Role of A ntibiotic P rophylaxis forC leanTD C P roced u res

Loay Salman, MD MBA

C hief:D ivision of N ephrologyand H ypertension

The Thomas O rdwayD istingu ished P rofessorof M edicineA lbanyM edicalC ollege,A lbany,N Y

13thA nnu alA S D IN S cientific M eeting–Febru ary,20 17

What is the Concern?

U S R DS -1999

Antibiotic prophylaxis for minimallyinvasive interventional procedures

•Zegal et al in 1998 sent a questionnaire regarding antibioticprophylactic usage to 2,039 members of the Society ofCardiovascular and Interventional Radiology (SCVIR).

Conclusion:

Indications for antibiotic prophylaxis are not clear tointerventionalists for a large number of vascular andnonvascular interventional procedures.

Zegaletal,JVasc Interv Radiol.1 998

Procedure related infection

Procedure related infection:

No consensus on definition.

Any documented infection at the procedure site or bloodstream that occur within 72 hours after the procedure.

Rate:

There is no data about dialysis access proceduresinfection rate.

SalmanL ,A sifA :SID . 2009

SalmanL ,A sifA :SID . 2009

JVascIntervR adiol2016;27:339– 343

Conclusions:The odds ratio of infection was 0.85 with antibiotic use but one was contained within theconfidence interval suggesting no significant difference in infection rate when antibioticswere used.

Recommendation

•Intravenous Antibiotic ProphylaxisRandomized controlled trials indicate that catheter-related infections andsepsis are reduced when prophylactic intravenous antibiotics areadministered to high-risk immunosuppressed cancer patients or neonates(C ategoryA 2evidence).

The literature is insufficient to evaluate outcomes associated with theroutine use of intravenous antibiotics (C ategory D evidence).

•Recommendations for Intravenous Antibiotic ProphylaxisFor immunocompromised patients and high-risk neonates, administerintravenous antibiotic prophylaxis on a case-by-case basis. Intravenousantibiotic prophylaxis should not be administered routinely.

P racticeGuidelinesforCentralVenousAccess:A R eportby theAmerican Society of Anesthesiologists T askForceonCentralVenousAccess

Anesthesiology3 2012,Vol.116,539-573

Recommendation

P ractice Gu ideline forA d u ltA ntibiotic P rophylaxis d u ringVascu larand InterventionalRadiologyP roced u res

JVasc Interv Radiol20 1 0 ;21 :1 611 –1 630

Recommendation

GuidelinesfortheP reventionofIntravascularCatheter-R elatedInfections,2011www.cdc.gov

What are the concerns ofAntibiotic use?

Concerns with routine use of antibiotics!

• Antibiotic resistance:• Mutation.• Transfer of resistance-encoding genetic material from one bacteria to another.• Increased number of susceptible host (i.e. immunocompromised).• Not following infection control practices.• M isu se oroveru se of antibiotics.

A cta P harmacolSin24,20 0 3

• Multi-drug-resistant organisms:• Methicilin-resistant Staphylococci (MRSA)• Vancomycin-resistant Enterococci (VRE)• Extended-spectrum beta-lactamase (ESBL)

There is clear evidence that infections with those organisms are diagnosed more frequentlyas compared with the past.

A m JInfectC ontrol28,20 0 0

•Antibiotic side effects:• Large prospective study reported that only 3.2% demonstrated

true penicillin allergy of which 0.2% were anaphylactic innature.

InternationalRheu matic FeverGrou p.L ancet1 991

• Another large prospective study reported that the rate of sideeffects is 22%.

C how etal,B rJA naesth97,20 0 6

•Antibiotic financial burden!

Concerns with routine use of antibiotics!

Important!

I. Peritoneal Dialysis Catheter Placement:

Prophylactic antibiotic use is recommended!

•Cefazolin•Vancomycin

Gadallahetal.A m JKidney D is,20 0 0Keane etal.P eritD ialInt.1 996;1 6(6):557

W ikdahletal.N ephrolD ialTransplant.1 997;1 2(1 ):1 57D ombros etal.N ephrolD ialTransplant.20 0 5;20 Su ppl9:ix3

II. Accidentally extruded Catheters

III. High risk patients

If Antibiotic is given!

•Timing: 30 – 60 minutes

van Kasteren et al. Clin Infect Dis. 2007;44(7):921Steinberg et al. Ann Surg. 2009 Jul;250(1):10-6

Bratzler et al. Surg Infect (Larchmt). 2013 Feb;14(1):73-156. Epub 2013 Mar 5

•Number of doses

C .J.Strachan,B M J1,1 977B owden etal.,A m JSu rg152,1 986

C lassen etal.,N EnglJM ed 326,1 992Goldmann e tal.JThorac C ardiovasc Su rg.1 977;73(3):470

H arbarthetal.C ircu lation.20 0 0 ;1 0 1 (25):291 6

Procedure Sterility!

Procedure Sterility!

Barrier PrecautionsUse maximal sterile barrier precautions, including theuse of a cap, mask, sterile gown, sterile gloves, and asterile full body drape, for the insertion of CVCs,PICCs, or guidewire exchange. Category IB

20 11 Gu idelines forthe P revention of Intravascu larC atheter-Related Infections

www.cdc.gov

Procedure Sterility!

Skin PreparationPrepare clean skin with a >0.5% chlorhexidinepreparation with alcohol before central venouscatheter and peripheral arterial catheter insertion andduring dressing changes. If there is a contraindicationto chlorhexidine, tincture of iodine, an iodophor, or70% alcohol can be used as alternatives. Category IA

20 11 Gu idelines forthe P revention of Intravascu larC atheter-Related Infections

www.cdc.gov

Tu u lietal.N EnglJM ed.20 1 6Feb 1 8;374(7):647-55

A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean Delivery

D arou iche etal.N EnglJM ed.20 1 0 Jan 7;362(1 ):1 8-26

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis

•Chlorhexidine gluconate:• It is a bactericidal agent, its uptake by bacteria and yeast is rapid and

maximum effect was attained within 20s.

H u go etal,P harmacol.1 964,1 965,1 966

• Chlorhexidine crosses the cell wall presumably by passive diffusionleading to damage to the delicate semipermeable membrane andsubsequently leakage of intracellular constituents.

• At low concentrations it has bacteriostatic effect and at highconcentrations it is bactericidal.

• Chlorhexidine has long lasting effect (>6 hours).

M cD onnellG,Ru ssellA D .C lin M icrobiolRev,1 999

Procedure Sterility!

Skin Preparation

•Iodophors, such as povidone-iodine:• Iodine rapidly penetrates into microorganisms and attacks key groups of

proteins which culminate in cell death.

• Their activity is much shorter than that of chlorhexidine gluconate.

• It can be inactivated by blood or serum proteins. That’s why once appliedto the skin they should be allowed to completely dry in order to maximizetheir antimicrobial action.

A ly R,M aibachH I.A m JInfectC ontrol,1 988

Gentry etal.Su rgery 98(1 ),1 985

•Alcohol:• Little is known about the exact mode of action of alcohol but it is generally believed

that they cause membrane damage and rapid denaturation of proteins.

• It is believed that it has germicidal activity against bacteria, fungi, and viruses.

• The effectiveness of pure alcohol solutions is limited by their lack of any residualactivity and their flammability.

M cD onnellG,Ru ssellA D .C lin M icrobiolRev ,1 999

Procedure Sterility!

Skin Preparation

There is no firm evidence that one type of hand antisepsis isbetter than another in reducing SSIs.C hlorhexidine glu conate scru bs may red u ce the nu mberof C FUs on hands compared withpovidone iodine scru bs;however,the clinicalrelevance of this su rrogate ou tcome is u nclear.A lcoholru bs withadditionalantiseptic ingredients may red u ce C FUs compared withaqu eou sscru bs.W ithregard to du ration of hand antisepsis,a 3minu te initialscru b red u ced C FUs onthe hand compared witha 2minu te scru b,bu tthis was very low qu ality evidence,and findingsabou ta longerinitialscru b and su bsequ entscru b d u rations are notconsistent.Itis u nclearwhethernailpicks and bru shes have a differentialimpacton the nu mberof C FUs remainingon the hand.Generally,almostallevidence available to inform decisions abou thandantisepsis approaches thatwere explored here were informed by low orvery low qu alityevidence.

Tanneretal.C ochrane D atabase S ystRev.20 1 6Jan 22;(1 ):C D 0 0 4288.

Procedure Sterility!

Hand Sanitization

Thankyou !