Surgical Infections

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Surgical Infections

• MS-3 Surgery Clerkship Lecture
• David C. Yu M.D.
• 10/25/10

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Ignaz Semmelweis

• 1847
• Realized that washing hand with a chlorinated
  lime solution decreased incidence of newborn
  death from puerperal fever.

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Joseph Lister

• 1883-1897
• British surgeon
• Used Carbolic Acid (Phenol) to clean hands,
  instruments and wipe on surgical wounds
  drastically decreased infections.

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Overview

• Recognizing Infection
• Soft Tissue Infections
• Post-operative Infections
• Surgical Site Infection
• Hospital Acquired Infections
• Antibiotic Prophylaxis
• Blood Born Pathogens

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Infection

• Infection is defined by
• Microorganisms in host tissue or the bloodstream
• Inflammatory response to their presence.

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Inflammatory Response

• Localized
• Rubor, Calor, Dolor, Tumor, and functio laesa
  (loss of function)
• Systemic
• Systemic Inflammatory Response Syndrome (SIRS)

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S.I.R.S.

• Any Two of the Following Criteria
• Temperature lt 36.0, gt38.0
• Heart Rate gt90
• Respiratory Rate gt20
• WBC lt4,000, gt12,000

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Sepsis

• Definition SIRS plus evidence of local or
  systemic infection.

Septic Shock
Definition Sepsis plus end organ hypoprofusion.
Mortality of up to 40
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Soft Tissue Infections

1. Cellulitis
2. Abscess
3. Necrotizing Infections

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Cellulitis
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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/Staphy
  lococcus)

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Abscess
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Abscess

• Definition Infectious accumulation of purulent
  material (Neutrophils) in a closed cavity
• Diagnosis Fluctuant Moveable and compressible
• Treatment Drainage

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Necrotizing Soft Tissue Infection
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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

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Necrotizing Soft Tissue Infection

• Common Pathogens
• Clostridium
• Group A streptococcus
• Polymicrobial
• Toxic Shock Syndrome
• Streptococcus
• Staphylococcus

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Post-Operative Infections

• Fever After Surgery
• The Five Ws
• Wind Atelectisis
• Water UTI
• Walking DVT
• Wonder Drug Medication Induced
• Wound Surgical Site Infection

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Surgical Site Infections

• 3rd most common hospital infection
• Incisional
• Superficial
• Deep
• Organ Space
• Generalized (peritonitis)
• Abscess

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Types of Surgery
Clean Hernia repair breast biopsy 1.5
Clean-Contaminated Cholecystectomy planned bowel resection 2-5
Contaminated Non-preped bowel resection 5-30
Dirty/infected perforation, abscess 5-30
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Host Risk Factors

• Diabetes mellitus
• Hypoxemia
• Hypothermia
• Leukopenia
• Nicotine (tobacco smoking)
• Immunosuppression
• Malnutrition
• Poor skin hygiene

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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

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Treatment

• Incisional open surgical wound, antibiotics for
  cellulitis or sepsis
• Deep/Organ space Source control, antibiotics for
  sepsis

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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

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Other Hospital Acquired Infections

1. Urinary Tract Infection
2. Indwelling Catheter Infection
3. Pneumonia

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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

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Occupational Blood Bourne Virus Infections
HBV HCV HIV
Risk from Needle stick 30 2 0.3
Chemoprophylaxis Yes No Yes
Vaccine Yes No No