House Keeping. Prevention of Infection. Strategies that Work

Transcription

1 Prevention of Infection Strategies that Work Javad Parvizi, MD, FRCS Professor of OrthopaedicSurgery Rothman Institute at Thomas Jefferson University House Keeping FROM THE GOTOWEBINAR PAGE: Click on the orange box with a white arrow to expand your control panel (upper right-hand corner of your screen). Type a question in the question box and click send. House Keeping CONTINUING EDUCATION Each 1 hour web meeting qualifies for 1 contact hour for nursing. 3M Health Care Provider is approved by the California Board of Registered Nurses CEP POST WEBINAR Link to Course Evaluation CE Certificate Included Forward to Others in Attendance 1

2 Disclosures RESEARCH SUPPORT: NIH OREF Stryker Orthopedics Depuy Zimmer Baxter 3M Biomemetics Ceramtec Smith and Nephew Board Member/Adviser Journal of Arthroplasty Philadelphia Orthopaedic Soc Eastern Orthopedic Assoc. United Healthcare 3M JBJS-A Bone and Joint Journal (British) Muller Foundation CONSULTANT: Zimmer Smith and Nephew Convatech TissueGene Ceramtec Emovi 3M Cadence INTELLECTUAL PROPERTY/ROYALTY:/OWNERSHIP SmarTech Elsevier Wolters Kluwer Slack Hip Innovation Technology CD Diagnostics Jaypee publishers Datatrace Implants Today 1890 THEMISTOKLES GLUCK. ailments of human joints will be treated by artificial materials. Periprosthetic Joint Infection 1976S SIR JOHN CHARNLEY joint sepsis will be the major hurdle in our way in the future.. 2

3 THA Infection: Medicare Data TKA Infection: Medicare Data 3

4 Infected Revisions: ,000 Infected THA 5,000 Infected TKA No. of Infected Revisions 4,000 3,000 2,000 1, Kurtz, S, Parvizi J JOA 2008 Infected Revisions : Burden Kurtz, S, et al JOA 2012 Cost 2009 $600 Million 4

5 Periprosthetic Joint Infection PREVENTION DIAGNOSIS TREATMENT Periprosthetic Joint Infection PREVENTION OF SSI GUIDELINES ARE IN DEVELOPMENT Medicine is an Art 5

6 Innovators Medicine Has Evolved Sir James Paget

7 Evidence Based Pyramid True Model of EBM International Consensus Meeting Philadelphia, August delegates 52 countries >100 societies 22 translations 7

8 International Consensus Group Step 6: Assemblage International Consensus Group Step 8: Publication Editorial in BJJ, CORR Full publication in JOA 15,000 copies of book Translation to 21 languages Numerous society websites Prevention of PJI OPTIMIZE HOST 8

9 Diabetes Control of glucose HbA1C <7% glucose <180 Ulcerations Neuropathy Control Nidus GI/GU (urine) Skin/nails No role for routine dental clearance Rheumatoid Arthritis Disease modifying agents (antimonoclonal antibodies)- Stop 4 weeks before and 8 weeks after Steroids (taper) Skin (ensure there is no ulcers) 9

10 Preoperative Optimization malnutrition obesity skin (psoriasis, eczma, ulcerations) vascular insufficiency?? smoking Peri-operative Factors Skin prep Gloves Draping Room Antibiotics Exposure Bleeding control Closure Dressing ANTIBIOTICS 10

11 Prevention of PJI Antibiotics PROPHYLACTIC ANTIBIOTICS Vancomycin (needs 1 hour) MRSA carriers Remote or recent MRSA Infection Institutionalized patients Healthcare workers Skin Prep Starts at Home Preoperative Optimization SKIN DECONTAMINATION Betadine shower Chlorhexidine wipes/showers Shaving (save until the OR) 11

12 SKIN PREP 9 step Matar W, et al JBJS 2012 Skin Prep SKIN PREP Most important agent is ALCOHOL Skin Prep Contamination of skin during draping May repeat skin prep Skin recolonizes Adhesive draping Drapes Johnston DH, et al: Br J Surg 74:64,

13 OR Environment LACK OF ADEQUATE SCIENCE Laminar flow Space suits Size/volume OR Environment WOUND CONTAMINATION Direct Fall-out Gloves Or Instruments THE PRIMARY SOURCE OF BACTERIA IN OR IS OR PERSONNEL OR Environment PEOPLE SHED UP TO 10,000 BACTERIA/MIN. DISPERSERS 13% of Men 5% of Post-menopausal Woman 1% of Pre-menopausal Women Traffic--- terrible 13

14 Gloves Puncture all cases > 3 hrs Cotton outer gloves reduce risk Change every 2 hrs Wound Irrigation OPTIMAL SOLUTION NOT KNOWN Wound Complications Drainage Hematoma Cellulitis Treat Aggressively 14

15 Hips do not lie Risk Factors for PJI RHEUMATOID ARTHRITIS STEROID THERAPY DIABETES MELLITUS PRIOR SEPTIC ARTHRITIS PRIOR ARTHROPLASTY MALIGNANCY LYMPHOCYTE <1.5X10 9 MORE THAN 4 HOSPITAL DAYS PRIOR TO TJR HOMOLOGOUS BLOOD DURATION OF HOSPITALIZATION DECUBITUS ULCERS NINS>1 SUPERFICIAL WOUND INFECTION WOUND DRAINAGE WOUND HEMATOMA WOUND DEHISCENCE Berbari EF, et al; Clin Infect Dis, 27:1247, 1998 Pulido L et al CORR 2009 Old scars Undermining Approach Gentle handling Expeditious surgery 15

16 Hematoma Serious Event Soft tissue ischemia/necrosis Prevents antibiotic access Nelson CL, et al: Clin Orthop 147:167, 1980 Hematoma Associated with the administration of anticoagulation Increases risk of PJI Parvizi J, et al: J Arthoplasty 2008 Anticoagulation Serious event Soft tissue ischemia/necrosis Prevents antibiotic access 16

17 Hematoma Low threshold for I & D if associated with drainage Large Active Hadden, J arth 1990 Beer, JBJS 1991 Acus, orthop 1992 Ritter, JBJS 1994 Niskanen, J arth 2000 Hallstrom, orthop rev 1992 Drains Cochrane database No difference in hematoma formation Higher blood loss Drainage HIPS WITH H/O DRAINAGE AFTER OPERATION HAVE 3 4X GREATER RISK OF INFECTION THAN THOSE THAT HEAL NORMALLY Surin et al. JBJS-B, 1984 Brown et al.jbjs-b,

18 Prevention of Wound Drainage WOUND OPTIMIZATION Meticulous closure Sealed dressing Infrequent dressing changes Watchful eye Surgical Dressing Protocol 1 st dressing change at 7 days No environmental wound exposure Reduces pain associated with dressing changes Ease for family/caretaker Excessive drainage evaluated via strikethrough Patients may shower immediately post operatively SSI caused by MRSA Screening and Decolonization? 18

19 Decolonization One time application One hour before surgery 12 hour effect 99% eradication Lowers SSI Phillips MS et al. IDSA 2012 Screening It appears that screening and decolonization reduces the incidence of SSI Logistic issues How to implement Perhaps most important is identifications Appropriate antibiotics Isolation Stay tuned Questions? 19