COMPLICANZE INFETTIVE IATROGENE - ?· PROFILASSI ANTIBIOTICA IN CHIRURGIA Surgical Site Infections (SSIs)…

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INFECTIONS IN END STAGE LIVER DISEASES AND LIVER

TRANSPLANTATION

Umberto Cillo, Antonio Ottobrelli, Nicola Petrosillo, Marco Senzolo, Gabriele Missale

COMPLICANZE INFETTIVE IATROGENE

COMPLICANZE INFETTIVE IATROGENE

CHIRURGIA MANOVRE INVASIVE PERCUTANEE ERCP NUTRIZIONE PARENTERALE

Durata di degenza, costi e rischio di mortalit della

chirurgia non-resettiva epatica nel paziente cirrotico

Cirrhosis complicated

by PH

Cirrhosis

Normal

Csikesz NG, et al. J Am Coll Surg 2009;208:96Millwala F, et al. WJG 2007; 13:4056

PROFILASSI ANTIBIOTICA IN CHIRURGIA

Surgical Site Infections (SSIs)PNLG Antibioticoprofilassi perioperatoria nell'adulto - 2008

FATTORI DI RISCHIO PER SSIs

Pessaux P, et al. Arch Surg 2003; 138:314

Pessaux P, et al. Arch Surg 2003; 138:314

Fattori di rischio per morbidit da infezioni extra SSI

Pessaux P, et al. Arch Surg 2003; 138:314

Fattori di rischio per morbidit da infezioni extra SSI

analisi multivariata

Infective risk assessment for surgical diagnostic and therapeutic

procedures, is there an evidence for antibiotic prophylaxis ?

Based on the high prevalence of infections and the related mortality rate in cirrhotic patients undergoing abdominal (as

well extra-abdominal) surgery, keen attention needs to be

taken in the clinical care of these patients. However, at this

time there are no studies available in the medical literature

addressing the specific issue of antibiotic prophylaxis in these

patients.

No specific recommendations are therefore available and further scientific efforts in this setting are urgently required in

the near future.

Antibiotic prophylaxis for patients undergoing elective

endoscopic retrograde cholangiopancreatography (1)

Brand M, et al. Cochrane Database of Systematic reviews , issue 11, 2010

Antibiotic prophylaxis for patients undergoing elective

endoscopic retrograde cholangiopancreatography (2)

Brand M, et al. Cochrane Database of Systematic reviews , issue 11, 2010

Infective risk assessment for ERCP in ESLD and OLT patient.

Which prophylaxis has to be adopted

Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography prevents cholangitis (RR 0.54, 95% CI 0.33-0.91), septicemia (RR 0.35, 95%, CI 0.111.11), bacteremia (RR 0.50, 95% CI 0.33-0.78) and pancreatitis (RR 0.54, 95% CI 0.29-1.00) but without evidence of overall mortality reduction (RR 1.33, 95 CI 0.32-5.44). (I A)

Of note, antibiotic prophylaxis benefit in preventing cholangitis was not demonstrated in patients in whom the ERCP resolved the biliary obstruction at the first procedure (RR 0.98, 95%; CI 0.35 to 2.69) (1). (I B).

Prophylactic use of Cefotaxime, Piperacillin, Cefonicid, Cefuroxime, Minocyclinedemonstrated the same efficacy ( I A)

In OLT patients with posttransplant biliary strictures, antibiotic prophylaxis is alwaysreccomended and continuation of antibiotics after the procedure may be beneficial (III B)

At this time there are no studies available in the medical literature addressing infective risk and the specific issue of antibiotic prophylaxis in patients with end ESLD

Banerjee S, et al. Gastrointest Endosc 2008;67:791

Brand M, et al. Cochrane Database of Systematic reviews , issue 11, 2010

Infective risk assessment for invasive diagnostic and

therapeutic percutaneous procedures in ESLD. Which

prophylaxis has to be adopted

Central venous access Hepatic venous pressure gradient measurement Transgiugular liver biopsy Toracenthesis Transjugular intrahepatic porto-systemic shunt

(TIPS)

Percutaneous tretment of liver tumors (PEI, RF) Transarterial chemoembolization (TACE)

Catheter related blood stream infections

(CR-BSIs)

Incidence of catheter related bloodstream infections

(CRBSIs) ranges between 3% to 4% in Europe with 1.12-

4.2 CRBSIs per 1000 catheter days, 8400-14,400 CRBSIs

episodes per year and 1000-1584 associated deaths per

year in a 4 countries epidemilogical study (II)

Tacconelli E, et al. J Hospital Infect 2009; 72:97

Central venous catheters treated with anti-infective

agents in preventing bloodstream infections

Hockenhull JC, et al. Health Technology Assessment 2008; Vol. 12

Gram negative bacteria are an increasing cause of CR-BSIs with

an incidence of 40%, but cirrhosis is associated with a lower risk

of Gram negative catheter related bacteraemia

Marcos M, et al. Antimicrob Chemoter 2011; 66:2119

Catheter related blood stream

infections (CR-BSIs)

Patients who have more susceptibility to infections are more prone to develop severe CR-BSIs (II), however no specific epidemiological data are present in cohorts of patients with end stage liver disease.

A significant advantage in preventing CRBSI of anti-infective central venous catheter has been demonstrated (I), but the indication to its use in cirrhotic patients needs further evidence.

Recommendations: no prohylaxis (C)

Endotipsitis-persistent infection of transjugular intrahepatic

portosystemic shunt: risk of infection and aetiologic agents

Mizrahi M, et al. Liver Int 2010;30:175

Bacteriemia incidence 35 cases/99 patients (35%)Sustained bacteriemia incidence 5/99 patients (5%)

Sustained bacteriemia developed a median of 100 days after TIPS placement (range, 6732 days)

De Simone JA, et al. Clinical Infectious Diseases 2000; 30:384

84 patients, 105 TIPS interventions: Infection rate 17%

Deibert P, et al. Dis Dis Sci 1998; 43:1708

High risk patients: Child C, variceal rebleedingInfection rate 53%

Powels A, et al. Hepatology 1996; 24:802

Endotipsitis-persistent infection of transjugular intrahepatic

portosystemic shunt: antibiotic prophylaxis

Deibert P, et al. Dis Dis Sci 1998; 43:1708

Treatment Ce ftriaxone 1 gr ev Ceftriaxone 2 gr ev p Tips re lated infec tion 1/40 1/42 ns

Gulberg V, et al. Hepato-Gastroenterology 1999; 46:1126

Endotipsitis-persistent infection of transjugular

intrahepatic portosystemic shunt

The use of prophylactic antibiotics during the initial TIPS procedure is controversial, and despite the lack of evidence,

prophylaxis is the common practice

Recommenations: Consideration should be given to remove the central venous catheter after TIPS insertion if not

necessary (B). 1 gr ceftriaxone ev prior the procedure (A). 1.5-

3gr Ampicillin/Sulbactam inravenously (B)

Percutaneous treatment of liver tumors

(PEI, RF, TACE)

Main infective complication is liver abscess, that is a rare event for PEI and RF ablation (0.2-1.1%), with higher incidence reported for

trans-arterial chemoembolization (0.6-2.6%) [Reed RA, at al. J Vasc Interv Radiol. 1994; 5:367]

Bouza C, et al. BMC Gastroenterol 2009; 9:31Curley SA, et al. Ann Surg 2004; 239:450

The biliary abnormality prone to ascending biliary infection is the most

important predisposing factor to the development of liver abscess

after TACE and RF

De Baere T, et al. Am J Roentgenol 2003;181:695

Abscess occurred significantly (p < 0.00001) more frequently in

patients bearing a bilioenteric anastomosis (3/3) than in other patients

(4/223)

TACE

Song SY, et al. J Vasc Interv Radiol 2001;12:313

RF

Percutaneous treatment of liver tumors,

antibiotic prophylaxis

TACE, TAERecommendation: in high risk patients Levofloxacin 500mg/d and metronidazole500mg td before procedure until 2 weeks after discharge along with bowel preparation with neomycin and erythromycin can be considered (B). Alternatively intravenous tazobactam/piperacillin for 36 hours after procedure (B)

PEI and RFA Recommendation: no prophylaxis (C).

Levofloxacin 500mg/d and metronidazole 500mg td before procedure until 2 weeks after discharge along with bowel preparation with neomycin and erythromycin can be considered in high risk patients (B)

Geschwind JF et al. J Vasc Interv Radiol 2002;13:1163

Patel S, et al. J Vasc Interv Radiol 2006;17:1931

Clinical management of patients with ESLD, which are the risks of

iatrogenic nosocomial infections related to parenteral nutrition

Yoneyama K, et al. J Gastroenterol 2002; 37:1028 Dupeyron C, et al. Infect Control Hosp Epidemiol 2001;22:427

Intravenous hyperalimentation (IVH) infection is one of the causes of hospital acquired infections in ESLD patient with an increased risk for Stphylococcus aureus

infections

% % % %

MSSA 111/589 18.8 %MRSA 96/589 16.3 %

Intravenous hyperalimentation (IVH) and

risk of CR-BIs

Recommendations:

Healthcare personnel who care for patients with ESLD should be trained on the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections (I A)

Intravascular catheter that are no longer essential should be promptly removed (I A)

Before insertion or during use of an intravascular catheter systemic antimicrobial prophylaxis should not been administered to prevent catheter colonization or catheter-related bloodstream infections (III C)

OGrady NP, et al. Am J Infect Control 2011;39(4 Suppl 1):S1

OSSERVAZIONI CONCLUSIVE

Chirurgia:

-nonostante vi sia una elevata frequenza di infezioni nelpaziente cirrotico e un significativo impatto sulla mortalit, non esistono studi di profilassi antibiotica in questi pazienti

Procedure diagnostiche ed interventistiche percutanee:

-il rischio infettivo per procedure come: TACE e RF deriva dastudi che hanno incluso anche pazienti non cirrotici

-gli studi comparativi di profilassi antibiotica per TACE neipazienti ad elevato rischio (anastomosi bilio-enteriche) sonostudi retrospettivi condotti in pazienti cirrotici e non cirrotici(metastasi ipervascolari)

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