Le Infezioni in Cardiochirurgia

(1)

Le Infezioni in Cardiochirurgia

U.O.S. Patologia Infettivologica: Dott. F. Dodi

(2)

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.

(3)

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%

(4)

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

(5)

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 centrale

Polmonite (HAP,VAP)

Sepsi

Endocardite su valvola protesica ad insorgenza precoce,

ad insorgenza tardiva

Mediastinite

(6)

Sources of Microbial Contamination of Surgical Wound

(7)

• Colonization

– Bacteria present in a wound with no signs or

symptoms of systemic inflammation

– Usually less than 10

5

_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

(8)

Infections Following

Cardiovascular Surgery

Surgical-site infection (SSI) following cardiovascular

surgery is an infrequent but devastating complication

leading 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 identified

in multiple studies, other factors are likely important in

outcome and prevention, such as operative management

and implicated pathogens.

(9)

Classification of Sternal Wound

Infection

TYPE DEPTH DESCRIPTION

1a superficial skin and subcutaneous tissue dehiscence 1b superficial exposure of sutured deep fascia

2a deep exposed bone, stable wired sternotomy 2b deep exposed bone, unstable wired sternotomy 3a deep exposed necrotic or fractured bone,

unstable, heart exposed 3b deep types 2 or 3 with septicemia

(10)

Infections Following

Cardiovascular Surgery

Acute mediastinitis is a rare but dreaded disease

that 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%.

(11)

Ann. Surg. 1997; 225: 766

Predominant Pathogen in Sternal

Wound Infections (1988 – 1996)

(12)

Infect. Control Hosp. Epidemiol. 2004; 25: 468

Microbiology of the Surgical Wound Cultures

(1997 – 2000)

(13)

Sternal surgical-site infection following

coronary 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

(14)

Morbidity Following Sternal

Wound Reconstruction

(15)

Bacteremia following

Cardiovascular Surgery

• Primary bacteremia

is present in 0,96% - 35% ,

mostly

Gram + (69% of which Staphylococcus aureus 30% - 40%), Gram – (11%) and

Candida spp. (6,9% - 20%)

• Secondary bacteremia

was noted in 18% instance

9 Majority of cases are due to S. aureus and 31,8% are

methicillin-resistant strains

9 In each case, S. aureus is also identified in the surgical wound

specimen

9 Most commonly is the sole pathogen (91%)

9 It is significantly associated with deep SSI (31,4%), with

superficial SSI (8,5%)

(16)

Infection of the Median Sternotomy

Wound

Sternal necrosis and invasive osteitis tend to be most

severe in patients with Gram-positive infection

Incidence

2,1% - 3% (27% - 41% of overall SSI)

Risk factors

Reduced oxygenation in the wound area

Duration of the wound drainage

Obesity

Mellitus diabetes

(17)

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

(18)

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.

(19)

(20)

Antibiotic Prophylaxis for

Cardiosurgical 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 considered

If MSSA continue to occur despite cefazolin, consider:

cefuroxime, cefamandole

(21)

Antibiotic Prophylaxis in Cardiac

Surgical 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-resistant staphylococci or seriuos allergy to beta-lactams

(22)

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 infections

caused by MRSA or MRSCN and for patients with allergy to penicillins or cephalosporins

(23)

Antimicrobial Surgical Prophylaxis

in Cardiovascular Surgery

Antibiotic prophylaxis in cardiovacsular surgery has been proven beneficial only in 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:

9 Intranasal mupirocine evening before, day of surgery and bid for 5 days post-operation

(24)

Profilassi Antibiotica Perioperatoria in

Cardiochirurgia

• Piano Nazionale Linee Guida

Interventi cardiochirurgici

Le Beta-lattamine mantengono ancora la loro efficacia nella prevenzione delle Infezioni del Sito Chirurgico, anche stafilococciche

Tale 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 chirurgici Riaffermazione 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

(25)

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 ore

¾ Vancomicina 1 g. e.v. come singola dose preoperatoria, da

ripetere ogni dodici ore per 48 ore se:

colonizzati da S. aureus, allergici

9 Mupirocina endonasale se:

(26)

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 administration

glicaemia 110 mg% (p < 0,001) • Decreasing of mediastinitis’s rate

from 1,6% to 0%

(27)

Prevention of Nosocomial Infection by

Decontamination of the Nasopharinx and Oropharinx

• Years 2003 – 2005, 991 patients

• Prospective, randomized, double-blind, placebo-controlled clinical trial

Intervention:

• Incidence nasal carriers

• Nasal decontamination by chlorhexidine gluconate or placebo

Results:

• 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 infections

(28)

Isolamenti da emocolture in pazienti

dell’U.O.Cardioghirurgia (gen –giu 2006)

fr Candida albicans sangue 1

sa Candida albicans sangue 4

bo Enterobacter aerogenes sangue 4

fo Enterococcus faecalis sangue 1

fr Enterococcus faecium sangue 1

fo Stafilococco coagulasi negativo sangue 1

gi Staphylococcus aureus sangue 2

be Staphylococcus aureus sangue 4

ta Staphylococcus aureus sangue 1

fo Staphylococcus epidermidis sangue 1

si Staphylococcus epidermidis sangue 2

ge Staphylococcus hominis sangue 1

pe Staphylococcus warneri sangue 1

(29)

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

4 ferita chirurgica Staphylococcus aureus 1

5 ferita chirurgica Staphylococcus epidermidis 1

5 ferita chirurgica Staphylococcus hominis 1

9 ferita chirurgica Staphylococcus warneri 1

(30)

% 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 dam icin a erit rom icin a lin ezol id fos fom icin a gen tam icin a Cip roflo xaci na lev oflo xaci na oxa cillin . rifa mpi cina trim etop rim /sul fam nor floxa cina van com icin a tei copl anin a tet raci clin a nitr ofur anto ina pen icill ina g

GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE TOTALE ISOLATI 13 1 ° SEMESTRE 2006

(31)

0,00% 10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00% 80,00% 90,00% 100,00% clindam icina er itromi cina linez olid Ci prof loxac ina fos fom icin a gen tam icin a le voflo xacin a ox acill in. rifam pici na trim etopr im/su lfam nor flox acin a vanc om icin a tei cop lani na tet rac iclina nitr ofur anto ina pen icillina g

% SENSIBILITA’ –

STAPH.EPIDERMIDIS

(32)

0,00% 10,00% 20,00% 30,00% 40,00% 50,00% 60,00% 70,00% 80,00% 90,00% 100,00% m erop enem Cip roflo x. gen tam icin a cef tazi dim e pip erac illin a pip er/ta zob cef epim e azt reon am im ipen em lev oflo x am ikac ina

%SENSIBILITA’- PSEUDOMONAS AERUGINOSA

(33)

conclusione

È opportuno che in ogni realtà chirurgica

locale 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)

(34)

(35)

0 2 4 6 8 10 12 14 16 S T A U S T A E P I E N T A E R P S E A E R E N T S P P S T A W A M O R M O A C IN E T E S C C O L K L E S P P P R O M IR MICRORGANISMI BATTERICI ISOLATI

GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE TOTALE ISOLATI 49, PAZIENTI 13 1 ° SEMESTRE 2006