Term
| why are core measure important? |
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Definition
#1 REASON: TO IMPROVE THE CARE OF PATIENTS
it isn't just about the numbers...
it is about the right care every time
#2: receive higher reimbursement from medicare and other payers
#3: these are reported to the public and you want to look good in the news |
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Term
| surgical care improvement project (SCIP) measures |
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Definition
INFECTION PREVENTIONS: IMPORTANT!
ANTIBIOTIC ADMINISTERED WITHIN ONE HOUR PRIOR TO SURGERY
if given early, the levels won't be high enough, if given late it won't have time to get to the site of the surgery
RECOMMENDED ANTIBIOTIC(S) GIVEN
ANTIBIOTIC DC'D WITHIN 24 HOURS AFTER SURGERY |
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Term
| epidemiology of surgical site infections (SSI) |
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Definition
most common complication of surgery
SSI occur in 3-6% of patients
cause of nosocommial infections
SSI are the 3rd most frequent cause overall
SSI are most frequent cause in surgical patients
prolong hospitalization
on average, lengthens stay ~7 days
increased cost of healthcare
direct annual cost of $5-$10 billion |
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Term
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Definition
in many cases, SSI are preventable
the administration of prophylactic antibiotics decreases the risk of infection after many surgical procedures and represents an important component of care
pharmacists should be directly involved in making sure that prophylactic antibiotics are administered appropriately |
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Term
| prophylactic antibiotics for surgery patients |
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Definition
antibiotics are most effective when given WITHIN ONE HOUR PRIOR TO SURGERY
SHORT DURATION ANTIBIOTICS ARE AS EFFECTIVE in preventing infection as long duration antibiotics
long duration antibiotics are more likely to cause development of DRUG RESISTANT bacteria |
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Term
| evidence: blood glucose control |
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Definition
CABG patients with uncontrolled blood glucose have significantly higher infection rates
deep wound infections in diabetic cardiac surgery patients were reduced by controlling mean blood glucose levels below 200 mg/dL |
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Term
| prophylactic antibiotic therapy |
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Definition
antibiotics administered prior to the contamination of previously sterile tissues or fluids
the goal is to prevent an infection from developing |
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Term
| presumptive (empiric) antibiotic therapy |
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Definition
antibiotic therapy is administered when an infection is suspected or presumed, but not yet proven
clinical scenarios include acute cholecystitis, open compound fractures, and acute appendicitis less than 24 hours in duration, gun shot wound to abdomen with colon injury |
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Term
| therapeutic antibiotic therapy |
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Definition
antibiotic therapy for a documented infection
once susceptibility for organism is back, then it can become definitive therapy
note: progression from prophylactic or presumptive antibiotic therapy to therapeutic antibiotic therapy may occur during surgery if signs of infection (or perforation) are evident. for example, findings of a gangrenous gallbladder or perforated appendix. |
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Term
| SSI risk factors: patient related (focus on these) |
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Definition
age (elderly)
nutritional status (malnutrition)
diabetes
smoking
obesity
coexisting infection at distal sites
colonization with resistant (Staph. aureus in nares)
altered immune response including the use of corticosteroids
length of preoperative stay |
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Term
| SSI risk factors: procedure related |
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Definition
duration of surgical scrub
preoperative skin preparation
preoperative shaving
duration of operation
antimicrobial prophylaxis
operating room ventilation
sterilization of instruments
implantation of prosthetic materials
surgical drains
surgical techniques |
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Term
| wound classification: clean |
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Definition
no antibiotics required unless high risk
no acute inflammation or transection of GI, GU, oropharyngeal, biliary, or respiratory tract
elective case with no technique break |
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Term
| wound classification: clean-contaminated |
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Definition
prophylactic antibiotics indicated
controlled opening of aforementioned tracts with minimal spillage/minor technique breaks
clean procedure done emergently or with major technique break |
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Term
| wound classification: contaminated |
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Definition
prophylactic antibiotics indicated
acute, non-purulent inflammation present
major spillage/technique break during clean-contaminated procedure |
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Term
| wound classification: dirty |
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Definition
therapeutic antibiotics required
obvious pre-existing infection present (abscess, pus, or necrotic tissue) |
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Term
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Definition
THE MOST IMPORTANT CONSIDERATION in choosing antibiotic prophylaxis is the BACTERIOLOGY OF THE SURGICAL SITE
organisms involved are acquired either from:
endogenous flora
exogenous contamination during procedure
most common organisms:
S. AUREUS
coagulase negative Staphylococci (S. epidermidis)
enterococci
E. coli
P. aeruginosa
with increasing use of broad spectrum antibiotics, MRSA and Candida species are becoming more prevalent causes of SSI |
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Term
| bacteriology: endogenous flora |
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Definition
organisms in the commensal flora are generally not pathogenic
often microbes are considered normal flora at certain anatomical locations, but are pathogens when isolated from other sites
normal endogenous flora often serve the host as a form of protection against opportunistic organisms that otherwise would colonize the surgical site
rarely normal endogenous flora are problematic unless they are found in large numbers
loss through the use of broad spectrum antibiotics can destabilize this homeostasis, thus allowing pathogenic bacteria to proliferate and infection to occur
if translocated to a sterile tissue site or fluid during the surgical procedure, normal flora can become pathogenic (ex: S. aureus, S. epidermidis, E. coli) |
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Term
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Definition
the placement of medical devices such as orthopedic implants, prosthetic heart valves, IV and urinary catheters clearly increases the risk of infection
bacterial colony forming units (CFUs) required to cause an SSI are markedly reduced
biofilm forming bacteria (Staphylococcus, Enterococcus, Pseudomonas, and Candida spp.) attach to the prosthetic device and are very difficult to remove |
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Term
| antimicrobial prophylaxis: timing |
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Definition
antibiotics should be administered such that they are DELIVERED TO THE SURGICAL SITE PRIOR TO THE INITIAL INCISION
best to give first dose with the induction of anesthesia. unfortunately, the literature suggests that many patients do not receive it this way
ideal to have available one hour before surgery
early (more than 2 hours prior to surgery) or late (after incision) administration of the first dose increases the risk of SSI |
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Term
| antimicrobial prophylaxis: duration |
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Definition
bactericidal concentrations should be maintained throughout the surgical prodecure
multiple doses may be required for longer procedures (> 3-4 hours)
proponents of re-dosing intraoperatively, suggest that the risk of SSI is just as high at wound closure as the initial incision
24 hours is usually more than sufficient, but 48 hours ok for cardiothoracic surgery |
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Term
| antimicrobial prophylaxis: extended duration |
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Definition
post-op abx is generally discouraged beyond the recommended time period
increases the likelihood of bacterial selection (i.e. development of resistance)
data from controlled trials does not support its added efficacy
increases treatment costs
still occasionally used |
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Term
| antimicrobial prophylaxis: selection of abx is dependent on... |
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Definition
type of surgical procedure (ex: laparoscopic, foreign body placement, etc.)
most frequent pathogens encountered based on procedure (ex: craniotomy vs. transphenoidal resection of brain tumor)
safety and efficacy profile of the abx
current literature supporting its use
susceptibility patterns of nosocomial pathogens within each instibution |
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Term
| antimicrobial prophylaxis: ANTIBIOTIC CHOICE |
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Definition
GRAM POSITIVE COVERAGE should typically be included as S. aureus and S. epidermidis are common skin flora (and therefore the 2 most frequently encountered organisms causing SSI)
broaden coverage to agents with GRAM NEGATIVE AND ANAEROBIC activity depending on both the surgical site (i.e. upper respiratory tract vs. GI, GU, etc.) and whether the operation will transect a hollow viscous or mucous membrane that may contain resident flora
if there are gram negatives in the procedure (GI tract) then this trumps the gram positive coverage |
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Term
| antimicrobial prophylaxis: ANTIBIOTIC CHOICE - most common agents |
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Definition
cephalosporins - appropriate spectrum of activity, low incidence of AEs, and low cost
cefazolin (1st generation) is preferred particularly for clean procedures
in cases where broader gram negative or anaerobic coverage is required, antianaerobic cephalosporins such as cefoxitin or cefotetan (cephamycins) are used
although 3rd generation cephalosporins (i.e. ceftriaxone) could be used, it is less than ideal b/c it does not cover S. aureus as well as the others
cephalosporins cover the main gram positives plus some gram negatives
cephalosporins cover NONE of the enterocuccus
3rd generations are better for Strep pneumo (gram +)
as gram - coverage is gained, they lose S. aureus coverage
other common agents:
metronidazole
clindamycin
ampicillin/sulbactam
ciprofloxacin or levofloxacin
vancomycin |
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Term
| special circumstances - penicillin allergy |
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Definition
there is some cross reactivity between penicillins and cephalosporins (rate ~2-10%)
first document that it is a true allergy, if so opt for a different class of drug (clindamycin [1st choice], vancomycin, etc.) relevant to the most common organisms encountered with the procedure |
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Term
| special circumstances: high incidence of MRSA at institution |
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Definition
can use vancomycin instead of a cephalosporin implantation of a prosthetic device will be performed
cardiothoracic surgeons are screening for MRSA and may use both when positive |
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Term
| antibiotic prophylactic recommendations for colorectal surgery (therapeutic antibiotics indicated for bowel perforation or peritonitis) |
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Definition
PO: neomycin + erythromycin pre-op (or metronidazole) acceptable
AND
IV: AMPICILLIN/SULBACTAM, CEFOXITIN, CEFOTETAN, ERTAPENEM
OR
CEFAZOLIN (OR CEFUROXIME) PLUS METRONIDAZOLE
beta-lactam allergic patients:
gentamicin plus metronidazole
OR
levofloxacin plus metronidazole
OR
clindamycin plus either gentamicin or quinolone or aztreonam
oral antibiotics are controversial in most procedures b/c there is not enough evidence proving they help except for colostomy reversal and rectal resections
the main point is to always use IV antibiotics with gram negative and anaerobic activity |
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Term
| antibiotic prophylactic recommendations for appendectomy |
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Definition
cefazolin plus metronidazole
OR
ampicillin/sulbactam
OR
cefotetan or defoxitin
beta-lactam allergic: gentamicin plus metronidazole
therapeutic antibiotics for perforated or ganrenous appendix |
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Term
| antibiotic prophylactic recommendations for urologic surgery |
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Definition
PO ciprofloxacin or trimethoprim/sulfa
therapeutic/definitive abx if bacteruria detected on pre-op urinary analysis |
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Term
| antibiotic prophylactic recommendations for cesarean section |
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Definition
CEFAZOLIN 2 GM x 1
timing is controversial (before incision or after umbilical cord clamped)
beta lactam allergy: pre-op metronidazole 1 g |
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Term
| antibiotic prophylactic recommendations for head and neck surgery |
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Definition
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Term
| antibiotic prophylactic recommendations for cardiothoracic surgery |
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Definition
cefazolin or cefuroxime x 24h
beta lactam allergy or high MRSA rate: vancomycin or clindamycin |
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Term
| antibiotic prophylactic recommendations for vascular surgery |
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Definition
cefazolin x 24h
beta lactam allergy or high MRSA rate: vancomycin or clindamycin |
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Term
| antibiotic prophylactic recommendations for orthopedic surgery |
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Definition
CEFAZOLIN X 24H
beta lactam allergy or high MRSA rate: vancomycin or clindamycin
presumptive therapy for open (compound) fractures |
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Term
| antibiotic prophylactic recommendations for neurosurgery |
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Definition
cefazolin or ceftriaxone
beta lactam allergy: vancomycin
cefazolin doesn't cross the BBB but the bacteria are on the skin not in the brain |
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Term
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Definition
oxygen assessment
blood cultures if appropriate
antibiotic timing (w/in 6 hours of arrival)
antibiotics should be given as soon as the diagnosis is made
initial antibiotic selection for community acquired pneumonia (CAP)
adult smoking cessation counseling
influenza vaccination
pneumococcal vaccination
also known as quality indicators that may be reported on the internet |
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Term
| pneumonia: blood cultures |
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Definition
pneumonia patients sick enough to be admitted to the ICU need to have blood culture drawn
ideally should be performed prior to first antibiotic
results can be used to optimize antibiotic therapy |
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Term
| pneumonia: timing of initial antibiotic |
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Definition
for patients with community acquired pneumonia, studies have shown that giving antibiotics within 6-8 hours of arrival reduces morality by 15-30%
therefore dose should be given as soon as diagnosis is made, ex: IN EMERGENCY DEPARTMENT PRIOR TO ADMISSION |
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Term
| pneumonia: selection of initial antibiotic |
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Definition
pneumonia patients should be assessed for severity of illness, allergies, and pseudomonal risk
different combinations of initial (empiric) antibiotics are recommended based on patient characteristics
patients receiving recommended antibiotics have a lower mortality rate |
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Term
| community acquired pneumonia or early onset hospital acquired pneumonia |
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Definition
pneumonia acquired outside of hospital or extended care facilities
OR
pneumonia acquired within 4 days of hospital admission
PLUS
no risk factors for multi drug resistant pathogens |
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Term
| nosocomial pneumonia and/or risk of multi drug resistant pathogens |
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Definition
healthcare associated pneumonia OR:
hospitalization for 2 or more days within past 90 days
residence in a nursing home or extended care facility within past 90 days
home infusion therapy within past 30 days
home wound care within past 30 days
chronic dialysis within past 30 days
OR
late onset (greater than 4 days after admission) hospital acquired pneumonia
OR
ventilator associated pneumonia
OR
risk of multi drug resistant pathogens:
antimicrobial therapy in preceding 90 days
immunosuppressive disease and/or therapy
high frequency of antibiotics resistance in the community hospital unit
severe structural lung disease (i.e. bronchiectasis)
malnutrition
recent broad spectrum antibiotic therapy (greater than 7 days in past 30 days)
chronic corticosteroid use (prednisone greater than 10mg/day)
pseudomonal risk factors include:
structural lung disease (i.e. bronchiectasis)
chronic corticosteroid use (prednisone greater than 10 mg/day)
immunosuppressive disease and/or therapy
neutropenia (absolute neutrophil counts < 500)
previous pseudomonas infection |
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Term
| pneumonia treatment - general floor: no pseudomonal risk (i.e. community acquired or early onset hospital acquired) |
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Definition
ceftriaxone IV
PLUS
azithromycin IV
OR
levofloxacin IV (recommended for patients with beta lactam allergy) |
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Term
| pneumonia treatment - general floor: pseudomonal risk (health care associated or multi drug resistant pathogens) |
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Definition
pick ONE of the following beta lactam antibiotics:
piperacillin/tazobactam IV
cefepime IV
doripenem IV
PLUS pick ONE of the following non beta lactam antibiotics:
levofloxacin IV
tobramycin IV PLUS azithromycin IV
OR
if beta lactam allergy:
aztreonam IV
PLUS
levofloxacin
optional:
tobramycin |
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Term
| pneumonia treatment - general floor: if the patient is at risk of MRSA |
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Definition
| normal therapy PLUS vancomycin or linezolid |
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Term
| antibiotics that cover pseudomonas |
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Definition
piperacillin
ticarcillin
ceftazidime
cefepime
imipenem
meropenem
doripenem
aztreonam
gentamicin
tobramycin
amikacin
polymyxin B
colistin
ciprofloxacin
levofloxacin (750mg)
use 2 drugs that cover pseudomonas (beta lactam + non beta lactam) |
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Term
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Definition
vancomycin
quinupristin-dalfoprisint
linezolid
daptomycin
tigecycline
telavacin
ceftaroline
aminoglycosides
TMP/sulfa
doxycycline
azithromycin
ciprofloxacin, levofloxacin, moxifloxacin
clindamycin
rifampin |
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Term
| pneumonia treatment - ICU: no pseudomonal risk (i.e. community acquired or early onset hospital acquired) |
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Definition
ceftriaxone
PLUS
azithromycin
OR
ceftriaxone
PLUS
levofloxacin
OR
if beta lactam allergy:
levofloxacin |
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Term
| pneumonia treatment - ICU: pseudomonal risk (i.e. health care associated or multi drug resistant pathogens) |
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Definition
pick ONE of the following beta lactam antibiotics:
piperacillin/tazobactam
cefepime
doripenem
PLUS pick ONE of the following non beta lactam antibiotics:
levofloxacin
tobramycin PLUS azithromycin
OR
if beta lactam allergy:
aztreonam
PLUS
levofloxacin
optional:
tobramycin |
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Term
| pneumonia treatment - ICU: if patient at risk for MRSA or VAP |
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Definition
| normal regimen PLUS pick ONE of the following: vancomycin or linezolid |
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Term
| renally eliminated antibiotics |
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Definition
beta lactams (penicillin, cephalosporins, carbapenems, monobactam = aztreonam)
aminoglycosides
trimethoprim-sulfamethoxazole
tetracyclines
tigecycline
FQs: ciprofloxacin, levofloxacin, gemifloxacin, NOT MOXIFLOXACIN
clindamycin
vancomycin
daptomycin
telavacin |
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Term
| non-renally eliminated antibiotics |
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Definition
macrolides
moxifloxacin
metronidazole
chloramphenicol
quinupristin/dalfopristin
linezolid |
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Term
|
Definition
DNA/RNA Inhibitors:
quinolones
rifampin
metronidazole
Ribosomal Protein Synthesis Inhibitors:
aminoglycosides
Cell Wall Agents:
beta lactams - penicillins, cephalosporins, carbapenems, monobactam (aztreonam)
glycopeptides - vancomycin
lipoglycopeptide - telavacin (combines properties of daptomycin and vancomycin)
Cyclic Lipopeptide:
daptomycin
polymyxin and colistin |
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Term
| types of healthcare associated infections |
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Definition
catheter related bloodstream infection (CRBSI)
catheter associated urinary tract infection (CAUTI)
ventilator associated pneumonia (VAP)
leads to:
increased length of stay (expensive)
medicare will not pay anymore
additional antibiotics cost money and lead to further resistance |
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Term
| types of multidrug resistant organisms |
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Definition
MRSA (and VISA/VRSA)
VRE
ESBLs - resistant to 3rd generation cephalosporins (ceftriaxone, cefotaxime, ceftazidime)
carbapenemase producing gram negative bacteria |
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Term
|
Definition
quin-dalf
linezolid
daptomycin
tigecycline |
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Term
| carbapenem resistant GNBs |
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Definition
often start as ESBLs
can share plasmid with other enteric GNBs
Pseudomonas aeruginosa
Acinetobacter baumanii
Stenotrophomonas maltophilia
Burkholderia cepacia |
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Term
| how to prevent all of these |
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Definition
WASH your hands!
use alcohol based hand sanitizers
less effective for VRE and NOT for C. difficile
question the catheter, especially foley
use antibiotics only when needed
shorten the duration when appropriate |
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Term
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Definition
education and isolation
minimize invasive ventilation
don't overdo sedation and analgesia
improve oral hygiene
decrease acid suppression medications and blood transfusions
control glucose |
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Term
| surgical prophylaxis summary |
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Definition
CEFAZOLIN is usually used to prevent Staph (MSSA) and Strep (beta-hemolytic) unless there is a high risk of enteric gram negatives such as GI procedures
START PRIOR TO INCISION, an no early than 1 hour before for most antibiotics
STOP WITHIN 24 HOURS for most surgeries |
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Term
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Definition
separate into categories of COMMUNITY ACQUIRED OR HEALTHCARE ASSOCIATED based on risk of resistance
drug(s) for S. PNEUMONIAE AND ATYPICALS ARE NEEDED FOR EVERY CAP
HAP AND VAP REQUIRE 1 MRSA ANTIBIOTIC PLUS 2 FOR PSEUDOMONAS AERUGINOSA
start as soon as possible after diagnosis |
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Term
|
Definition
carbapenems (imipenem, ertapenem, doripenem)
cephamycins (cefoxitin and cefotetan)
aminoglycosides
FQs |
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