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 British surgeonBritish surgeon Used Carbolic Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.Used Carbolic Acid (Phenol) to clean hands, instruments and wipe on surgical wounds drastically decreased infections.

Overview Recognizing InfectionRecognizing Infection Soft Tissue InfectionsSoft Tissue Infections Post-operative InfectionsPost-operative Infections –Surgical Site Infection –Hospital Acquired Infections Antibiotic ProphylaxisAntibiotic Prophylaxis Blood Born PathogensBlood 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: Heart Rate : >90 3.Respiratory Rate: >20 4.WBC: 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

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 PathogensCommon Pathogens –Clostridium –Group A streptococcus –Polymicrobial Toxic Shock SyndromeToxic Shock Syndrome –Streptococcus –Staphylococcus

Post-Operative Infections Fever After SurgeryFever After Surgery The “Five W’s”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 infection3rd most common hospital infection IncisionalIncisional –Superficial –Deep Organ SpaceOrgan Space –Generalized (peritonitis) –Abscess

Types of Surgery Clean Hernia repair breast biopsy 1.5% Clean- Contaminated Cholecystectomy planned bowel resection planned bowel resection2-5% Contaminated Non-preped bowel resection 5-30% Dirty/infected perforation, abscess 5-30%

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

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

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

Operative Antibiotic Prophylaxis Decreases bacterial counts at surgical siteDecreases bacterial counts at surgical site Given within 30 minutes prior to starting surgeryGiven within 30 minutes prior to starting surgery Vancomycin 1-2 hours prior to surgeryVancomycin 1-2 hours prior to surgery Redose for longer surgeryRedose for longer surgery Do not continue beyond 24 hoursDo 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 indicatedUse only when indicated Start with broad spectrum antibiotics designed to cover likely pathogensStart with broad spectrum antibiotics designed to cover likely pathogens Take cultures when possibleTake cultures when possible Deescalate spectrum once pathogen is knowDeescalate spectrum once pathogen is know Have a plan for durationHave a plan for duration

Occupational Blood Bourne Virus Infections HBVHCVHIV Risk from Needle stick 30%2%0.3% ChemoprophylaxisYesNoYes VaccineYesNoNo