Presentation on theme: "Surgical Foundations Infectious Disease Topics in Surgery"— Presentation transcript:
1 Surgical Foundations Infectious Disease Topics in Surgery Surgical Emergencies in IDAntibiotic ProphylaxisFever in the Post-op PatientCommon Nosocomial InfectionsHand HygieneMark Downing and Jennie JohnstoneDivision of Infectious DiseasesSaint Joseph’s Health Centre
2 Surgical Emergencies in Infectious Diseases Mark DowningInfectious Diseases/Antimicrobial StewardshipSaint Joseph’s Health Centre
3 Disclosures I am not a surgeon This is meant to be interactive I have not written your examI have written two other Royal College examsThey love cases where ID and Surgery meetThis is meant to be interactiveParticipation encouragedI will not pick on you (even though Blitz said I could)
4 ObjectivesGo through common questions related to ‘Surgical Emergencies’ in Infectious Diseases using casesNecrotizing FasciitisDeep Neck Space infectionsEmpyemaSpinal Epidural AbscessEndopthalmitisEndocarditisIe When are antibiotics not enough and patient needs source control
5 Case #1 55 yo male, history of diabetes Right leg pain x 48 hours Fever, tachycardic, hypotensiveLeg +++ tenderWBC 18, Creatinine 170 , Lactate 5What is your next step?
7 Necrotizing Fasciitis: Pathogenesis Infection of muscle fascia and overlying subcutaneous fatSpreads quickly due to poor blood supplyOverlying (skin) and underlying (muscle) tissues have better blood supply so often sparedHard to diagnose nec fasc with physical examLudwig’s Angina: H&N regionFournier’s Gangrenebreach in GI or urethral mucosa causing perineal involvement
8 Nec Fasc: Clinical Features Pain out of keeping of physical examSystemic toxicityRapid evolutionCompartment syndromeAnaesthesiaNecrosis
9 How would you confirm the diagnosis? Necrotizing Fasciitis is a surgical diagnosisClinical exam/tests not sufficient to rule in or outCan do either bedside biopsy or take to OR depending on level of suspicion without delayUseful adjunctive testsCKXraysCT/MRI
10 Case #1 Blood cultures drawn from yesterday positive for GPC in chains How would you manage this patient beyond going to the OR for debridement?
11 Necrotizing Fasciitis: Antimicrobial therapy Type I: Mixed anaerobes and aerobes (think Fourniers)PipTazo + Clindamycin +/- VancoType 2: Classically Group A Strep, also Staph aureus (including MRSA)Ceftriaxone + Clindamycin +/- VancoB-lactams don’t work well with dense burden of organsimsAdd Clindamycin (‘Eagle Effect’)Group A Strep is a toxin-mediated diseaseAdd Clindamycin (protein synthesis)Consider IVIG (evidence not great)
12 Case #1 Transferred to ICU for supportive care Started empirically on PipTazo/Clinda/IVIGTo OR for extensive debridement left legWound/Blood cultures confirmed to be Group A StrepAntibiotics streamlined to Penicillin G/ClindamcinBack to OR next day: margins clean
13 Nec Fasc: Follow-upPatients should return to the OR in 24-48h to to reassess margins for evidence of spreadWounds often need grafting once cleanConsider diverting colostomy early in patients with FourniersPost-exposure prophylaxis for close contacts of Group A Strep cases with Keflex
14 Nec Fasc: Summary Pain out of keeping of exam and systemic toxicity Do not delay surgical exploration to make diagnosis and initiate source controlAntibioticsEarly and BroadGroup A Strep causes toxic shockClindamycin +/- IVIGPost exposure prophylaxisReturn to the OR early to check margins
15 Case #2 30 yo female 2 weeks post-partum Sore throat, chest pain, fever: to ER?PE: CT Thorax orderedWide mediastinumUnusual looking aorta: ?dissectionPleural effusionsBlood cultures positive for Group A StrepWhat is the ‘danger space’?
16 Deep Neck Space Infections Odontogenic or oropharyngeal infections may extend along fascial places and are often life threateningLudwig’s Angina: sublingual, submaxillary and submandibular spaceLemierre Syndrome: infeciton of carotid sheath leading to septic thrombophlebitis
18 The Danger SpaceBehind retropharyngeal space lies a space that descends directly into the mediastinumRetropharyngeal infections can quickly spread down by gravityNecrotizing mediastinitisEmpyemaTamponade
19 Retropharyngeal Infections Is it cellulitis vs abscessCellulitis: no drainage, just antibioticsAbscess: Drainage + AbxMay be difficult to determine by direct visualization, CT helpful (serial scans)Ceftriaxone/FlagylAny evidence of mediastinal spread should lead to a surgical intervention
20 Case #3 70 yo male w left sided pleuritic chest pain, fever PMHx: CHF, CADSpO2 88% in ER on RACXR: LLL consolidation/effusionRx Ceftriaxone/Azithro, IVF x5 daysRemains febrile, hypoxicRepeat CXR: larger left sided effusionWhat do you send the thoracentesis for?
21 Parapneumonic Effusion vs Empyema Parapneumonic effusion represents inflammatory fluid in pleural spaceCultures negativeOften responds to antibiotics aloneEmpyema represents actual infection in pleural spaceCultures positive unless on antibiotics or atypical organismNeeds drainage
22 “Do Not Let the Sun Set on Emypema” Thoracentesis diagnostic test of choicepH <7.2 highly suggestiveLight’s criteriaPleural Protein/Serum protein > 0.5Pleural LDH/Serum LDH >0.6Cultures: positive unless on antibiotics or atypicalCT Thorax w contrast useful diagnostic test: pleural enhancement strongly suggests empyema
23 Empyema: Management Antibiotics Drainage almost always necessary Direct at Strep pneumo/Staph aureus/AnaerobesCeftriaxone/FlagylTaylor to culturesContinue until radiographic/clinical resolutionDrainage almost always necessaryChest tube drainage sufficient in 2/3 patientsFibrinolytic therapy for loculated effusionsVATS/Thoracotomy
24 Case #4 50 yo female, IV drug user To ER with fever, severe back pain x 5 daysNo numbness, weakness, bowel/bladder dysfunctionIII/VI Systolic Ejection MurmurMRI Spine Done:
28 Spinal Epidural Abscess Most often begins as discitis at focal levelOnce infection spreads to epidural space can spread longitudinally>50% caused by Staph aureusGNB, Strep, anaerobesCeftriaxone +/- Vanco +/- FlagylMRI test of choiceBetter for soft tissues and spinal cord
29 Spinal Epidural Abscess: Surgical Indications Neurological exam is keyNumbness/Weakness?Bowel/Bladder dysfunction?Neurologic dysfunction (myelopathy) is main indication for emergent decompressionPain alone not an indicationIf paralysis >36-72h, surgery unlikely to be of benefit
30 Case #5 60 yo male prolonged ICU stay for pancreatitis Now on TPN Fever- Blood cultures positive for Candida albicans x 1Started on Fluconazole, central line D/CedRepeat blood cultures negative, fever resolvedAny other investigations that need to be done?
32 Candida Endopthalmitis ~10% of patients with candidemia will have ocular involvementSome may be asymptomaticAntifungals do not penetrate well into vitreous chamberEvery patient with candidemia should have a dilated fundoscopic examChorioretinitis: systemic antifungalsVitritis: systemic antifungals + intravitreal antifungals +/- vitrectomy
33 Case #6 50 yo male admitted with fever, myalgias Blood cultures 6/6 positive MSSATEE: 1.2 cm veg on AV, severe ARStarted on IV CloxacillinProgressive SOB, hypoxiaCXR: Pulmonary EdemaWhat are the surgical indications for infective endocarditis?
34 Infective Endocarditis Classify based on organism, most important prognostic factorEg MSSA AV IEAlso need to considerNative vs Prosthetic valveRight vs Left sidedDiagnosis based primarily onMultiple positive blood cultures over timeVegetation on echocardiogramAntibiotics cornerstone of therapy +/- surgery
35 Surgical Indications for IE Antimicrobial failure+ Blood Cx >1 week on therapySignificant valvular dysfunction leading to CHFMore than one serious emoblic episodePathogen resistant to antimicrobialsEg. All fungiLocal suppurative complications (abscess)Vegatation >1 cm
36 RCT of surgery within 48h vs standard care Patients with left sided endocarditis, severe valvular dysfunction and vegetation >1 cmPts excluded if already had indication for urgent surgery or large ischemic/hemorrhagic strokeComposite outcome of death, emolic event, reoccurence of IE or hospitalization for CHF
39 Case #5While awaiting transfer for Cardiac Surgery assessment, patient develops slurred speech and right sided weaknessCT Head shows new left hemispheric septic emboliCan this patient still go for surgery?
41 Timing of Cardiac Surgery in IE patients with Stroke Mild ischemic stroke: no delay neededTIA or <30% of one brain lobeMod-Severe ischemic stroke: >2 weeksHemorrhagic stroke: >4 weeks
42 Summary Necrotizing Fasciitis Deep Neck Space Infections Empyema Pain out of keeping of exam and systemic toxicityDo not delay a surgical diagnosisDeep Neck Space InfectionsRetropharyngeal abscesses can be life threatening due to spread through ‘danger space’EmpyemaDiagnosis depends on pleural fluid analysispH, LDH, Protein, CulturesDrainage
43 Summary Spinal Epidural Abscess Candida endophalmitis Neurological compromise is primary surgical indicationCandida endophalmitisEvery patient with Candidemia needs fundoscopyVitritis requires local antifungals +/- vitrectomyInfective endocarditisTwo main surgical indicationsAntibiotic failure, CHF secondary to valvular diseaseEarly surgery betterDelay only in severe stroke cases
44 ResourcesInfectious Diseases Society of America GuidelinesMandell Principles and Practices of Infectious Diseases 7th editionUptodate