Surgical InfectionsSurgical Infections

MS-3 Surgery Clerkship LectureMS-3 Surgery Clerkship Lecture

Natalia Hannan M.D.Natalia Hannan M.D.

07/05/1107/05/11

Ignaz SemmelweisIgnaz Semmelweis

18471847

Realized that washing Realized that washing hand with a chlorinated hand with a chlorinated lime solution decreased lime solution decreased incidence of newborn incidence of newborn death from “puerperal death from “puerperal fever’.fever’.

Joseph ListerJoseph Lister

• 1883-18971883-1897• British surgeonBritish surgeon• Used Carbolic Acid Used Carbolic Acid

(Phenol) to clean (Phenol) to clean hands, instruments hands, instruments and wipe on surgical and wipe on surgical wounds drastically wounds drastically decreased infections.decreased infections.

OverviewOverview

• Recognizing InfectionRecognizing Infection

• Soft Tissue InfectionsSoft Tissue Infections

• Post-operative InfectionsPost-operative Infections– Surgical Site InfectionSurgical Site Infection– Hospital Acquired InfectionsHospital Acquired Infections

• Antibiotic ProphylaxisAntibiotic Prophylaxis

• Blood Born PathogensBlood Born Pathogens

Infection

Infection is defined by:Infection is defined by:

1.1. Microorganisms in host tissue or Microorganisms in host tissue or the bloodstream the bloodstream

2.2. Inflammatory response to their Inflammatory response to their presence.presence.

Inflammatory ResponseInflammatory Response

Localized: Localized: – Rubor, Calor, Dolor, Tumor, and functio Rubor, Calor, Dolor, Tumor, and functio

laesa (loss of function)laesa (loss of function)

Systemic: Systemic: – Systemic Inflammatory Response Syndrome Systemic Inflammatory Response Syndrome

(SIRS)(SIRS)

S.I.R.S.S.I.R.S.

Any Two of the Following CriteriaAny Two of the Following Criteria

1.1. Temperature: < 36.0, >38.0Temperature: < 36.0, >38.0

2.2. Heart Rate : >90Heart Rate : >90

3.3. Respiratory Rate: >20Respiratory Rate: >20

4.4. WBC: <4,000, >12,000WBC: <4,000, >12,000

SepsisSepsis

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

Septic ShockSeptic Shock

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

Soft Tissue Infections:Soft Tissue Infections:

1.1. CellulitisCellulitis

2.2. AbscessAbscess

3.3. Necrotizing InfectionsNecrotizing Infections

CellulitisCellulitis

CellulitisCellulitisDefinition: Diffuse infection with severe Definition: Diffuse infection with severe

inflammation of dermal and subcutaneous layers inflammation of dermal and subcutaneous layers of the skinof the skin

Diagnosis: Pain, Warmth, HyperesthesiaDiagnosis: Pain, Warmth, Hyperesthesia

Treatment: Antibiotics. Treatment: Antibiotics.

Common Pathogens: Skin Flora Common Pathogens: Skin Flora (Streptococcus/Staphylococcus)(Streptococcus/Staphylococcus)

AbscessAbscess

AbscessAbscess

Definition: Infectious accumulation of Definition: Infectious accumulation of purulent material (Neutrophils) in a purulent material (Neutrophils) in a closed cavityclosed cavity

Diagnosis: Fluctuant: Moveable and Diagnosis: Fluctuant: Moveable and compressiblecompressible

Treatment: DrainageTreatment: Drainage

Necrotizing Soft Tissue Necrotizing Soft Tissue InfectionInfection

Necrotizing Soft Tissue Necrotizing Soft Tissue InfectionInfection

Definition: Deep infection of skin and soft tissue Definition: Deep infection of skin and soft tissue that may spread rapidly along facial planes.that may spread rapidly along facial planes.

Diagnosis: Purely Clinical, dishwater discharge, Diagnosis: Purely Clinical, dishwater discharge, gray tissue, pain out of proportion to gray tissue, pain out of proportion to examination, bulla, and dark, golden examination, bulla, and dark, golden discoloration.discoloration.

Treatment: True Surgical Emergency, AntibioticsTreatment: True Surgical Emergency, Antibiotics

Necrotizing Soft Tissue Necrotizing Soft Tissue InfectionInfection

• Common PathogensCommon Pathogens

– ClostridiumClostridium

– Group A streptococcusGroup A streptococcus

– PolymicrobialPolymicrobial

• Toxic Shock SyndromeToxic Shock Syndrome

– StreptococcusStreptococcus

– StaphylococcusStaphylococcus

Post-Operative InfectionsPost-Operative Infections

• Fever After SurgeryFever After Surgery

• The “Five W’s”The “Five W’s”– Wind: AtelectisisWind: Atelectisis– Water: UTIWater: UTI– Walking: DVTWalking: DVT– Wonder Drug: Medication Induced Wonder Drug: Medication Induced – Wound: Surgical Site InfectionWound: Surgical Site Infection

Surgical Site InfectionsSurgical Site Infections

• 3rd most common hospital infection3rd most common hospital infection

• Incisional Incisional

– SuperficialSuperficial

– DeepDeep

• Organ SpaceOrgan Space

– Generalized (peritonitis)Generalized (peritonitis)

– AbscessAbscess

Types of SurgeryTypes of Surgery

Clean Clean Hernia repairHernia repair

breast biopsybreast biopsy

1.5%1.5%

Clean-Clean-ContaminatedContaminated

CholecystectomyCholecystectomy

planned bowel resectionplanned bowel resection

2-5%2-5%

Contaminated Contaminated Non-preped bowel Non-preped bowel resectionresection

5-30%5-30%

Dirty/infected Dirty/infected perforation, abscessperforation, abscess 5-30%5-30%

Host Risk FactorsHost Risk Factors

• Diabetes mellitusDiabetes mellitus• HypoxemiaHypoxemia• HypothermiaHypothermia• LeukopeniaLeukopenia• Nicotine (tobacco smoking)Nicotine (tobacco smoking)• ImmunosuppressionImmunosuppression• MalnutritionMalnutrition• Poor skin hygienePoor skin hygiene

Perioperative Risk Perioperative Risk FactorsFactors

• Operative site shavingOperative site shaving• Breaks in operative sterile techniqueBreaks in operative sterile technique• Improper antimicrobial prophylaxisImproper antimicrobial prophylaxis• Prolonged hypotensionProlonged hypotension• Contaminated operating room Contaminated operating room • Poor wound care postoperativelyPoor wound care postoperatively• HyperglycemiaHyperglycemia• Wound closure techniqueWound closure technique

TreatmentTreatment

• Incisional: open surgical wound, Incisional: open surgical wound, antibiotics for cellulitis or sepsisantibiotics for cellulitis or sepsis

• Deep/Organ space: Source control, Deep/Organ space: Source control, antibiotics for sepsisantibiotics for sepsis

Operative Antibiotic Operative Antibiotic ProphylaxisProphylaxis

• Decreases bacterial counts at surgical siteDecreases bacterial counts at surgical site

• Given within 30 minutes prior to starting Given within 30 minutes prior to starting surgerysurgery

• 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 Other Hospital Acquired InfectionsInfections

1.1. Urinary Tract InfectionUrinary Tract Infection

2.2. Indwelling Catheter InfectionIndwelling Catheter Infection

3.3. PneumoniaPneumonia

Use/Choice of AntibioticsUse/Choice of Antibiotics

• Use only when indicatedUse only when indicated

• Start with broad spectrum antibiotics Start with broad spectrum antibiotics designed to cover likely pathogensdesigned to cover likely pathogens

• Take cultures when possibleTake cultures when possible

• Deescalate spectrum once pathogen is Deescalate spectrum once pathogen is knowknow

• Have a plan for durationHave a plan for duration

Occupational Blood Occupational Blood Bourne Virus InfectionsBourne Virus Infections

HBVHBV HCVHCV HIVHIV

Risk from Risk from

Needle stickNeedle stick

30%30% 2%2% 0.3%0.3%

ChemoprophylaxisChemoprophylaxis YesYes NoNo YesYes

VaccineVaccine YesYes NoNo NoNo