Conquering Surgical Infections In 2014

Conquering Surgical Infections in 2014
Stephanie S. Davis, MSHA, RN, CNOR
Vice President of Surgical Services
Julia Moody, MS AM(ASCP)
Director of Infection Prevention
Hospital Corporation of American (HCA)
Nashville, TN
Faculty Disclosure
Stephanie S. Davis, MSHA, RN, CNOR
Julia A. Moody, MS, SM (ASCP)
7. No conflict.
AORN’s policy is that the subject matter experts must disclose any financial relationship in a company
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7. No conflict of interest
• Review Publicly Reported surgical site infections (SSIs)
• Describe common organisms and costs associated with
• Examine the evidence of recent studies and their affect
on infection rates for certain surgical procedures.
• Discuss the future trends and changes to our practice
that can decrease surgical infection rates and events.
• 2014 Updates to Public Reporting of SSI
Conquering Surgical Infections
• Publicly Reported Post Operative Surgical
Site Infections (SSIs)
– Two different sets of metrics:
• Healthcare Associated Conditions (HACs) and
• Healthcare Associated Infections (HAIs)
• Common Causes and Costs of SSI infections
• Key infection prevention practices
• What’s New in Studies to Reduce SSIs?
• 2014 updates to Publicly Reported SSIs
Regulatory Rationale to Reduce SSIs
• CMS HACs Pay for Performance
– Deficit Reduction Act (DRA) of 2005 required there be an adjustment in
Medicare DRG payment for certain hospital-acquired conditions (HACs)
with Present on Admission (POA) coding
– Events are sourced from administrative coding based on provider
• CMS / NHSN HAIs Pay for Reporting
– 2010 Patient Payment and Affordable Care Act names Healthcare
Associated Infections (HAIs) and HHS target is to reduce SSIs by 25%.
– Reporting is via the CDC National Healthcare Safety Network using
infection prevention based surveillance definitions and risk adjustments
Regulatory Rationale to Reduce SSIs:
2013 Public Reporting
- Colorectal
- Abdominal Hysterectomy
State mandated HAIs
- Open heart
- Hip and knee joints
- Other
– Mediastinitis
– Bariatric
– Orthopedic procedures
– Cardiac implantable
electronic device
– Readmissions and
Proportion of Hospital-Acquired Infections
(HAIs) in the US
SSI = Surgical Site Infections
CAUTI = Catheter Associated
Urinary Tract Infection
HO-HCFA CDI = Hospital
onset Healthcare Facility
Associated C difficile Infection
CLABSI = Central Line
Associated Bloodstream
VAP = Ventilator Associated
ID Week 2013 Abstract 497
NHSN Reported Data
NHSN Primary Causes of SSI
Source: Hidron et al., ICHE 2008
Health Care–Associated Infections
A Meta-analysis of Costs and Financial Impact
on the US Health Care System
 Annual cost $9.8
 SSI contributed the
most to overall costs33.7% of total
 MRSA SSIs increase
cost and LOS
JAMA Intern Med 2013: published online September
9 2
Conquering Surgical Infections
• Public Reporting of Post Operative Surgical Site
Infections (SSIs)
– Two different sets of metrics: Healthcare Associated
Conditions (HACs) and Healthcare Associated
Infections (HAIs)
• Key infection prevention strategies
– Evidence for practices
• What’s New in Studies to Reduce SSIs?
• 2014 updates to Publicly Reported SSIs
Preventing SSI:
Important Modifiable Risk Factors
• Optimize Antimicrobial prophylaxis
• Appropriate skin or site preparation
– Hair removal
– Skin cleansing and preparation
Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
SSI: Important Modifiable Risk Factors
• Optimize Antimicrobial Prophylaxis
– Right choice (procedure specific)
– Right time (pre-incision dose)
– Right dose based on body mass index
• Cefazolin increased from 1g to 2g for defined
weight decreased SSIs
• ASHP 2013 publication with new dosing
– Redosing for procedures >3h
– Presence of antibiotic resistant organisms like MRSA
ASHP 2013
Medical Letter 2012
Timing of Antimicrobial Prophylaxis and the
Risk of SSIs
Ann Surg 2009; 250:10
Perioperative Prophylactic Antibiotics
Timing of Administration
Infections (%)
Hours From Incision
Classen. NEJM. 1992;328:281.
2013 Changes in Antimicrobial Prophylaxis
• Cardiac and Orthopedic procedures
– Screen for Staphylococcus aureus, both MRSA
and MSSA, and decolonize
– Add Vancomycin to Cefazolin when MRSA positive
or unknown status at time of surgery
• Colon procedures
– Ceftriaxone (if institution has increased resistance to
first and second generation cephalosporins) plus
metronidazole over use of a carbepenem
ASHP 2013
2013 Changes in Antimicrobial Prophylaxis
• Cesarean Section
– Cefazolin given before surgical incision instead of former
recommendation after cord clamped
• Does not routinely support topical antimicrobials for
irrigations (i.e. CHG)
– Parenteral prophylaxis is adequate
• Shortening postoperative prophylaxis
– 2013 guideline states most cases can be treated with a single
dose preoperatively. Duration should be <24h*
– There is no data to support continuation of surgical prophylaxis
until all drains are removed
*Upcoming CDC guidelines will not
recommend postop dosing
2013 Surgical Antimicrobial Prophylaxis
• Weight-based dosing: e.g. Cefazolin dosing from 1gm
to 2gm routine (2gm to 3gm for >120kg)
• Re-dosing
• Re-dosing for blood loss over 1500 ml
• Add Gentamicin to some procedures to cover Gram
negative bacteria (for beta-lactam allergy or known
colonization with MRSA when vancomycin used)
• If antibiotic prophylaxis is continued postoperatively,
duration should be <24 hours regardless of the presence
of intravascular catheters or indwelling drains
ASHP 2013
Prophylactic Antibiotics
Size of Patient and Size of Dose
Surg 1989; 106:750
• Morbidly obese patients having bariatric
• Cefazolin levels lower than in non-obese
patients at same dose
• Cefazolin dose changed from 1 g to 2 g
– Infection rate at 1 g: 16.5%
– Infection rate at 2 g: 5.6%
Timing of Antimicrobial Prophylaxis
and the Risk of SSIs
Ann Surg 2009; 250:10
Intraop Redosing
in Surgeries > 4 h
Infection Risk
no redosing
Surgical Prophylaxis Dosing Table
SSI: Important Modifiable Risk Factors
• Skin and site preparation to reduce microbes
– Presurgical shower (regular or antimicrobial soap)
• Clean towel and clean clothing
– Avoid hair removal unless hair will interfere
• Do not use razors
• Instruct patients to not shave prior to the procedure
• Use clippers if removal is necessary, clip
immediately prior to the procedure to minimize risk
• Disrupting the protective skin surface, allows
microbes to gain tissue access
SSI: Important Modifiable Risk Factors
– Use an approved labeled skin antiseptic agent
• Activity is enhanced with alcohol combination
• Apply and follow manufacturers instructions
• Let dry or dwell thoroughly for maximum
– Water based or Waterless Surgical Hand Scrubs
• Apply for the indicated time
• Products differ in action and time to achieve
– Sterile draping to prevent bacterial contamination
Antiseptic Surgical Skin Preparations
• Lower SSI rates for iodine containing products
– Comparison of 3 products (povidine iodine, iodine plus alcohol,
CHG plus alcohol) in sequential implementation adult general clean
and clean contaminated surgery (Swenson ICHE 2009)
• Significantly lower SSI rates for CHG-alcohol compared
with iodine paint and scrub for superficial and deep SSI, but
not organ/space SSI.
– Multicenter study of adults undergoing clean-contaminated surgery
(Darouiche NEJM 2010; 362:18)
• Which is the better prep? CHG+alcohol or Iodine+alcohol?
– No recommendation due to absence of direct comparison
Preventing SSI:
Important Modifiable Risk Factors
• Glucose control
• Blood transfusion
• Adequate intraoperative oxygen levels
• Operative time and efficiencies
Mangram AJ, et al. Infect Control Hosp Epidemiol.
SSI and Glucose Control
General and Vascular Procedures
 Results
 ↑SSI Risk(multivariate analysis)
 Post-op glucose
 ASA class
 Length of operation
• SSI rate increased 30% for every 40
mg/dL glucose > 110
Ann Surg 26
2008; 248:203
General Surgical Operative Duration is Associated with
Increased Risk-Adjusted Infectious Complication Rates and
Length of Stay
J Am Coll Surg 2010;210:60-65
Study Design: Nearly 300,000 operations performed at 173 hospitals
from 2005 to 2007, found the 30-day rate of infectious complications
rose by almost 2.5% for every 30 minutes between incision and closing.
Findings: After adjusting for patient variables, type and complexity of
surgery, wound class, and need for transfusion, operative time
remained a significant predictor of postoperative infection.
Surgeries lasting 2.1 to 2.5 hours had nearly double the risk of
infectious complications compared to those patients whose procedure
no more than an hour.
Across all procedures, hospital stays increased geometrically along
with operative times, at a rate of about 6% for every 30 minutes.
Mean Number of Complications in Intervention
Hospitals and Control Hospitals before and after
Implementation of the Surgical Safety Checklist
de Vries EN et al. N Engl J Med 2010;363:1928-1937
SSI 3.8%→2.7% P 0.006
HCA Template for a Surgical Safety Checklist
Surgical Safety Checklist
Time Out
Before Induction of Anesthesia
Before Skin Incision
Before Surgeon and Patient Leave the Room
(Circulator Initiates)
(Circulator Initiates)
(Circulator Initiates)
*Team Members should stop activity and respond to each question of the briefing, time out, and debriefing.
Circulator announces the results of the
counts (instrument, sponge, needle as
Circulator confirms exact procedure and
diagnosis with surgeon.
Has the patient been identified using two
unique identifiers?
Confirm that all team members have
introduced themselves by name and role.
Who are providers and what is the
procedure site and side?
Is this the correct patient, correct procedure
and correct side?
Images displayed and labeled
Consent correct
Reports confirm site and side
Position correct
Circulator confirms all specimens are
accurately labeled.
What are the safety concerns for this
Appropriate pre-op antibiotic selected and
DVT risk
Normothermia assured
Anticipated blood loss
Patient history or medication - use
Implants and equipment needed present
Fire risk
Expected length of procedure
Any other concerns?
Were there any delays for this case? (Assign
delay codes)
Are there any permanent changes to the
preference card?
Equipment or instrument malfunctions or
Does this patient have any drug or latex
Has the anesthesia safety check been
(Machine and medication check)
Does the patient have a difficult airway or
aspiration risk?
Is there a need for any anesthesia
procedures before the incision (central line,
What are the key concerns for recovery and
management of the patient?
Are medications secured?
2011 Updated Recommendations for Control
of Surgical Site Infections
• Reduce environmental contamination in OR
• Preoperative antiseptic showering and cleansing
• Clipping to remove hair
• Prep skin with an alcoholic CHG or alcohol iodophor
• Double gloving and incise drape use
• Minimize tissue damage and dead spaces
• Drains and placement
Alexander 2011 Annals of Surgery
2011 Updated Recommendations for Control
of Surgical Site Infections
• Optimize prophylactic antibiotics
– Selection, Timing, Weight Based dose and Redosing
• Normothermia 36oC or higher
• Oxygenation
• Glucose Control <180 mg/dL
• Smoking cessation
• Limit blood transfusions and fluids
Alexander 2011 Annals of Surgery
Conquering Surgical Infections
• Public Reporting of Post Operative Surgical Site
Infections (SSIs)
– Two different sets of metrics: Healthcare
Associated Conditions (HACs) and Healthcare
Associated Infections (HAIs)
– Historical Background
• Key infection prevention strategies
• What’s New in Studies to Reduce SSIs?
• 2014 updates to Public Reporting of SSIs
BMJ 2013: Effectiveness of a bundled intervention
of decolonization and prophylaxis to decrease
Gram positive surgical site infections after
cardiac or orthopedic surgery
• What’s already known on this topic:
 Surgical site infections (SSIs) are potentially preventable adverse events of
cardiac and orthopedic operations
 SSIs significantly increase hospital length of stay, readmission rates,
healthcare costs, and mortality rates
 Clinicians and researchers have debated whether nasal decolonization or
glycopeptide antibiotic prophylaxis reduce SSIs caused by Gram positive
• Study type: Systemic review and meta-analysis
BMJ 2013;346:f2743 doi: 10.1136/bmj.f2743
BMJ2013: Effectiveness of a bundled intervention
of decolonization and prophylaxis to decrease
Gram positive surgical site infections after
cardiac or orthopedic surgery
• What this study adds among patients undergoing
cardiac or orthopedic surgery:
 Nasal decolonization with mupirocin ointment was protective against
Gram positive SSIs
 Preoperative prophylaxis with anti-methicillin resistant
Staphylococcus aureus (MRSA) antibiotics when given to all
patients was not protective against Gram positive SSIs
 A bundle that included nasal decolonization and anti-MRSA
prophylaxis for MRSA carriers was significantly protective against
Gram positive SSIs
BMJ 2013;346:f2743 doi: 10.1136/bmj.f2743
HCA’s MRSA Solution: The A,B,Cs…
• Active Surveillance of
high risk patients
• Barrier Precautions
• Compulsive Hand
• Disinfection /
• Executive
• Program initiated in 2008 across system
• Presurgical nares screening of MRSA in open heart,
open spine, hip joint and knee joint replacements
• Decolonization by surgeon preference
• Initiate contact precautions for MRSA positive
patients by screening or history
• Promoted vancomycin for perioperative prophylaxis
• Reduced SSIs due to MRSA by 15% [SHEA 2010
Abstract,, 2013 J Healthcare Quality]
Study Design 2012-2013
• Quasi Experimental in Adult patients (18 y/o and older)
– Based on 2013 BMJ review and meta analysis
– 20 HCA hospitals
• Cardiac operations
– Primarily CABG and valve replacements performed by sternotomy approach
• Orthopedic operations
– Hip (total and partial) arthroplasty
– Knee (total and partial) arthroplasty
• Algorithm: Screening for MRSA and MSSA, CHG plus mupirocin
decolonization and surgical prophylaxis
STOP SSI Study Outcomes
• Implementation of the algorithm will be associated with:
– Lower rates of SSIs (MRSA, MSSA, & other Grampositives)
– Shorter lengths of stay
– Lower readmission rates
– Improved patient outcomes
• Study period June 2012 to March 2014
Surgical CUSP to Reduce SSIs
Wick Am Coll Surg 2012
• Study Design: Pilot CUSP (Comprehensive Unit-based
Safety Program) in Colorectal Surgical Patients
• Interventions and Checklist:
– Preoperative CHG showers
– Selective elimination of mechanical bowel prep
– Standardized skin prep to CHG
– Optimal antibiotic prophylaxis
– Preanesthesia warming
– Enhanced sterile techniques for skin and fascial closure
• Outcomes:
– Decreased SSIs 33%, p value < 0.05
– Implementing safety science improves patient outcomes
2012 Surgical Site Infections Project
Joint Commission Center for Transforming HealthCare
Background: 7 leading hospital and health systems collaborated with
the American College of Surgeons to reduce colorectal SSIs
Design: Identification of 34 unique correlating variables for risk of
colorectal SSIs: patient characteristics, surgical procedure, antibiotic
administration, preoperative/intraoperative/postoperative processes and
– Reduced superficial incisional SSIs by 45% and all types of colorectal SSIs by
32 percent.
– Estimated cost savings of more than $3.7M for 135 estimated SSI cases
– Decreased Average Length of Stay for hospital patients with any type of
colorectal SSI from 15 to 13 days
2012 Surgical Site Infections Project
Joint Commission Center for Transforming HealthCare
Contributing Factors for Targeted Solutions
• Preop testing and health screening to identify risk factors
• Management of medical conditions that increase the risk of SSIs
• Preop skin cleansing and disinfection
• Protocol/orderset variation
• Weight based dosing and redosing
• Normothermia
• Closure processes
• Intra and post-operative wound management
New Evidence to Reduce SSIs
2013 Publications
• High perioperative Oxygen supplementation has
benefit in open abdominal procedures especially
colorectal surgeries. Munoz-Price et al 2013 CID
• Blood transfusion was associated with a risk of
major infection post cardiac surgery.
Recommendations include limiting RBC use.
Horvath et al 2013 J Thorac Surg
• Choice of IV antibiotic prophylaxis for colorectal
surgery does matter. Deierhoi et al 2013 J Am Coll Surg
New Evidence to Reduce SSIs
2013 Publications
• Decolonization to reduce SSIs due to S. aureus
– Mupirocin and CHG bathing reduced SSIs in
orthopedic, vascular, cardiac or neurosurgical
proedures Thompson and Houston AJIC 2013
– S. aureus screening and decolonization in Orthopedic
surgery is cost effective to reduce Chen et al SSIs 2013
Clin Orthop Relat Res
– Pre-admission CHG bathing reduces SSIs in total hip
arthroplasty Kapadia et al 2013 J Arthroplasty
CDC 2014 SSI Update
• Glycemic Control
– Further research is needed to understand the association between
hemoglobin A1C levels and the risk of SSI in diabetic and
non‐diabetic patients. (No recommendation / unresolved issue).
– In diabetic and non‐diabetic surgical patients perioperative
glycemic control using blood glucose target levels <180mg/dL
(standard practice) is recommended. (Category IB)
– Further research to define optimal blood glucose target levels in
diabetic, non‐diabetic, and critically‐ill surgical patients should
evaluate the benefits and harms associated with glycemic control in
different surgical populations, and postoperative settings which may
impact choice of optimal target levels, delivery methods, timing of
instituting, and duration of the protocol. (No recommendation /
unresolved issue)
CDC 2014 SSI Update
• Normothermia
– Maintenance of perioperative normothermia is recommended.
(Category 1A)
• Oxygenation
– In patients undergoing general anesthesia with mechanical ventilation,
increased fraction of inspired oxygen (intraoperatively and
post‐extubation in the immediate postoperative period) is
recommended and should be administered in combination with
strategies to optimize tissue oxygen delivery through maintenance of
perioperative normothermia and adequate volume replacement.
(Category 1A)
– Further research addressing the optimal fraction of inspired oxygen,
timing, duration, and delivery method in SSI prevention should also
evaluate potential benefits and harms. (No recommendation/ unresolved
CDC 2014 SSI Update
• Exhaust Suit
– Further research addressing the use of orthopaedic
exhaust suits in arthroplasty procedures should
evaluate their impact on surgical site infections,
potential benefits and harms, the surgical personnel
that should wear them, and the impact on their safety.
(No recommendation/unresolved issue)
Conquering Surgical Infections
• Publicly Reported Post Operative Surgical Site Infections
– Two different sets of metrics:
• Healthcare Associated Conditions (HACs) and
• Healthcare Associated Infections (HAIs)
• Common Causes and Costs of SSI infections
• Key infection prevention practices
• What’s New in Studies to Reduce SSIs?
• 2014 updates to Publicly Reported SSIs
2014 NHSN Surgical Procedure Reporting
Required Data Elements
– Patient ID
– Gender
– Date of Birth
– Procedure Code
– Procedure Date
– Outpatient Y/N
– Cut time/close time to
calculate duration in
Hours and Minutes
– Wound Class (*NEW no
unknowns accepted)
– ASA score
– Scope Y/N
– Emergent Y/N
– *NEW Closure Primary
or Other
– General Anesthesia Y/N
– Trauma Y/N
2014 NHSN Surgical Procedure Reporting
Required Data Elements
‾ *NEW required Spinal
Level Approach
• *NEW Specific type of
Total joint replacement
‾ *NEW height feet and
• *NEW Specific type of
Hemi joint replacement
‾ *NEW weight
• *NEW Type of
Resurfacing joint
replacement (HPRO)
‾ *NEW diabetes
‾ *NEW Type of HPRO or
Surveillance Changes SSI
• Primary incisional closure: definition changed to
include all incisions with some closure to the
level of the skin, regardless of extruding wicks,
wires, etc.
• Implant variable: no longer used to determine
length of follow-up and removed from data
collection requirements
2013 NHSN Post Operative Surveillance
• Rationale for reduced surveillance follow-up:
– Majority of infections occur within 90 days after the
primary surgical procedure
– Many patients were lost to follow-up after 90 days
– Surgeon’s signed off patient follow-up
– Co-morbidities and new medical conditions unrelated
to the primary surgical procedure complicate
associating the infection to the primary procedure
2013 Surveillance Changes SSI
• 90 days: deep incisional • 30 days:
and organ / space SSI
– Superficial SSIs of
any procedure type
– Secondary incisional
SSIs of any procedure
– Deep Incisional and
Organ / Space SSI for
all procedure types not
listed in the 90 day
Top Take-Aways
• Antibiotic timing needs to be as close to incision time as
Dosages have gone up and redosing is required for long
• Preop bathing to be implemented. Tell patients to use a
clean towel and place on freshly laundered clothing.
• Normothermia is here to stay.
• Double gloving, decreased OR traffic, proper
temp/humidity, air exchanges.
• Clipping for hair removal.
• Limit blood transfusions.
To-Do’s for Best Practice
• Expand nares screening for MRSA and MSSA in cardiac
and orthopedic procedures
• Review perioperative antimicrobial prophylaxis
ordersets and include new guidelines
• Hardwire antimicrobial administration processes
• Hardwire perioperative documentation
• Adjust and align SSI surveillance for 2013 nd 2014
• Communicate rationale for changes
Preventing SSIs
• Prevention is a
bundle of
practices when
performed in a
highly reliable
manner result in
safe, positive
patient outcomes.
CDC, NHSN Semiannual Report. December 2009.
Hidron et al., Antimicrobial Resistant Pathogens associated with HAIs. Annual NHSN Report ICHE 2008 (29):996-1011
NHSN SSI Surveillance definitions accessed at NHSN website
Culver, et al. Surgical wound infection rates by wound class, operative procedure and paitnet risk index. Amer J Med.
1991;91(suppl 3B):152S.
Mangram AJ, et al. Guideline for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol 1999; 20:250
Anderson et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals Infect Control Hosp Epidemiol 2008;
Steinberg et al Timing of Antimicrobial Prophylaxis and the Risk of Surgical Site Infections Ann Surg 2009; 250:10
Classen et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection N Engl J
Med.. 1992;328:281.
Forse et al. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989; 106:750
Campbell et al, Surgical Site Infection Prevention: The Importance of Operative Duration and Blood Transfusion—Results
of the First American College of Surgeons–National Surgical Quality Improvement Program Best Practices Initiative J Am
Coll Surg 2008;207:810–820
Swenson et al. Effects of Preoperative Skin Preparation on Postoperative Wound Infection Rates: A Prospective Study of
3 Skin Preparation Protocols Infect Control Hosp Epidemiol 2009; 30:964-971
General Surgical Operative Duration is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of S Darouche
et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis N Engl J Med 2010;362:18-26.
STOP SSI Collaborative:
Roa et al. A Preoperative Decolonization Protocol for Staphylococcus aureus Prevents Orthopaedic Infections. Clin Orthop Relat Res
2008; 466:1343
Bode et al. Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus N Engl J Med 2010;362:9-17.
Haynes et al A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491
de Vries et al. Effect of a Comprehensive Surgical Safety System on Patient Outcomes N Engl J Med 2010;363:1928-1937
Diekema et al. Current Practice in Staphylococcus aureus Screening and Decolonization Infect Control Hosp Epidemiol 2011;32(10):1042
2012 Treatment Guidelines from The Medical Letter: Antimicrobial Prophylaxis for Surgical Procedures, Volume 10 (Issue 122) October
Alexander et al, Updated Recommendations for Control of Surgical Site Infections Ann Surg 2011;253:1082–1093
Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections Am Coll Surg
2012; 212:193-199
2012 Surgical Site Infections Project Joint Commission Center for Transforming HealthCare , accessed December 2012
Bratzler et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis during Surgery. Am J Health-Syst Pharm. 2013; 70:195-283

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