Le Infezioni in Cardiochirurgia

Le Infezioni in Cardiochirurgia
A.O.U. San Martino, Genova
U.O.S. Patologia Infettivologica: Dott. F. Dodi
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=
Tipo di Intervento=
urgente 5,9%
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 postoperatorie 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
Osteomielite 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 vs Contamination –
Definitions
• 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
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.
Mamta Sharma, Infect. Control. Hosp. Epidemiol. 2004; 25: 468
Classification of Sternal Wound
Infection
TYPE
DEPTH
1a
1b
2a
2b
3a
superficial
superficial
deep
deep
deep
3b
deep
DESCRIPTION
skin and subcutaneous tissue dehiscence
exposure of sutured deep fascia
exposed bone, stable wired sternotomy
exposed bone, unstable wired sternotomy
exposed necrotic or fractured bone,
unstable, heart exposed
types 2 or 3 with septicemia
Glyn J., Ann. Surg. 1997; 225; 766
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%.
Ann. Thorac. Surg. 1984; 38: 415
J. Thorac. Cardiovasc. Surg. 2006; 132: 537
Predominant Pathogen in Sternal
Wound Infections (1988 – 1996)
Ann. Surg. 1997; 225: 766
Microbiology of the Surgical Wound Cultures
(1997 – 2000)
Infect. Control Hosp. Epidemiol. 2004; 25: 468
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
Sharma M., et al., Infect. Control. Hosp. Epidemiol. 2004; 25: 468
Morbidity Following Sternal
Wound Reconstruction
Ann. Surg. 1997; 225; 766
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%)
Eur. J. Surg. 1998; 164: 217
Chest 2003; 124: 2244
Infect. Control Hosp. Epidemiol. 2004; 25: 468
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
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 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
Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, 2000
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
Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 2001
Prophylactic Antibiotics in Cardiosurgery
Type of surgery: cardiovascular,coronary bypass, valvle surgery
Prefered regimen:
Alternative 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)
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
Bartett J.G., Pocket Book of Infectious Disease Therapy, 2002
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
o Cefuroxime
2 g IV as a single dose or q8h for 1-2 days
1,5 g IV as a single dose or q12h for 1-2 days
If elevated frequency of MRSA, high risk patients, MRSA colonized:
ƒ 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
The Sanford Guide to Antimicrobial Thepapy, 2006
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
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 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:
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 administration
glicaemia 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 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
JAMA 2006; 296: 2460
Isolamenti da emocolture in pazienti
dell’U.O.Cardioghirurgia (gen –giu 2006)
paziente
fr
sa
bo
fo
fr
fo
gi
be
ta
fo
si
ge
pe
microrganismo
Candida albicans
Candida albicans
Enterobacter aerogenes
Enterococcus faecalis
Enterococcus faecium
Stafilococco coagulasi negativo
Staphylococcus aureus
Staphylococcus aureus
Staphylococcus aureus
Staphylococcus epidermidis
Staphylococcus epidermidis
Staphylococcus hominis
Staphylococcus warneri
campione
sangue
sangue
sangue
sangue
sangue
sangue
sangue
sangue
sangue
sangue
sangue
sangue
sangue
n° isolamenti
1
4
4
1
1
1
2
4
1
1
2
1
1
Isolamenti da ferita chirurgica U.O Cardiochirurgia gen –giu 2006
organismo
paziente
campione
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
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GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE
TOTALE ISOLATI 13 1 ° SEMESTRE 2006
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GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE
TOTALE ISOLATI 6
1 ° SEMESTRE 2006
%SENSIBILITA’- PSEUDOMONAS AERUGINOSA
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GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE
TOTALE ISOLATI 3
1 ° SEMESTRE 2006
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)
Istituto Superiore della Sanità
MICRORGANISMI BATTERICI ISOLATI
16
14
12
10
8
6
4
2
0
PROMIR
GERMI ISOLATI DA SANGUE, FERITE CHIRURGICHE
TOTALE ISOLATI 49, PAZIENTI 13 1 ° SEMESTRE 2006
KLESPP
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MO RMO
STAW A
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STAE PI
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+ Candida albicans: 5