiochirurgia: Prof. De Bellis P. Dott....
Le Infezioni in Cardiochirurgia
U.O.S. Patologia Infettivologica: Dott. F. Dodi
A.O.U. San Martino, Genova
Hanno Collaborato
UTI Cardiochirurgia:Prof. De Bellis P. Dott. Buscaglia G.
Cardiochirurgia:Prof. Passerone G.C. Prof. Martinelli L.
Laboratorio di Microbiologia: Dott.ssa Molinari M.P.Dott.ssa Gritti P.
U.O.C. Malattie Infettive: Dott.ssa Pagano G. Dott. Dodi F. Dott. Gaffuri L.
Sorveglianza delle Infezioni Ospedaliere (I.O.) in Cardiochirurgia (1)
Osp. San Camillo e INMI – Roma, anno 2000 (Marzo – Dicembre) 646 pazienti operati, età media 67 aa., degenza media post-operatoria 2gg.,
osservazione fino 30 gg.
Regime di Ricovero= urgente 5,9%Tipo di Intervento= by-pass 59,4% valvolare 34,8%
Incidenza I.O.= 11,5%; pz. con almeno una I.O.= 10% 11 infezioni e 9,5 pz. infetti/1000 gg. degenza post-operatoria
Infezione Sito Chirurgico= 60,8% (di cui 40% post-dimissione)Batteriemia primitiva= 18,9% Polmonite= 5,4%
Mortalità= 4,6%BEN-Notiziario ISS, 2001; 14: 1
Sorveglianza delle Infezioni Ospedaliere (I.O.) in Cardiochirurgia (2)
Profilassi Antibiotica Perioperatoria: Cefazolina 66,4% Amoxicillina/acido clavulanico 26,3%
Isolati Microbiologici: Gram – positivi 48,7% Gram – negativi 45,9%
Identificazione Batteriologica: S. aureus 32% di cui 54,2% MRSA P. aeruginosa 14,5% S. coag. neg. 12% di cui 77,8% MRCNS
BEN-Notiziario ISS 2001; 14: 1
Infezioni Nosocomiali in Pazienti Cardiochirurgici
Le caratteristiche peculiari delle infezioni post-operatorie in cardiochirurgia sono:
Infezione sito chirurgico superficiale, profonda Infezione delle vie urinarie Infezione da catetere vascolare centralePolmonite (HAP,VAP)Sepsi Endocardite su valvola protesica ad insorgenza precoce,
ad insorgenza tardiva MediastiniteOsteomielite sternale
Sources of Microbial Contamination of Surgical Wound
Principles and Practice of Infectiuos Diseases, Eds.: G.L. Mandell, R.G. Gordon jr., J.E. Bennet, Churchill Livingstone, New York, 1990
• Colonization– Bacteria present in a wound with no signs or
symptoms of systemic inflammation– Usually less than 105 cfu/mL
• Contamination– Transient exposure of a wound to bacteria– Varying concentrations of bacteria possible– Time of exposure suggested to be < 6 hours– SSI prophylaxis best strategy
Colonization vs Contamination –Definitions
Infections FollowingCardiovascular Surgery
Surgical-site infection (SSI) following cardiovascularsurgery is an infrequent but devastating complicationleading to significant morbidity, mortality and cost. The incidence is reported to vary between 0,5% and 7,7%. Although individual host risk factors have been identifiedin multiple studies, other factors are likely important in outcome and prevention, such as operative management and implicated pathogens.
Mamta Sharma, Infect. Control. Hosp. Epidemiol. 2004; 25: 468
Classification of Sternal WoundInfection
TYPE DEPTH DESCRIPTION
1a superficial skin and subcutaneous tissue dehiscence1b superficial exposure of sutured deep fascia 2a deep exposed bone, stable wired sternotomy2b deep exposed bone, unstable wired sternotomy3a deep exposed necrotic or fractured bone,
unstable, heart exposed3b deep types 2 or 3 with septicemia
Glyn J., Ann. Surg. 1997; 225; 766
Infections FollowingCardiovascular Surgery
Acute mediastinitis is a rare but dreaded diseasethat complicates cardiac surgery.
It is an organ-space infection involving the mediastinum and necessitating debridment.
The reported incidence varies from 0,4% to 5%.
Its related mortality rates is from 8,6% to 77%.
Ann. Thorac. Surg. 1984; 38: 415 J. Thorac. Cardiovasc. Surg. 2006; 132: 537
Ann. Surg. 1997; 225: 766
Predominant Pathogen in SternalWound Infections (1988 – 1996)
Infect. Control Hosp. Epidemiol. 2004; 25: 468
Microbiology of the Surgical Wound Cultures(1997 – 2000)
Sternal surgical-site infection followingcoronary artery bypass graft: prevalence and
complications during a 42-month period
• Time of study: June 1997 – December 2000• 3,443 patients undergoing CABG • Sternal SSI developed in 3,5%: 58,2% SSWI, 41,8% DSWI
• On average, infection occurred 21,5 days (range, 4 to 315) after CABG
• Most cases were diagnosed on readmission (59%) • 20 cases (16%) were identified by postdischarge surveillance
Sharma M., et al., Infect. Control. Hosp. Epidemiol. 2004; 25: 468
Morbidity Following SternalWound Reconstruction
Ann. Surg. 1997; 225; 766
Bacteremia followingCardiovascular Surgery
• Primary bacteremia is present in 0,96% - 35% , mostlyGram + (69% of which Staphylococcus aureus 30% - 40%), Gram – (11%) and Candida spp. (6,9% - 20%)
• Secondary bacteremia was noted in 18% instanceMajority of cases are due to S. aureus and 31,8% are methicillin-resistant strainsIn each case, S. aureus is also identified in the surgical woundspecimen Most commonly is the sole pathogen (91%) It is significantly associated with deep SSI (31,4%), withsuperficial SSI (8,5%)
Eur. J. Surg. 1998; 164: 217 Chest 2003; 124: 2244 Infect. Control Hosp. Epidemiol. 2004; 25: 468
Infection of the Median SternotomyWound
Sternal necrosis and invasive osteitis tend to be mostsevere in patients with Gram-positive infection
Incidence2,1% - 3% (27% - 41% of overall SSI)Risk factorsReduced oxygenation in the wound areaDuration of the wound drainage Obesity Mellitus diabetes
Zentralbl. Chir. 1992; 117: 389 Ann. Surg: 1997; 225: 766
Prosthetic Valve Endocarditis
• Pathogenesis and Microbiology• 2% (1/3 the first few months)• Early: inoculation at op or transient bacteremia
increased risk of PVE: IE of native valve before op, mechanical valve, IV drug abuse, male,
• Late: resemble native IE• Early: S. epidermidis > S. aureus > G(-) bacilli• Late: Streptococcus viridans, S. aureus• Nosocomial: S. epidermidis > S. aureus >
Enterococcis, G(-) bacilli, fungi
What is Biofilm?
• Biofilms are multicellular aggregates of bacteria and yeast that congregate on surfaces.
• Biofilm may be formed on any surface exposed to biofilm-forming bacteria and some amount of water.
• Biofilms are formed to protect the bacteria from host defenses, antibiotics, and from harsh environmental conditions.
Biofilms
Antibiotic Prophylaxis forCardiosurgical Procedures
Cardiothoracic and vascular surgery: median sternotomy, coronary artery bypass grafting, valve surgery
cefazolin 1 g i.v. every 4 to 6 hours continued for 48 – 72 hours
If MRSA infections become frequent: vancomycin 15 mg/kg preoperatively, 10 mg/kg during surgery,
and q 8 hr thereafter should be consideredIf MSSA continue to occur despite cefazolin, consider:
cefuroxime, cefamandole
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, 2000
Antibiotic Prophylaxis in CardiacSurgical Procedures
Nature of Operation: Clean
Type of Operation: Cardiac, Vascular
Recommended Drugs: Cefazolin 1 g i.v. Vancomycin* 1 g i.v.
Time of Administration: At induction of anesthesia
* If presents high prevalence of infections caused by methicillin-resistantstaphylococci or seriuos allergy to beta-lactams
Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 2001
Prophylactic Antibiotics in Cardiosurgery
Type of surgery: cardiovascular,coronary bypass, valvle surgery
Prefered regimen: cefazolin* 1-2 g i.v. pre-op. (and q8h X 48 h) cefuroxime* 1-2 g i.v. pre-op (and q12h X 48 h)
Alternative regimen: vancomycin** 1 g i.v. pre-op (and q12h X 48 h)
* pre-op usually indicates administration with induction of anesthesia, intra-op doses often given with prolonged procedures, a single dose is adeguate
**vancomycin is preferred for hospital with high rate of wound infectionscaused by MRSA or MRSCN and for patients with allergy to penicillins or cephalosporins
Bartett J.G., Pocket Book of Infectious Disease Therapy, 2002
Antimicrobial Surgical Prophylaxisin Cardiovascular Surgery
Antibiotic prophylaxis in cardiovacsular surgery has been proven beneficial onlyin the following procedures: • cardiac surgery • any vascular procedures that inserts prothesis/ foreign body • procedures on the leg that involve a groin incision
Antibiotic prophylaxis: o Cefazolin 2 g IV as a single dose or q8h for 1-2 days o Cefuroxime 1,5 g IV as a single dose or q12h for 1-2 days
If elevated frequency of MRSA, high risk patients, MRSA colonized:Vancomycin 1 g IV as a single dose or q12h for 1-2 days
Nasal culture positive patients for S. aureus: Intranasal mupirocine evening before, day of surgery and bid for 5 days
post-operation
The Sanford Guide to Antimicrobial Thepapy, 2006
Profilassi Antibiotica Perioperatoria in Cardiochirurgia
• Piano Nazionale Linee Guida Interventi cardiochirurgiciLe Beta-lattamine mantengono ancora la loro efficacia nella prevenzione delle
Infezioni del Sito Chirurgico, anche stafilococcicheTale efficacia è conservata anche in presenza di un’alta frequenza di resistenza
alla Meticillina da parte degli stafilococchi Raccomandazione per la dose unica preoperatoria e l’eventuale ripetizione della
dose antibiotica intraoperatoria a causa della dilatazione dei tempi chirurgiciRiaffermazione della scarsa utilità di prosecuzione della profilassi antibiotica
chirurgica oltre le 24 ore
PNLG – Ministero della salute Italiano, 2003 Infect. Control Hosp. Epidemiol. 1998; 19: 234 Giorn.It.Infez.Osp. 1999; 6: 157 J. Thorac. Cardiovasc. Surg. 2000; 120: 1120
Profilassi Antibiotica Perioperatoria in Cardiochirurgia
• Protocollo di Profilassi Chirurgica A.O.U. San Martino Genova
Procedure cardiochirurgiche• Cefazolina 2 g. e.v. come singola dose preoperatoria, da
ripetere ogni otto ore per 48 oreVancomicina 1 g. e.v. come singola dose preoperatoria, da ripetere ogni dodici ore per 48 ore se: colonizzati da S. aureus, allergici
Mupirocina endonasale se: colonizzati endonasali da S. aureus
Perioperative Glucose Control and Development of Surgical Wound Infection in Cardiosurgery Procedures
• Risk factors following Coronary Artery By-pass: hyperglicaemia, mellitus diabetes state (duration, preoperative HbA1c),longstanding vascular effects, SIRS
1) Vulnerability to surgical wound infection
2) Increasing risk of mediastinitis
• Measurement of glicaemia during post operative days 0 – 1 – 2 good control is glicaemia < 130 mg% for more 50%
• Trigger for insulin administrationglicaemia 110 mg% (p < 0,001)
• Decreasing of mediastinitis’s rate from 1,6% to 0%
Ann. Thorac. Surg. 2005; 80: 902 J. Hosp. Infect. 2005; 61: 201
Prevention of Nosocomial Infection byDecontamination of the Nasopharinx and Oropharinx
• Years 2003 – 2005, 991 patients• Prospective, randomized, double-blind, placebo-controlled clinical trialIntervention:• Incidence nasal carriers • Nasal decontamination by chlorhexidine gluconate or placeboResults:• Incidence nosocomial infection 19,8% vs. 26,2% • Lower respiratory tract and deep surgical site infections less common in the
chlorhexidine gluconate group (p= 0,002) • Hospital stay 9,5 days in chlorhexidine gluconate group vs. 10,3 days in placebo group • Reduction in S. aureus nasal carriage in chlorhexidine group 57,5% vs. 18,1% in placebo
group (p= 0,001) Conclusion:S. aureus decontamination of the nasopharynx and oropharynx appears to be an effective
method to reduce nosocomial infectionsJAMA 2006; 296: 2460
Isolamenti da emocolture in pazienti dell’U.O.Cardioghirurgia (gen –giu 2006)
fr Candida albicans sangue 1sa Candida albicans sangue 4bo Enterobacter aerogenes sangue 4fo Enterococcus faecalis sangue 1fr Enterococcus faecium sangue 1fo Stafilococco coagulasi negativo sangue 1gi Staphylococcus aureus sangue 2be Staphylococcus aureus sangue 4ta Staphylococcus aureus sangue 1fo Staphylococcus epidermidis sangue 1si Staphylococcus epidermidis sangue 2ge Staphylococcus hominis sangue 1pe Staphylococcus warneri sangue 1
paziente microrganismo campione n° isolamenti
Isolamenti da ferita chirurgica U.O Cardiochirurgia gen –giu 2006
paziente campione organismo n° isolamenti
1 ferita chirurgica Acinetobacter jeunii 1
2 ferita chirurgica Enterobacter aerogenes 1
2 ferita chirurgica Enterococcus faecalis 1
3 ferita chirurgica Escherichia coli 1
3 ferita chirurgica Morganella morganii 2
4 ferita chirurgica Pseudomonas aeruginosa 2
3 ferita chirurgica Pseudomonas aeruginosa 1
5 ferita chirurgica Stafilococco coagulasi negativo 1
6 ferita chirurgica Stafilococco coagulasi negativo 1
3 ferita chirurgica Stafilococco coagulasi negativo 1
7 ferita chirurgica Stafilococco coagulasi negativo 1
4 ferita chirurgica Staphylococcus aureus 1
8 ferita chirurgica Staphylococcus aureus 2
2 ferita chirurgica Staphylococcus aureus 1
6 ferita chirurgica Staphylococcus aureus 2
5 ferita chirurgica Staphylococcus epidermidis 1
2 ferita chirurgica Staphylococcus epidermidis 1
6 ferita chirurgica Staphylococcus epidermidis 1
5 ferita chirurgica Staphylococcus hominis 1
9 ferita chirurgica Staphylococcus warneri 1
10 ferita chirurgica Staphylococcus warneri 1
% SENSIBILITA’- STAPH.AUREUS
0,00%10,00%20,00%30,00%40,00%50,00%60,00%70,00%80,00%90,00%
100,00%
clin
damicin
a e
ritromici
na li
nezolid
fosfo
micina
gen
tamicina
Ciprof
loxacin
a
levo
floxa
cina
oxa
cillin
. ri
fampicina
trim
etoprim/su
lfam
norf
loxacin
a
vanc
omicina
teico
planina te
tracic
lina
nitro
furantoina p
enicil
lina g
GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE TOTALE ISOLATI 13 1 ° SEMESTRE 2006
0,00%
10,00%
20,00%
30,00%
40,00%
50,00%
60,00%
70,00%
80,00%
90,00%
100,00%
clin
damicin
a e
ritrom
icina
line
zolid
Cipr
oflox
acina
fosfo
micina
gen
tamicin
a le
voflo
xacin
a o
xacill
in. ri
fampic
ina
trim
etopri
m/sulfa
m n
orflox
acina
van
comicin
a te
icoplan
ina te
tracic
lina
nitro
furanto
ina p
enicil
lina g
% SENSIBILITA’ – STAPH.EPIDERMIDIS
GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE TOTALE ISOLATI 6 1 ° SEMESTRE 2006
0,00%10,00%20,00%30,00%40,00%50,00%60,00%70,00%80,00%90,00%
100,00%
mero
pene
m C
iprofl
ox.
gen
tamicin
a c
eftaz
idime
pipe
racillin
a p
iper/ta
zob
cefe
pime
aztr
eona
m im
ipenem
levo
flox
amika
cina
%SENSIBILITA’- PSEUDOMONAS AERUGINOSA
GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE TOTALE ISOLATI 3 1 ° SEMESTRE 2006
conclusioneÈ opportuno che in ogni realtà chirurgicalocale venga effettuato un monitoraggio della flora batterica responsabile delle complicanze infettive postoperatorie e
delle sensibilità di questa agli antibiotici utilizzati in profilassi…
Programma nazionale per le linee guida (PNLG)Istituto Superiore della Sanità
02468
10121416
ST
AU
ST
AE
PI
EN
TA
ER
PS
EA
ER
EN
TS
PP
ST
AW
A
MO
RM
O
AC
INE
T
ES
CC
OL
KLE
SP
P
PR
OM
IR
MICRORGANISMI BATTERICI ISOLATI
GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE TOTALE ISOLATI 49, PAZIENTI 13 1 ° SEMESTRE 2006
+ Candida albicans: 5