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