Surgical Infections

MS-3 Surgery Clerkship Lecture Natalia Hannan M.D. 07/05/11

Ignaz Semmelweis
1847 Realized that washing hand with a chlorinated lime solution decreased incidence of newborn death from puerperal fever.

Joseph Lister
1883-1897 British surgeon Used Carbolic Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.

Overview
Recognizing Infection Soft Tissue Infections Post-operative Infections
Surgical Site Infection Hospital Acquired Infections

Antibiotic Prophylaxis Blood Born Pathogens

Infection
Infection is defined by: 1. Microorganisms in host tissue or the bloodstream 2. Inflammatory response to their presence.

Inflammatory Response
Localized:
Rubor, Calor, Dolor, Tumor, and functio laesa (loss of function)

Systemic:
Systemic Inflammatory Response Syndrome (SIRS)

S.I.R.S.
Any Two of the Following Criteria 1. 2. 3. 4. Temperature: < 36.0, >38.0 Heart Rate : >90 Respiratory Rate: >20 WBC: <4,000, >12,000

Sepsis
Definition: SIRS plus evidence of local or systemic infection.

Septic Shock
Definition: Sepsis plus end organ hypoprofusion. Mortality of up to 40%

Soft Tissue Infections:

1. Cellulitis 2. Abscess 3. Necrotizing Infections

Cellulitis

Cellulitis
Definition: Diffuse infection with severe inflammation of dermal and subcutaneous layers of the skin

Diagnosis: Pain, Warmth, Hyperesthesia

Treatment: Antibiotics. Common Pathogens: Skin Flora (Streptococcus/Staphylococcus)

Abscess

Abscess
Definition: Infectious accumulation of purulent material (Neutrophils) in a closed cavity
Diagnosis: Fluctuant: Moveable and compressible Treatment: Drainage

Necrotizing Soft Tissue Infection

Necrotizing Soft Tissue Infection

Definition: Deep infection of skin and soft tissue that may spread rapidly along facial planes.
Diagnosis: Purely Clinical, dishwater discharge, gray tissue, pain out of proportion to examination, bulla, and dark, golden discoloration. Treatment: True Surgical Emergency, Antibiotics

Necrotizing Soft Tissue Infection

Common Pathogens Clostridium Group A streptococcus Polymicrobial Toxic Shock Syndrome Streptococcus Staphylococcus

Post-Operative Infections
Fever After Surgery The Five Ws
Wind: Atelectisis Water: UTI Walking: DVT Wonder Drug: Medication Induced Wound: Surgical Site Infection

Surgical Site Infections

3rd most common hospital infection Incisional Superficial Deep Organ Space Generalized (peritonitis) Abscess

Types of Surgery
Clean
CleanContaminated Contaminated Dirty/infected

Hernia repair breast biopsy Cholecystectomy planned bowel resection Non-preped bowel resection
perforation, abscess

1.5%
2-5% 5-30% 5-30%

Host Risk Factors

Diabetes mellitus Hypoxemia Hypothermia Leukopenia Nicotine (tobacco smoking) Immunosuppression Malnutrition Poor skin hygiene

Perioperative Risk Factors

Operative site shaving Breaks in operative sterile technique Improper antimicrobial prophylaxis Prolonged hypotension Contaminated operating room Poor wound care postoperatively Hyperglycemia Wound closure technique

Treatment
Incisional: open surgical wound, antibiotics for cellulitis or sepsis
Deep/Organ space: Source control, antibiotics for sepsis

Operative Antibiotic Prophylaxis

Decreases bacterial counts at surgical site Given within 30 minutes prior to starting surgery Vancomycin 1-2 hours prior to surgery Redose for longer surgery Do not continue beyond 24 hours

Other Hospital Acquired Infections

1. Urinary Tract Infection 2. Indwelling Catheter Infection 3. Pneumonia

Use/Choice of Antibiotics
Use only when indicated Start with broad spectrum antibiotics designed to cover likely pathogens Take cultures when possible Deescalate spectrum once pathogen is know Have a plan for duration

Occupational Blood Bourne Virus Infections

HBV HCV Risk from Needle stick Chemoprophylaxis 30% Yes 2% No HIV 0.3% Yes

Vaccine

Yes

No

No