Le Infezioni in Cardiochirurgia - Area-c54.it infezioni in cardiochirurgia.pdfInfezioni Nosocomiali...

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




4 ferita chirurgica Staphylococcus aureus 1




5 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

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

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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…

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+ Candida albicans: 5

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