Surgical InfectionSurgical InfectionJohn Pender, MDJohn Pender, MD

BSOM, East Carolina UniversityBSOM, East Carolina University

April 1, 2005April 1, 2005

SSISSI

SuperficialSuperficial DeepDeep Organ/spaceOrgan/space

Soft tissue/woundSoft tissue/wound

Third most reported nosocomial infectionsThird most reported nosocomial infections16% of all reported nosocomial infections16% of all reported nosocomial infectionsMost common surgical patient nosocomial Most common surgical patient nosocomial

infection (38%)infection (38%)2/3 involved surgical incision, 1/3 deep 2/3 involved surgical incision, 1/3 deep

structures accessed by incisionstructures accessed by incisionDeaths in patients with nosocomial Deaths in patients with nosocomial

infections—77% related to infection.infections—77% related to infection.

SSISSI

1992 $3,152 in extra charges1992 $3,152 in extra charges1980 extra ten days of hospitalization1980 extra ten days of hospitalization12%-84% present after discharge12%-84% present after dischargeMost present within 21 daysMost present within 21 days

Risk factors for SSIRisk factors for SSI

DiabetesDiabetesNicotine Nicotine SteroidsSteroidsMalnutritionMalnutritionLength of preoperative hospitalizationLength of preoperative hospitalizationNares colonization Nares colonization Staph AureusStaph AureusPerioperative transfusionPerioperative transfusion

PreopPreop

ScrubScrub10 or 2 min ? With what?10 or 2 min ? With what?

Skin prep Skin prep Iodophors, chlorahexadine, or ETOHIodophors, chlorahexadine, or ETOH

Hair removalHair removalNight before? Night before? NO (5% vs .6%)NO (5% vs .6%)

Antiseptic showeringAntiseptic showeringReduce skin flora Reduce skin flora onlyonly

Antimicrobrial prophylaxisAntimicrobrial prophylaxis

Clean contaminated proceduresClean contaminated proceduresVascular casesVascular casesCardiac casesCardiac casesOrthopedic prosthetic casesOrthopedic prosthetic cases

Second generation cephalosporin for distal Second generation cephalosporin for distal intestinal tractintestinal tract

Timing Timing

Class I (clean)Class I (clean)

Atraumatic wound w/o inflammation. No Atraumatic wound w/o inflammation. No respiratory, GU,GI,or biliary tract enteredrespiratory, GU,GI,or biliary tract entered

Hernia repairHernia repair? infection rate? infection rate

Class I (clean)Class I (clean)

Atraumatic wound w/o inflammation. No Atraumatic wound w/o inflammation. No respiratory, GU,GI,or biliary tract enteredrespiratory, GU,GI,or biliary tract entered

Hernia repairHernia repair1.5% infection rate1.5% infection rate

Class II(clean/contaminated)Class II(clean/contaminated)

Controlled entrance into respiratory, Controlled entrance into respiratory, GU,GI,or biliary tractsGU,GI,or biliary tracts

Cholecytectomy, elective bowel resectionCholecytectomy, elective bowel resection? infection rate ? infection rate

Class II(clean/contaminated)Class II(clean/contaminated)

Controlled entrance into respiratory, Controlled entrance into respiratory, GU,GI,or biliary tractsGU,GI,or biliary tracts

Cholecytectomy, elective bowel resectionCholecytectomy, elective bowel resection7.5% infection rate7.5% infection rate

Class III(contaminated)Class III(contaminated)

Traumatic wounds, major breaks in sterile Traumatic wounds, major breaks in sterile techniques, gross spillage of GI contents, techniques, gross spillage of GI contents, Acute non-purulent inflammationAcute non-purulent inflammation

AppendectomyAppendectomy? infection rate? infection rate

Class III(contaminated)Class III(contaminated)

Traumatic wounds, major breaks in sterile Traumatic wounds, major breaks in sterile techniques, gross spillage of GI contents, techniques, gross spillage of GI contents, Acute non-purulent inflammationAcute non-purulent inflammation

AppendectomyAppendectomy15% infection rate15% infection rate

Class IV (dirty)Class IV (dirty)

Old trauma wounds; devitalized tissue; Old trauma wounds; devitalized tissue; existing clinical infection, perforated existing clinical infection, perforated viscera.viscera.

Hartmann’s for diverticular perforationHartmann’s for diverticular perforation? Infection rate? Infection rate

Class IV (dirty)Class IV (dirty)

Old trauma wounds; devitalized tissue; Old trauma wounds; devitalized tissue; existing clinical infection, perforated existing clinical infection, perforated viscera.viscera.

Hartmann’s for diverticular perforationHartmann’s for diverticular perforation40% infection40% infection

Merely a flesh woundMerely a flesh wound

50 y.o. obese, diabetic in ED50 y.o. obese, diabetic in ED

Heroic MD lanced a small infected “cyst” Heroic MD lanced a small infected “cyst” on the patient’s labia two days ago. on the patient’s labia two days ago. Despite MD’s efforts, the erythema has Despite MD’s efforts, the erythema has developed and she now has “dishwater” developed and she now has “dishwater” drainage from the area that has a foul drainage from the area that has a foul odor.odor.

Necrotizing Soft Tissue InfectionNecrotizing Soft Tissue Infection

Debridement/ResuscitationDebridement/ResuscitationDebridementDebridementDebridementDebridementAntibioticsAntibioticsNutrition Nutrition

1.5 to 2 times basal1.5 to 2 times basal requirements requirementsTreatment delays are predictive of adverse Treatment delays are predictive of adverse

outcomeoutcome

Antibiotic therapy for NSTIAntibiotic therapy for NSTI

Penicillin and aminoglycosidePenicillin and aminoglycosideClindamycin or metronidazoleClindamycin or metronidazole+/- Vancomycin+/- VancomycinAlternative: unasyn/zosynAlternative: unasyn/zosynSilvadene slurySilvadene slury

Necrotizing Soft Tissue InfectionNecrotizing Soft Tissue Infection

Mortality rate as high as 40% (17%)Mortality rate as high as 40% (17%) Impaired immune systemImpaired immune systemCompromised tissue blood supplyCompromised tissue blood supplyMicroorganisms (Polymicrobial)Microorganisms (Polymicrobial) ““skin poppin’” or “muscling”skin poppin’” or “muscling”1/3 dibetics1/3 dibetics90% comorbid conditions90% comorbid conditions

Run away?Run away?

Hydradenitis suppurativaHydradenitis suppurativa

Infection of apocrine sweat glandsInfection of apocrine sweat glandsaxilla, groin, perineum, any skin foldaxilla, groin, perineum, any skin foldSingle abscess treated by I&DSingle abscess treated by I&DDoxycycline 100mg BIDDoxycycline 100mg BIDExcision with STSG (15%)Excision with STSG (15%)

50 y/o diabetic s/p AAA repair50 y/o diabetic s/p AAA repair

Presents w/ fever, leukocytosis and an Presents w/ fever, leukocytosis and an erythematous left groin.erythematous left groin.

Infected Vascular GraftInfected Vascular Graft

Inguinal incision is independent risk factorInguinal incision is independent risk factorLength of case and blood lossLength of case and blood loss0.5% to 5%0.5% to 5%Prosthetic HD grafts 10%-20%Prosthetic HD grafts 10%-20%S. AureusS. Aureus

Extracellular glycocalyxExtracellular glycocalyxNegative cultureNegative culture

50 y/o diabetic with 2 & 3 degree 50 y/o diabetic with 2 & 3 degree burnsburns

Develops full thickness necrosis of second Develops full thickness necrosis of second degree areas a few days laterdegree areas a few days later

Third degree burn eschar unexpectedly Third degree burn eschar unexpectedly separated, revealing hemorrhagic separated, revealing hemorrhagic discoloration of the sub eschar fat.discoloration of the sub eschar fat.

Burn InfectionsBurn Infections

Necrotic tissue readily colonizedNecrotic tissue readily colonizedHigh bacteria counts are NOT a reliable High bacteria counts are NOT a reliable

indication of an infected burn indication of an infected burn Histological examination to determine Histological examination to determine

invasivenessinvasivenessTX: debridement and antibioticsTX: debridement and antibiotics

50 y/o diabetic in rehab50 y/o diabetic in rehab

presents with rust colored fluid draining presents with rust colored fluid draining from stump. Extremity is edematous and from stump. Extremity is edematous and has some associated erythema. has some associated erythema.

Gas gangreneGas gangrene

Beta hemolytic streptBeta hemolytic streptClostridial perfringes (gram pos rods)rareClostridial perfringes (gram pos rods)rare50% polymicrobial50% polymicrobialRapid lyses of tissues w/ relatively little Rapid lyses of tissues w/ relatively little

response from hostresponse from hostEndotoxinEndotoxin

Gas gangreneGas gangrene

Aggressive debridement & antibioticsAggressive debridement & antibioticsRepeat antibioticsRepeat antibiotics

Catheter SepsisCatheter Sepsis

80% of cases, colonized catheters had 80% of cases, colonized catheters had been inserted by inexperienced and been inserted by inexperienced and experienced residents experienced residents

Key is to identify before sepsis developsKey is to identify before sepsis developsMultilumen, number of manipulations, Multilumen, number of manipulations,

occlusive dressingocclusive dressingStapylococcus epidermis, S. Aureus, yeastStapylococcus epidermis, S. Aureus, yeast

True /False gram negative sepsisTrue /False gram negative sepsis

Endotoxin is the lipopolysaccharide Endotoxin is the lipopolysaccharide component of gram positive bacterial cell component of gram positive bacterial cell wallswalls

Endotoxin triggers release of IL-, IL-6, and Endotoxin triggers release of IL-, IL-6, and TNF from macrophagesTNF from macrophages

Lipid A region is primary initiator of sepsisLipid A region is primary initiator of sepsisAntibodies directed at TNF may be Antibodies directed at TNF may be

beneficialbeneficial

True /False septic shockTrue /False septic shock

Endotoxin is the lipopolysaccharide Endotoxin is the lipopolysaccharide component of gram positive bacterial cell component of gram positive bacterial cell wallswalls

Endotoxin triggers release of IL-, IL-6, Endotoxin triggers release of IL-, IL-6, and TNF from macrophagesand TNF from macrophages

Lipid A region is primary initiator of Lipid A region is primary initiator of sepsissepsis

Antibodies directed at TNF may be Antibodies directed at TNF may be beneficialbeneficial

Gram-Negative SepsisGram-Negative Sepsis

E.coliE.coli, pseudomonas, klebsiella, , pseudomonas, klebsiella, EnterobacterEnterobacter

>30% mortality>30% mortality13 cases per 1,000 hospital admissions13 cases per 1,000 hospital admissionsHypotension, hypoxia, acidosis, Hypotension, hypoxia, acidosis,

compliment and coagulation cascade compliment and coagulation cascade activationactivation

Lipopolysaccharide (LPS)/ endotoxinLipopolysaccharide (LPS)/ endotoxin

Gram-Negative SepsisGram-Negative Sepsis 6ml/kg, plateau <30, good oxygen delivery 6ml/kg, plateau <30, good oxygen delivery ResuscitationResuscitation SVO2SVO2 Daily breathing trialsDaily breathing trials Sedation protocolSedation protocol SUPSUP DVT prophylaxisDVT prophylaxis XigrisXigris

reduces microvascular dysfunction by reducing inflammation reduces microvascular dysfunction by reducing inflammation and coagulation, and increasing fibrinolysis. and coagulation, and increasing fibrinolysis.

Recombinant Protein CRecombinant Protein C

It's pretty much my favorite It's pretty much my favorite animal. It's like a lion and a animal. It's like a lion and a

tiger mixed... bred for its skills tiger mixed... bred for its skills in magic.in magic.

Which one of the following are/is Which one of the following are/is characteristic of Tetracyclinescharacteristic of Tetracyclines

A. BactericidalA. BactericidalB. activity against Mycobacterium B. activity against Mycobacterium

tuberculosistuberculosisC. Discoloration of teethC. Discoloration of teethD. Risk of SuperinfectionD. Risk of SuperinfectionE. Narrow spectrumE. Narrow spectrum

Which one of the following are/is Which one of the following are/is characteristic of Tetracyclinescharacteristic of Tetracyclines

A. BactericidalA. BactericidalB. activity against Mycobacterium B. activity against Mycobacterium

tuberculosistuberculosisC. C. Discoloration of teethDiscoloration of teethD. Risk of SuperinfectionD. Risk of SuperinfectionE. Narrow spectrumE. Narrow spectrum

TetracyclinesTetracyclines

Most Gram positivesMost Gram positivesMany gram NegativesMany gram NegativesAlters Ribosomal protein synthesisAlters Ribosomal protein synthesis

BacteriostaticBacteriostatic

Which one of the following are/is Which one of the following are/is characteristic of Aminoglycosidescharacteristic of Aminoglycosides

A. Active against a broad spectrum of A. Active against a broad spectrum of Gram negative AerobesGram negative Aerobes

B. Emergence of Resistant bacterial B. Emergence of Resistant bacterial strains does not occurstrains does not occur

C. narrow margin between therapeutic and C. narrow margin between therapeutic and toxic levelstoxic levels

D. nephrotoxicityD. nephrotoxicityE. OtotoxicityE. Ototoxicity

Which one of the following are/is Which one of the following are/is characteristic of Aminoglycosidescharacteristic of Aminoglycosides

A. Active against a broad spectrum of A. Active against a broad spectrum of Gram negative AerobesGram negative Aerobes

B. Emergence of Resistant bacterial B. Emergence of Resistant bacterial strains does not occurstrains does not occur

C. narrow margin between therapeutic C. narrow margin between therapeutic and toxic levelsand toxic levels

D. nephrotoxicityD. nephrotoxicityE. OtotoxicityE. Ototoxicity

AminoglycosidesAminoglycosides

Pseudomonas Pseudomonas resistance developing resistance developing

30s ribosome binding30s ribosome bindingOxygen dependent step therefore no Oxygen dependent step therefore no

anaerobic activityanaerobic activity

Inhibits cell wall synthesisInhibits cell wall synthesis

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Inhibits cell wall synthesisInhibits cell wall synthesis

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Impairment of bacterial DNA Impairment of bacterial DNA synthesissynthesis

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Impairment of bacterial DNA Impairment of bacterial DNA synthesissynthesis

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Disruption of membrane barrier Disruption of membrane barrier functionfunction

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Disruption of membrane barrier Disruption of membrane barrier functionfunction

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Disruption of ribosomal protein Disruption of ribosomal protein synthesissynthesis

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones

Disruption of ribosomal protein Disruption of ribosomal protein synthesissynthesis

A. Amphotericin BA. Amphotericin BB. PenicillinB. PenicillinC. CephalosporinsC. CephalosporinsD. AminoglycosidesD. AminoglycosidesE. QuinolonesE. Quinolones