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Surgical Infection

Surgical Infection. John Pender, MD BSOM, East Carolina University April 1, 2005. SSI. Superficial Deep Organ/space. Soft tissue/wound. Third most reported nosocomial infections 16% of all reported nosocomial infections Most common surgical patient nosocomial infection (38%)

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Surgical Infection

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  1. Surgical Infection John Pender, MD BSOM, East Carolina University April 1, 2005

  2. SSI • Superficial • Deep • Organ/space

  3. Soft tissue/wound • Third most reported nosocomial infections • 16% of all reported nosocomial infections • Most common surgical patient nosocomial infection (38%) • 2/3 involved surgical incision, 1/3 deep structures accessed by incision • Deaths in patients with nosocomial infections—77% related to infection.

  4. SSI • 1992 $3,152 in extra charges • 1980 extra ten days of hospitalization • 12%-84% present after discharge • Most present within 21 days

  5. Risk factors for SSI • Diabetes • Nicotine • Steroids • Malnutrition • Length of preoperative hospitalization • Nares colonization Staph Aureus • Perioperative transfusion

  6. Preop • Scrub • 10 or 2 min ? With what? • Skin prep • Iodophors, chlorahexadine, or ETOH • Hair removal • Night before? NO (5% vs .6%) • Antiseptic showering • Reduce skin flora only

  7. Antimicrobrial prophylaxis • Clean contaminated procedures • Vascular cases • Cardiac cases • Orthopedic prosthetic cases • Second generation cephalosporin for distal intestinal tract • Timing

  8. Class I (clean) • Atraumatic wound w/o inflammation. No respiratory, GU,GI,or biliary tract entered • Hernia repair • ? infection rate

  9. Class I (clean) • Atraumatic wound w/o inflammation. No respiratory, GU,GI,or biliary tract entered • Hernia repair • 1.5% infection rate

  10. Class II(clean/contaminated) • Controlled entrance into respiratory, GU,GI,or biliary tracts • Cholecytectomy, elective bowel resection • ? infection rate

  11. Class II(clean/contaminated) • Controlled entrance into respiratory, GU,GI,or biliary tracts • Cholecytectomy, elective bowel resection • 7.5% infection rate

  12. Class III(contaminated) • Traumatic wounds, major breaks in sterile techniques, gross spillage of GI contents, Acute non-purulent inflammation • Appendectomy • ? infection rate

  13. Class III(contaminated) • Traumatic wounds, major breaks in sterile techniques, gross spillage of GI contents, Acute non-purulent inflammation • Appendectomy • 15% infection rate

  14. Class IV (dirty) • Old trauma wounds; devitalized tissue; existing clinical infection, perforated viscera. • Hartmann’s for diverticular perforation • ? Infection rate

  15. Class IV (dirty) • Old trauma wounds; devitalized tissue; existing clinical infection, perforated viscera. • Hartmann’s for diverticular perforation • 40% infection

  16. Merely a flesh wound

  17. 50 y.o. obese, diabetic in ED • Heroic MD lanced a small infected “cyst” on the patient’s labia two days ago. Despite MD’s efforts, the erythema has developed and she now has “dishwater” drainage from the area that has a foul odor.

  18. Necrotizing Soft Tissue Infection • Debridement/Resuscitation • Debridement • Debridement • Antibiotics • Nutrition • 1.5 to 2 times basal requirements • Treatment delays are predictive of adverse outcome

  19. Antibiotic therapy for NSTI • Penicillin and aminoglycoside • Clindamycin or metronidazole • +/- Vancomycin • Alternative: unasyn/zosyn • Silvadene slury

  20. Necrotizing Soft Tissue Infection • Mortality rate as high as 40% (17%) • Impaired immune system • Compromised tissue blood supply • Microorganisms (Polymicrobial) • “skin poppin’” or “muscling” • 1/3 dibetics • 90% comorbid conditions

  21. Run away?

  22. Hydradenitis suppurativa • Infection of apocrine sweat glands • axilla, groin, perineum, any skin fold • Single abscess treated by I&D • Doxycycline 100mg BID • Excision with STSG (15%)

  23. 50 y/o diabetic s/p AAA repair • Presents w/ fever, leukocytosis and an erythematous left groin.

  24. Infected Vascular Graft • Inguinal incision is independent risk factor • Length of case and blood loss • 0.5% to 5% • Prosthetic HD grafts 10%-20% • S. Aureus • Extracellular glycocalyx • Negative culture

  25. 50 y/o diabetic with 2 & 3 degree burns • Develops full thickness necrosis of second degree areas a few days later • Third degree burn eschar unexpectedly separated, revealing hemorrhagic discoloration of the sub eschar fat.

  26. Burn Infections • Necrotic tissue readily colonized • High bacteria counts are NOT a reliable indication of an infected burn • Histological examination to determine invasiveness • TX: debridement and antibiotics

  27. 50 y/o diabetic in rehab • presents with rust colored fluid draining from stump. Extremity is edematous and has some associated erythema.

  28. Gas gangrene • Beta hemolytic strept • Clostridial perfringes (gram pos rods)rare • 50% polymicrobial • Rapid lyses of tissues w/ relatively little response from host • Endotoxin

  29. Gas gangrene • Aggressive debridement & antibiotics • Repeat antibiotics

  30. Catheter Sepsis • 80% of cases, colonized catheters had been inserted by inexperienced and experienced residents • Key is to identify before sepsis develops • Multilumen, number of manipulations, occlusive dressing • Stapylococcus epidermis, S. Aureus, yeast

  31. True /False gram negative sepsis • Endotoxin is the lipopolysaccharide component of gram positive bacterial cell walls • Endotoxin triggers release of IL-, IL-6, and TNF from macrophages • Lipid A region is primary initiator of sepsis • Antibodies directed at TNF may be beneficial

  32. True /False septic shock • Endotoxin is the lipopolysaccharide component of gram positive bacterial cell walls • Endotoxin triggers release of IL-, IL-6, and TNF from macrophages • Lipid A region is primary initiator of sepsis • Antibodies directed at TNF may be beneficial

  33. Gram-Negative Sepsis • E.coli, pseudomonas, klebsiella, Enterobacter • >30% mortality • 13 cases per 1,000 hospital admissions • Hypotension, hypoxia, acidosis, compliment and coagulation cascade activation • Lipopolysaccharide (LPS)/ endotoxin

  34. Gram-Negative Sepsis • 6ml/kg, plateau <30, good oxygen delivery • Resuscitation • SVO2 • Daily breathing trials • Sedation protocol • SUP • DVT prophylaxis • Xigris • reduces microvascular dysfunction by reducing inflammation and coagulation, and increasing fibrinolysis. • Recombinant Protein C

  35. It's pretty much my favorite animal. It's like a lion and a tiger mixed... bred for its skills in magic.

  36. Which one of the following are/is characteristic of Tetracyclines • A. Bactericidal • B. activity against Mycobacterium tuberculosis • C. Discoloration of teeth • D. Risk of Superinfection • E. Narrow spectrum

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