Presentation on theme: "Joseph Castellano M.D. 9/29/09"— Presentation transcript:
1 Joseph Castellano M.D. 9/29/09 Surgical InfectionsJoseph Castellano M.D.9/29/09
2 DefinitionInfections that require surgical intervention to resolve completelyInfections that develop as a complication of surgeryCaused by the invasion, resident, and proliferation of pathogens such as bacteria, viruses and fungi.
4 Furuncle Cutaneous staph abscesses Bacterial colinization begins in hair follicles and can cause cellulitis and abscess formationTreatment with surgical drainage if large, antibiotics +/-
5 CarbunclesCutaneous abscess that spreads through the dermis into subcutaneous regionCommon with diabeticsTreatment with I & D, antibiotics +/-
6 Intra-abdominal infection Primary microbial peritonitisAscities, peritoneal dialysisTx: antibioticsSecondary microbial peritonitis: contamination of the peritoneal cavity due to perforation or severe inflammation and infection of an intra-abdominal organAppendicitis, diverticulitis, perforation, etc.therapy requires source control to resect the diseased organ; débridement of necrotic, infected tissue and debris; and administration of antimicrobial agents directed against aerobes and anaerobes
7 Intra-abdominal infection Patients in whom standard therapy fails develop an intra-abdominal abscess, leakage from a gastrointestinal anastomosis leading to postoperative peritonitis, or tertiary (persistent) peritonitis.Intra-abdominal abscess: perc drain vs. surgical intervention, short course of antibiotics
8 Organ Specific Infections Hepatic abscesses80% pyogenic, 20% parasitic and fungalPyogenic abscess treated with sampling and 4-6 weeks of antibiotics, larger abscesses may need perc drain.
9 Organ Specific Infections Pancreatic necrosisDevelops in 10-15% of patients who develop severe hemorrhagic pancreatitisSterile and Infected necrosisempiric antibiotic therapy with carbapenems or fluoroquinolones that achieve high pancreatic tissue levels reduce the incidence and severity of pancreatic infectionenteral feedings initiated early, using nasojejunal feeding tubes – prevents translocation of bacteria
10 Organ Specific Infections Secondary pancreatic infectionSuspected in patients whose systemic inflammatory response (fever, elevated WBC count, or organ dysfunction) fails to resolve, or in those individuals who initially recuperate, only to develop sepsis syndrome 2 to 3 weeks laterCT-guided aspiration or identification of gas within the pancreas on CT scan, mandate operative intervention50% mortality if no surgical intervention if infected necrosisLower mortality in sterile necrosis
11 CellulitisInflammation of the dermal and subcutaneous tissues secondary to nonsuppurative bacterial invasion.Redness, edema, and localized tendernessMay infect the lymphatics leading to lymphangitisTreatment against Group A strep
12 Necrotizing Fasciitis Rapidly progressive, multiple organisms, invades fascial planesCauses vascular thrombosis as it progresses, resulting in necrosis of the tissues involved.Overlying skin may be normalHemorrhagic bullae may develop from edema; crepitus; systemic toxicity“dishwater gray” discharge with anaerobic infectionGroup A strep, mixed anaerobes + coliforms, MRSATreatment is surgical debridement, send gram stainVanc, carbapenems, and Pen G
13 Surgical Site Infection 38% of nosocomial infections, 2-5% of patientsFactors:Health of the patientOperative techniqueTimely administration of preoperative antibioticsNo benefit to antiseptic bath over other wash productsNo benefit to barrier devices except glovesGood surgical techniques: gentle traction, hemostasis, removal of devitalized tissue, obliteration of dead space, irrigation, wound closure without tension
14 Risk FactorsMicroorganism: Remote site infection, long term care facility, duration of the procedure, wound class, ICU patient, prior antibiotic therapy, preop shaving, bacterial number, virulence, and antimicrobial resistanceLocal Wound: Surgical technique – Hematoma/ seroma, necrosis, sutures, drains, foreign bodiesPatient: Age, immunosuppression, steroids, malignancy, obesity, diabetes, malnutrition, multiple comorbidities, transfusions, cigarette smoking, oxygen, temperature, glucose control
15 Risk FactorsDrains:Should be omitted after hepatic, colonic, or rectal resection with primary anastomosis and after appendectomy for any stage of appendicitisShould be used after esophageal resection and total gastrectomyContamination increases with duration of operationElectrocautery: pinpoint coagulation, dividing tissue under tension decreases tissue destruction
16 Surgical Site Infection Difference is SSI based on hand hygiene? Hand rubbing vs. hand scrubbingCompliance 44% vs 28%
17 Wound classificationClean wounds were defined as uninfected operative wounds in which no inflammation was encountered and the wound was closed primarily. By definition, a viscus (respiratory, alimentary, genital, or urinary tract) was not entered during a clean procedure.Clean-contaminated wounds were defined as operative wounds in which a viscus was entered under controlled conditions and without unusual contamination.Contaminated wounds included open, fresh accidental wounds, operations with major breaks in sterile technique or gross spillage from a viscus. Wounds in which acute, purulent inflammation was encountered also were included in this category.Dirty wounds were defined as old traumatic wounds with retained devitalized tissue, foreign bodies, or fecal contamination or wounds that involve existing clinical infection or perforated viscus.
18 Antibiotic Prophylaxis Timing: Percent of SSI for dose given early, preoperative, perioperative, and postop are 3.8, 0.6, 1.4 and 3.3 respectivelyProphylaxis with cefazolin has been effective for most clean procedures. Cefuroxime can be given for thoracic and ortho procedures.For procedures that might involve bowel anaerobes, cefoxitin is more effective than cefazolin.
19 ABX Recs Colon/Whipple: Bowel prep/oral prophylaxis/ IV prophylaxis Neomycin, Erythromycin, CefoxitinCholecystectomy open or laparoscopic prophylaxis recommended for pt age>60, previous biliary surgery, acute symptoms, jaundice (benefit less clear with lap): cefoxitin or unasynUncomplicated appendectomy: cefoxitin or unasynPenetrating abdominal trauma: Cefoxitin or Unasyn – continue post op for 24 hoursIHR: uncomplicated, no prophylaxis; complicated, cefoxitinMastectomy: no abx recommendedVascular cases: Cefazolin
20 Other Recs Esophageal and gastroduodenal: Cefazolin ERCP: routine abx prophylaxis does not reduce sepsis/cholangitisRepeat dosing: Procedure lasting more than 4 hours or when major blood loss occursContinuation of Abx past 24 hours post op is not recommendedHair removal with clippers immediately preopPreop or postop hyperglycemia increase risk of SSIPerioperative normothermia
22 UTIDiagnosis should be considered with urinalysis positive for WBCs, bacteria, or a positive leukocyte esterase.Confirmed with culture > 10K colonies in symptomatic patient or > 100K colonies in asymptomatic patientTreatment with days with a single antibiotic that achieves high levels in the urine is appropriateRemove catheter
23 Pneumonia High risk with prolonged mechanical ventilation Frequently multi-resistant organismsDiagnosis by XrayBAL with gram stain and cultureAntibiotics based on local antibiogram with beta-lactam, aminoglycoside or fluoroquinolone, and vanc or linezolid.Treat for 7-8 days
24 Bacteremic Episodes Indwelling catheters 25% of catheters will become colonized, and 5% will be associated with bacteremiaProlonged insertion, insertion under emergency conditions, manipulation under nonsterile conditions, and perhaps the use of multilumen catheters increase the risk of infection.Confirmed with blood culture from peripheral site and catheter that grow same bacteriaTreatment is removal of catheter.In patients with difficult access and grow low virulence bugs, such as S. epidermidis, treatment with days of antibiotics is effective 50-60% of the time.
25 Sepsis Syndrome Empiric antimicrobial therapy, institution specific Fluid rescucitationMetabolic supportSite specific infection controlAppropriate therapy associated with two to three fold reduction in mortalityLow dose steroid for patients with hypotension refractory to vasopressorsSTIM testHydrocortisone 100mg/8hr vs. continuous infusionXigris associated with 6% reduction in mortalityantithrombotic, profibrinolytic, and anti-inflammatory propertiesConsider in patients with severe infection and at least one organ failing