Surgical Infections MS-3 Surgery Clerkship Lecture Natalia Hannan M.D. 07/05/11
Dec 18, 2014
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. Temperature: < 36.0, >38.0
2. Heart Rate : >90
3. Respiratory Rate: >20
4. 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 W’s”
– 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 Hernia repairbreast biopsy
1.5%
Clean-Contaminated
Cholecystectomy planned bowel resection
2-5%
Contaminated Non-preped bowel resection
5-30%
Dirty/infected perforation, abscess 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 HIV
Risk from Needle stick
30% 2% 0.3%
Chemoprophylaxis Yes No Yes
Vaccine Yes No No