Surgical Surgical InfectionsInfections

Joseph Castellano M.D.Joseph Castellano M.D.

9/29/099/29/09

DefinitionDefinition

Infections that require surgical Infections that require surgical intervention to resolve completelyintervention to resolve completely

Infections that develop as a Infections that develop as a complication of surgerycomplication of surgery

Caused by the invasion, resident, Caused by the invasion, resident, and proliferation of pathogens such and proliferation of pathogens such as bacteria, viruses and fungi.as bacteria, viruses and fungi.

Outcomes of Microbial Outcomes of Microbial InvasionInvasion

EradicationEradication Containment leads to abscess Containment leads to abscess

(furuncle, carbuncle, hidradenitis (furuncle, carbuncle, hidradenitis suppurativa, intra-abdominal suppurativa, intra-abdominal abscesses)abscesses)

Locoregional infection (cellulitis, soft Locoregional infection (cellulitis, soft tissue infection, lymphangitis)tissue infection, lymphangitis)

Systemic infection (bacteremia, Systemic infection (bacteremia, fungemia)fungemia)

FuruncleFuruncle

Cutaneous staph Cutaneous staph abscessesabscesses

Bacterial Bacterial colinization begins colinization begins in hair follicles and in hair follicles and can cause cellulitis can cause cellulitis and abscess and abscess formationformation

Treatment with Treatment with surgical drainage if surgical drainage if large, antibiotics +/-large, antibiotics +/-

CarbunclesCarbuncles

Cutaneous abscess that spreads Cutaneous abscess that spreads through the dermis into through the dermis into subcutaneous regionsubcutaneous region

Common with diabeticsCommon with diabetics Treatment with I & D, antibiotics +/-Treatment with I & D, antibiotics +/-

Intra-abdominal Intra-abdominal infectioninfection

Primary microbial peritonitisPrimary microbial peritonitis Ascities, peritoneal dialysisAscities, peritoneal dialysis Tx: antibioticsTx: antibiotics

Secondary microbial peritonitis: Secondary microbial peritonitis: contamination of the peritoneal cavity due to contamination of the peritoneal cavity due to perforation or severe inflammation and perforation or severe inflammation and infection of an intra-abdominal organ infection of an intra-abdominal organ Appendicitis, diverticulitis, perforation, etc. Appendicitis, diverticulitis, perforation, etc. therapy requires source control to resect the therapy requires source control to resect the

diseased organ; débridement of necrotic, infected diseased organ; débridement of necrotic, infected tissue and debris; and administration of tissue and debris; and administration of antimicrobial agents directed against aerobes and antimicrobial agents directed against aerobes and anaerobes anaerobes

Intra-abdominal Intra-abdominal infectioninfection

Patients in whom standard therapy Patients in whom standard therapy fails develop an intra-abdominal fails develop an intra-abdominal abscess, leakage from a abscess, leakage from a gastrointestinal anastomosis leading gastrointestinal anastomosis leading to postoperative peritonitis, or to postoperative peritonitis, or tertiary (persistent) peritonitis. tertiary (persistent) peritonitis.

Intra-abdominal abscess: perc drain Intra-abdominal abscess: perc drain vs. surgical intervention, short vs. surgical intervention, short course of antibioticscourse of antibiotics

Organ Specific InfectionsOrgan Specific Infections

Hepatic abscessesHepatic abscesses 80% pyogenic, 20% parasitic and fungal80% pyogenic, 20% parasitic and fungal Pyogenic abscess treated with sampling Pyogenic abscess treated with sampling

and 4-6 weeks of antibiotics, larger and 4-6 weeks of antibiotics, larger abscesses may need perc drain.abscesses may need perc drain.

Organ Specific InfectionsOrgan Specific Infections Pancreatic necrosisPancreatic necrosis

Develops in 10-15% of patients who develop Develops in 10-15% of patients who develop severe hemorrhagic pancreatitissevere hemorrhagic pancreatitis

Sterile and Infected necrosisSterile and Infected necrosis empiric antibiotic therapy with empiric antibiotic therapy with

carbapenemscarbapenems or fluoroquinolones that or fluoroquinolones that achieve high pancreatic tissue levels reduce achieve high pancreatic tissue levels reduce the incidence and severity of pancreatic the incidence and severity of pancreatic infectioninfection

enteral feedings initiated early, using enteral feedings initiated early, using nasojejunal feeding tubes – prevents nasojejunal feeding tubes – prevents translocation of bacteriatranslocation of bacteria

Organ Specific InfectionsOrgan Specific Infections

Secondary pancreatic infectionSecondary pancreatic infection Suspected in patients whose systemic Suspected in patients whose systemic

inflammatory response (fever, elevated WBC inflammatory response (fever, elevated WBC count, or organ dysfunction) fails to resolve, or in count, or organ dysfunction) fails to resolve, or in those individuals who initially recuperate, only to those individuals who initially recuperate, only to develop sepsis syndrome 2 to 3 weeks later develop sepsis syndrome 2 to 3 weeks later

CT-guided aspiration or identification of gas CT-guided aspiration or identification of gas within the pancreas on CT scan, mandate within the pancreas on CT scan, mandate operative intervention operative intervention

50% mortality if no surgical intervention if 50% mortality if no surgical intervention if infected necrosisinfected necrosis

Lower mortality in sterile necrosisLower mortality in sterile necrosis

CellulitisCellulitis

Inflammation of the dermal and Inflammation of the dermal and subcutaneous tissues secondary to subcutaneous tissues secondary to nonsuppurative bacterial invasion.nonsuppurative bacterial invasion.

Redness, edema, and localized Redness, edema, and localized tendernesstenderness

May infect the lymphatics leading to May infect the lymphatics leading to lymphangitislymphangitis

Treatment against Group A strepTreatment against Group A strep

Necrotizing FasciitisNecrotizing Fasciitis Rapidly progressive, multiple organisms, invades Rapidly progressive, multiple organisms, invades

fascial planesfascial planes Causes vascular thrombosis as it progresses, Causes vascular thrombosis as it progresses,

resulting in necrosis of the tissues involved.resulting in necrosis of the tissues involved. Overlying skin may be normalOverlying skin may be normal Hemorrhagic bullae may develop from edema; Hemorrhagic bullae may develop from edema;

crepitus; systemic toxicitycrepitus; systemic toxicity ““dishwater gray” discharge with anaerobic dishwater gray” discharge with anaerobic

infectioninfection Group A strep, mixed anaerobes + coliforms, Group A strep, mixed anaerobes + coliforms,

MRSAMRSA Treatment is surgical debridement, send gram Treatment is surgical debridement, send gram

stainstain Vanc, carbapenems, and Pen GVanc, carbapenems, and Pen G

Surgical Site InfectionSurgical Site Infection 38% of nosocomial infections, 2-5% of patients38% of nosocomial infections, 2-5% of patients Factors:Factors:

Health of the patientHealth of the patient Operative techniqueOperative technique Timely administration of preoperative antibioticsTimely administration of preoperative antibiotics

No benefit to antiseptic bath over other wash No benefit to antiseptic bath over other wash productsproducts

No benefit to barrier devices except glovesNo benefit to barrier devices except gloves Good surgical techniques: gentle traction, Good surgical techniques: gentle traction,

hemostasis, removal of devitalized tissue, hemostasis, removal of devitalized tissue, obliteration of dead space, irrigation, wound obliteration of dead space, irrigation, wound closure without tensionclosure without tension

Risk FactorsRisk Factors Microorganism: Remote site infection, long Microorganism: Remote site infection, long

term care facility, duration of the procedure, term care facility, duration of the procedure, wound class, ICU patient, prior antibiotic wound class, ICU patient, prior antibiotic therapy, preop shaving, bacterial number, therapy, preop shaving, bacterial number, virulence, and antimicrobial resistancevirulence, and antimicrobial resistance

Local Wound: Surgical technique – Local Wound: Surgical technique – Hematoma/ seroma, necrosis, sutures, Hematoma/ seroma, necrosis, sutures, drains, foreign bodiesdrains, foreign bodies

Patient: Age, immunosuppression, steroids, Patient: Age, immunosuppression, steroids, malignancy, obesity, diabetes, malnutrition, malignancy, obesity, diabetes, malnutrition, multiple comorbidities, transfusions, multiple comorbidities, transfusions, cigarette smoking, oxygen, temperature, cigarette smoking, oxygen, temperature, glucose controlglucose control

Risk FactorsRisk Factors

Drains: Drains: Should be omitted after hepatic, colonic, or rectal Should be omitted after hepatic, colonic, or rectal

resection with primary anastomosis and after resection with primary anastomosis and after appendectomy for any stage of appendicitisappendectomy for any stage of appendicitis

Should be used after esophageal resection and Should be used after esophageal resection and total gastrectomytotal gastrectomy

Contamination increases with duration of Contamination increases with duration of operationoperation

Electrocautery: pinpoint coagulation, Electrocautery: pinpoint coagulation, dividing tissue under tension decreases dividing tissue under tension decreases tissue destructiontissue destruction

Surgical Site InfectionSurgical Site Infection

Difference is SSI based on hand Difference is SSI based on hand hygiene? Hand rubbing vs. hand hygiene? Hand rubbing vs. hand scrubbingscrubbing

Compliance 44% vs 28%Compliance 44% vs 28%

Wound classificationWound classification Clean wounds were defined as uninfected operative Clean wounds were defined as uninfected operative

wounds in which no inflammation was encountered and wounds in which no inflammation was encountered and the wound was closed primarily. By definition, a viscus the wound was closed primarily. By definition, a viscus (respiratory, alimentary, genital, or urinary tract) was not (respiratory, alimentary, genital, or urinary tract) was not entered during a clean procedure. entered during a clean procedure.

Clean-contaminated wounds were defined as operative Clean-contaminated wounds were defined as operative wounds in which a viscus was entered under controlled wounds in which a viscus was entered under controlled conditions and without unusual contamination. conditions and without unusual contamination.

Contaminated wounds included open, fresh accidental Contaminated wounds included open, fresh accidental wounds, operations with major breaks in sterile technique wounds, operations with major breaks in sterile technique or gross spillage from a viscus. Wounds in which acute, or gross spillage from a viscus. Wounds in which acute, purulent inflammation was encountered also were included purulent inflammation was encountered also were included in this category. in this category.

Dirty wounds were defined as old traumatic wounds with Dirty wounds were defined as old traumatic wounds with retained devitalized tissue, foreign bodies, or fecal retained devitalized tissue, foreign bodies, or fecal contamination or wounds that involve existing clinical contamination or wounds that involve existing clinical infection or perforated viscus. infection or perforated viscus.

Antibiotic ProphylaxisAntibiotic Prophylaxis Timing: Percent of SSI for dose given Timing: Percent of SSI for dose given

early, preoperative, perioperative, and early, preoperative, perioperative, and postop are 3.8, 0.6, 1.4 and 3.3 postop are 3.8, 0.6, 1.4 and 3.3 respectivelyrespectively

Prophylaxis with cefazolin has been Prophylaxis with cefazolin has been effective for most clean procedures. effective for most clean procedures. Cefuroxime can be given for thoracic Cefuroxime can be given for thoracic and ortho procedures.and ortho procedures.

For procedures that might involve bowel For procedures that might involve bowel anaerobes, cefoxitin is more effective anaerobes, cefoxitin is more effective than cefazolin.than cefazolin.

ABX RecsABX Recs Colon/Whipple: Bowel prep/oral prophylaxis/ IV Colon/Whipple: Bowel prep/oral prophylaxis/ IV

prophylaxisprophylaxis Neomycin, Erythromycin, CefoxitinNeomycin, Erythromycin, Cefoxitin

Cholecystectomy open or laparoscopic prophylaxis Cholecystectomy open or laparoscopic prophylaxis recommended for pt age>60, previous biliary surgery, recommended for pt age>60, previous biliary surgery, acute symptoms, jaundice (benefit less clear with lap): acute symptoms, jaundice (benefit less clear with lap): cefoxitin or unasyncefoxitin or unasyn

Uncomplicated appendectomy: cefoxitin or unasynUncomplicated appendectomy: cefoxitin or unasyn Penetrating abdominal trauma: Cefoxitin or Unasyn – Penetrating abdominal trauma: Cefoxitin or Unasyn –

continue post op for 24 hourscontinue post op for 24 hours IHR: uncomplicated, no prophylaxis; complicated, IHR: uncomplicated, no prophylaxis; complicated,

cefoxitincefoxitin Mastectomy: no abx recommendedMastectomy: no abx recommended Vascular cases: CefazolinVascular cases: Cefazolin

Other RecsOther Recs Esophageal and gastroduodenal: CefazolinEsophageal and gastroduodenal: Cefazolin ERCP: routine abx prophylaxis does not ERCP: routine abx prophylaxis does not

reduce sepsis/cholangitisreduce sepsis/cholangitis Repeat dosing: Procedure lasting more than Repeat dosing: Procedure lasting more than

4 hours or when major blood loss occurs4 hours or when major blood loss occurs Continuation of Abx past 24 hours post op is Continuation of Abx past 24 hours post op is

not recommendednot recommended Hair removal with clippers immediately Hair removal with clippers immediately

preoppreop Preop or postop hyperglycemia increase risk Preop or postop hyperglycemia increase risk

of SSIof SSI Perioperative normothermiaPerioperative normothermia

Postoperative Postoperative Nosocomial InfectionsNosocomial Infections

UTIUTI PneumoniaPneumonia Bacteremic EpisodesBacteremic Episodes Sepsis SyndromeSepsis Syndrome

UTIUTI

Diagnosis should be considered with Diagnosis should be considered with urinalysis positive for WBCs, bacteria, or urinalysis positive for WBCs, bacteria, or a positive leukocyte esterase.a positive leukocyte esterase.

Confirmed with culture > 10K colonies in Confirmed with culture > 10K colonies in symptomatic patient or > 100K colonies symptomatic patient or > 100K colonies in asymptomatic patientin asymptomatic patient

Treatment with 10-14 days with a single Treatment with 10-14 days with a single antibiotic that achieves high levels in the antibiotic that achieves high levels in the urine is appropriateurine is appropriate

Remove catheterRemove catheter

PneumoniaPneumonia

High risk with prolonged mechanical High risk with prolonged mechanical ventilationventilation

Frequently multi-resistant organismsFrequently multi-resistant organisms Diagnosis by XrayDiagnosis by Xray BAL with gram stain and cultureBAL with gram stain and culture Antibiotics based on local antibiogram Antibiotics based on local antibiogram

with beta-lactam, aminoglycoside or with beta-lactam, aminoglycoside or fluoroquinolone, and vanc or linezolid.fluoroquinolone, and vanc or linezolid.

Treat for 7-8 daysTreat for 7-8 days

Bacteremic EpisodesBacteremic Episodes Indwelling cathetersIndwelling catheters

25% of catheters will become colonized, and 5% 25% of catheters will become colonized, and 5% will be associated with bacteremiawill be associated with bacteremia

Prolonged insertion, insertion under emergency Prolonged insertion, insertion under emergency conditions, manipulation under nonsterile conditions, manipulation under nonsterile conditions, and perhaps the use of multilumen conditions, and perhaps the use of multilumen catheters increase the risk of infection.catheters increase the risk of infection.

Confirmed with blood culture from peripheral site Confirmed with blood culture from peripheral site and catheter that grow same bacteriaand catheter that grow same bacteria

Treatment is removal of catheter.Treatment is removal of catheter. In patients with difficult access and grow low In patients with difficult access and grow low

virulence bugs, such as S. epidermidis, treatment virulence bugs, such as S. epidermidis, treatment with 14-21 days of antibiotics is effective 50-60% of with 14-21 days of antibiotics is effective 50-60% of the time.the time.

Sepsis SyndromeSepsis Syndrome Empiric antimicrobial therapy, institution specificEmpiric antimicrobial therapy, institution specific Fluid rescucitationFluid rescucitation Metabolic supportMetabolic support Site specific infection controlSite specific infection control Appropriate therapy associated with two to three fold Appropriate therapy associated with two to three fold

reduction in mortalityreduction in mortality Low dose steroid for patients with hypotension Low dose steroid for patients with hypotension

refractory to vasopressorsrefractory to vasopressors STIM testSTIM test Hydrocortisone 100mg/8hr vs. continuous infusionHydrocortisone 100mg/8hr vs. continuous infusion

Xigris associated with 6% reduction in mortalityXigris associated with 6% reduction in mortality antithrombotic, profibrinolytic, and anti-inflammatory antithrombotic, profibrinolytic, and anti-inflammatory

propertiesproperties Consider in patients with severe infection and at least Consider in patients with severe infection and at least

one organ failingone organ failing