Download Surgical-Infections

Surgical Infections
MS-3 Surgery Clerkship Lecture
David C. Yu M.D.
10/25/10
Ignaz Semmelweis
1847
Realized that washing
hand with a chlorinated
lime solution decreased
incidence of newborn
death from “puerperal
fever’.
Joseph Lister
• 1883-1897
• British surgeon
• Used Carbolic Acid
(Phenol) to clean
hands, instruments
and wipe on surgical
wounds drastically
decreased infections.
Overview
• Recognizing Infection
• Soft Tissue Infections
• Post-operative Infections
– Surgical Site Infection
– Hospital Acquired Infections
• Antibiotic Prophylaxis
• Blood Born Pathogens
Infection
Infection is defined by:
1. Microorganisms in host tissue or
the bloodstream
2. Inflammatory response to their
presence.
Inflammatory Response
Localized:
– Rubor, Calor, Dolor, Tumor, and functio
laesa (loss of function)
Systemic:
– Systemic Inflammatory Response Syndrome
(SIRS)
S.I.R.S.
Any Two of the Following Criteria
1.
2.
3.
4.
Temperature: < 36.0, >38.0
Heart Rate : >90
Respiratory Rate: >20
WBC: <4,000, >12,000
Sepsis
Definition: SIRS plus evidence of local
or systemic infection.
Septic Shock
Definition: Sepsis plus end organ
hypoprofusion. Mortality of up to
40%
Soft Tissue Infections:
1. Cellulitis
2. Abscess
3. Necrotizing Infections
Cellulitis
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/Staphylococcus)
Abscess
Abscess
Definition: Infectious accumulation of
purulent material (Neutrophils) in a
closed cavity
Diagnosis: Fluctuant: Moveable and
compressible
Treatment: Drainage
Necrotizing Soft Tissue
Infection
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
Necrotizing Soft Tissue
Infection
• Common Pathogens
– Clostridium
– Group A streptococcus
– Polymicrobial
• Toxic Shock Syndrome
– Streptococcus
– Staphylococcus
Post-Operative Infections
• Fever After Surgery
• The “Five W’s”
–
–
–
–
–
Wind: Atelectisis
Water: UTI
Walking: DVT
Wonder Drug: Medication Induced
Wound: Surgical Site Infection
Surgical Site Infections
• 3rd most common hospital infection
• Incisional
– Superficial
– Deep
• Organ Space
– Generalized (peritonitis)
– Abscess
Types of Surgery
Clean
CleanContaminated
Contaminated
Dirty/infected
Hernia repair
breast biopsy
Cholecystectomy
planned bowel resection
Non-preped bowel
resection
1.5%
perforation, abscess
5-30%
2-5%
5-30%
Host Risk Factors
•
•
•
•
•
•
•
•
Diabetes mellitus
Hypoxemia
Hypothermia
Leukopenia
Nicotine (tobacco smoking)
Immunosuppression
Malnutrition
Poor skin hygiene
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
Treatment
• Incisional: open surgical wound,
antibiotics for cellulitis or sepsis
• Deep/Organ space: Source control,
antibiotics for sepsis
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
Other Hospital Acquired
Infections
1. Urinary Tract Infection
2. Indwelling Catheter Infection
3. Pneumonia
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
Occupational Blood
Bourne Virus Infections
HBV HCV
HIV
Risk from
Needle stick
Chemoprophylaxis
30%
2%
0.3%
Yes
No
Yes
Vaccine
Yes
No
No