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Surgical Infections

Chapter 6
Schwartz Principles of Surgery 11th ed
Key Points
• Sepsis
• presence of infection and the host response to infection
• clinical spectrum, ranging from sepsis (SIRS plus infection) to severe sepsis
(organ dysfunction), to septic shock (hypotension requiring vasopressors).

• Outcomes in patients with sepsis are improved with an organized


approach to therapy that includes rapid resuscitation, antibiotics, and
source control.
Key Points
• Source control is a key concept in the treatment of most surgically
relevant infections.
• Infected or necrotic material must be drained or removed as part of
the treatment plan in this setting.
• Delays inadequate source control are associated with Worsened
outcomes
Key Points
• Principles relevant to appropriate antibiotic prophylaxis for surgery:
• select an agent with activity against organisms commonly found at the site of
surgery
• administer the initial dose of the antibiotic within 30 minutes prior to incision
• redose the antibiotic during long operations based upon the half-life of the
agent to ensure adequate tissue levels
• limit the antibiotic regimen to no more than 24 hours after surgery for routine
prophylaxis
Key Points
• When using antimicrobial agents for therapy of serious infection, several
principles should be followed:
• identify likely sources of infection
• select an agent (or agents) that will have efficacy against likely organisms for
these sources,
• begin therapy rapidly with broad coverage, as inadequate or delayed
antibiotic therapy results in increased mortality,
• when possible, obtain cultures early and use results to refine therapy,
• if no infection is identified after 3 days, strongly consider discontinuation of
antibiotics, based upon the patient’s clinical course,
• discontinue antibiotics after an appropriate course of therapy.
Historical Background
• Ignaz Semmelweis
• rinse their hands thoroughly in chlorine water
• reduced the mortality rate from puerperal fever on the teaching ward to
1.5%,
• Louis Pasteur
• Germ theory
• contagious diseases are caused by specific microbes and that these microbes
are foreign to the infected organism
• Staphylococcus and Streptococcus pneumoniae (pneumococcus)
• Joseph Lister
• carbolic acid
• Robert Koch
• developed techniques for culture of Bacillus anthracis
• four postulates
• the suspected pathogenic organism should be present in all cases of the disease and
absent from healthy animals
• the suspected pathogen should be isolated from a diseased host and grown in a pure
culture in vitro
• cells from a pure culture of the suspected organism should cause disease in a healthy
animal
• the organism should be reisolated from the newly diseased animal and shown to be the
same as the original
• Charles McBurney
• first intra-abdominal operation to treat infection via “source control”
• Sir Alexander Fleming
• Penicillin
• Frank Meleney, William Altemeier
• Aerobic and anaerobic
• William Osler
• cytokines
Pathogenesis of Infection
Pathogenesis of Infection
• Host Defenses
• several layers of endogenous defense mechanisms that serve to
prevent microbial invasion, limit proliferation of microbes within
the host, and contain or eradicate invading microbes.
• integument or skin
• Several possible outcomes can occur subsequent to microbial invasion and the
interaction of microbes with resident and recruited host defenses:
• Eradication
• Containment
• locoregional infection
• systemic infection
• Infection
• presence of microorganisms in host tissue or the bloodstream.
• classic findings of rubor, calor, and dolor in areas such as the skin or
subcutaneous tissue are common
• SIRS
• reflects a pro- inflammatory state in response to a variety of disease processes
• Sepsis
• SIRS caused by infection
• life-threatening organ dysfunction caused by a dysregulated host response to
infection
• Sequential Organ Failure Assessment (SOFA)
• qSOFA
• altered mental status
• systolic blood pressure of 100 mmHg or less
• respiratory rate greater than 22 breaths/minute
• Severe Sepsis
• Septic Shock
Relationship between infection and systemic inflammatory response syndrome (SIRS).
Sepsis is the presence both of infection and the systemic inflammatory response, shown here as
the intersection of these two areas. Other conditions may cause SIRS as well (trauma, aspiration,
etc.). Severe sepsis (and septic shock) are both subsets of sepsis.
MICROBIOLOGY OF INFECTIOUS
AGENTS
Bacteria
• responsible for the majority of surgical infections.
• classified based upon a number of additional characteristics, including
morphology, the pattern of division (e.g., single organisms, groups of
organisms in pairs, clusters, and chains), and the presence and
location of spores
Fungi
• use of special stains
• Initial identification is assisted by observation of the form of
branching and septation in stained specimens or in culture.
• Final identification is based on growth characteristics in special
media, similar to bacteria, as well as on the capacity for growth at a
different temperature (25°C vs. 37°C).
• cause nosocomial infections in surgical patients as part of
polymicrobial infections or fungemia, rare causes of aggressive soft
tissue infections, and opportunistic pathogens that cause infection in
the immunocompromised host
Virus
• identified by indirect means (i.e., the host antibody response)
• identify the presence of viral DNA or ribonucleic acid (RNA) using
methods such as polymerase chain reaction
• occur in the immunocompromised host
• Relevant viruses
• adenoviruses, cytomegalovirus, Epstein-Barr virus, herpes simplex virus, and
varicella- zoster virus.
• Surgeons must be aware of the manifestations of hepatitis B and C
viruses, as well as human immunodeficiency virus infections,
including their capacity to be transmitted to healthcare workers
PREVENTION AND TREATMENT
OF SURGICAL INFECTIONS
General Principles
• Prophylaxis
• Maneuvers to diminish the presence of exogenous and
endogenous microbes
• consist of a variety of mechanical and chemical modalities.
• Important principles in prophylaxis: skin preparation, antimicrobial
therapy, and patient physiological management.
Source Control
• drainage of all purulent material, debridement of all infected, devitalized tissue
and debris, and/or removal of foreign bodies at the site of infection, plus
remediation of the underlying cause of infection
• Delay in operative intervention, whether due to misdiagnosis or the need for
additional diagnostic studies, is associated with increased morbidity and
occasional mortality
• antimicrobial agents are of secondary importance to effective surgery with regard
to treatment of surgical infections
Appropriate Use of Antimicrobial Agents
• Prophylaxis
• limited to the time prior to and during the operative procedure
• There is no evidence that administration of postoperative doses of an
antimicrobial agent provides additional benefit, and this practice should be
discouraged
Appropriate Use of Antimicrobial Agents
• Emperic Therapy
• use of antimicrobial agents when the risk of a surgical infection is
high, based on the underlying disease process , or when significant
contamination during surgery has occurred.
• often employed in critically ill patients in whom a potential site of
infection has been identified and severe sepsis or septic shock
occurs.
• should be limited to a short course of treatment (3 to 5 days) and
should be curtailed as soon as possible based on microbiologic
data coupled with improvements in the clinical course of the
patient.
INFECTIONS OF SIGNIFICANCE IN
SURGICAL PATIENTS
Surgical Site Infections (SSIs)
• Infections of the tissues, organs, or spaces exposed by surgeons during
performance of an invasive procedure.
• Classifications:
• Incisional
• superficial and deep incisional categories.
• organ/space infections
• Three factors :
• degree of microbial contamination of the wound during surgery
• duration of the procedure
• host factors such as diabetes, malnutrition, obesity, immune suppression, and a number
of other underlying disease states.
Surgical Wounds
Intra-Abdominal Infections
• Primary Peritonitis
• Secondary Peritonitis
• Tertiary (Persistent) Peritonitis
Primary Peritonitis
• microbes invade the normally sterile confines of the peritoneal cavity via hematogenous
dissemination from a distant source of infection or direct inoculation.
• more common among patients who retain large amounts of peritoneal fluid due to ascites,
and among those individuals who are being treated for renal failure via peritoneal dialysis.
• Monomicrobial
• rarely require surgical intervention
• Diagnosis:
• identification of risk factors
• physical examination that reveals diffuse tenderness and guarding without localized findings
• absence of a surgically treatable source of infection on an imaging study
• presence of more than 250 neutrophils/mL in fluid obtained via paracentesis
Secondary Microbial Peritonitis
• contamination of the peritoneal cavity due to perforation or severe
inflammation and infection of an intra-abdominal organ.
• Examples:
• appendicitis, perforation of any portion of the gastrointestinal tract, or diverticulitis

• effective therapy requires source control to resect or repair the


diseased organ; debridement of necrotic, infected tissue and debris;
and administration of antimicrobial agents directed against aerobes
and anaerobes.
Tertiary (Persistent) Peritonitis
• more common in immunosuppressed patients in whom peritoneal host defenses
do not effectively clear or sequester the initial secondary microbial peritoneal
infection
• associated with mortality rates in excess of 50%
Organ Specific Infections
• Hepatic Abscess
• Pyogenic liver abscess
• manipulation of the biliary tract to treat a variety of diseases
• E coli, K pneumoniae, and other enteric bacilli, enterococci, and Pseudomonas spp.
• the most common anaerobic bacteria are Bacteroides spp., anaerobic streptococci, and
Fusobacterium spp.
• C albicans and other related yeast cause the majority of fungal hepatic abscesses
• Small (<1 cm), multiple abscesses – 4 to 6-week course of antibiotics.
• Larger abscesses – percutaneous drainage
Organ Specific Infections
• Splenic Abscess
• Extremely rare
• Secondary pancreatic infections
• occur in approximately 10% to 15% of patients who develop severe pancreatitis
with necrosis.
Infections of the Skin and Soft Tissue
• These infections can be classified according to whether surgical intervention is
required.
• Methicillin-resistant S aureus (MRSA) infection should be suspected if infection
persists after treatment with adequate drainage and administration of first-line
antibiotics.
• Aggressive soft tissue infections
• require immediate surgical intervention plus administration of antimicrobial agents.
• Failure to rapidly recognize and treat these infections results in an extremely high mortality
rate (∼80–100%), and even with expedient therapy mortality rates are high (16–24%)
Sepsis
BIOLOGICAL WARFARE AGENTS
• Bacillus anthracis (Anthrax)
• Yersinia pestis (Plague)
• Smallpox
• Francisella tularensis (Tularemia)
Anthrax
• Bacillus anthracis
• Inhalational anthrax develops after a 1- to 6-day incubation period, with
nonspecific symptoms
• respiratory distress, chest pain, and diaphoresis.
• Diagnosis: eliciting an exposure history
• Xray findings: widened mediastinum and pleural effusions
• Postexposure prophylaxis: ciprofloxacin or doxycycline
• Amoxicillin
• Treatment: combination therapy with ciprofloxacin, clindamycin, and
rifampin.
Plague
• Yersinia pestis
• transmitted via flea bites from rodents
• clinical manifestations
• epidemic pneumonia with blood-tinged sputum if aerosolized
bacteria are used
• “Bubo” if fleas
• Diagnosis is confirmed via aspirate of the bubo and a direct
antibody stain to detect plague bacillus
• Postexposure prophylaxis: Doxycycline
• Treatment: streptomycin, an aminoglycoside, doxycycline, a
fluoroquinolone, or chloramphenicol
Smallpox
• Variola
• eradication in the late 1970s.
• highly infectious in the aerosolized form
• incubation period of 10 to 12 days,
• malaise, fever, vomiting, and headache appear, followed by
development of a characteristic centripetal rash
Tularemia
• Tick
• After inoculation, this organism proliferates within macrophages.
• cough and demonstrate pneumonia on chest roentgenogram.
• Enlarged lymph nodes occur in approximately 85% of patients..
• Treatment: aminoglycoside or second-line agents such as doxycycline and
ciprofloxacin.

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