Surgical Infections Surgical

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					 Surgical Infections




MS-3 Surgery Clerkship Lecture
      David C. Yu M.D.
          10/25/10
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 repair              1.5%
                 breast biopsy
Clean-           Cholecystectomy            2-5%
Contaminated      planned bowel resection
Contaminated     Non-preped bowel           5-30%
                 resection
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          30%   2%   0.3%
Needle stick
Chemoprophylaxis   Yes   No   Yes

Vaccine            Yes   No   No