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SURGICAL INFECTION AND ANTIBIOTICS. OUTLINE Introduction and overview Definitions and SIRS Risk factors for surgical infections Strategies for infection prevention Peritonitis and intraabdominal abscess Special infections Infection risk for the surgeon. SURGICAL INFECTION AND ANTIBIOTICS.

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SURGICAL INFECTION AND ANTIBIOTICS

OUTLINE

  • Introduction and overview

  • Definitions and SIRS

  • Risk factors for surgical infections

  • Strategies for infection prevention

  • Peritonitis and intraabdominal abscess

  • Special infections

  • Infection risk for the surgeon


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SURGICAL INFECTION AND ANTIBIOTICS

Infection

The inflammatory response to the presence of microorganisms


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SURGICAL INFECTION AND ANTIBIOTICS

Sepsis

The systemic inflammatory response syndrome in response to infection


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SURGICAL INFECTION AND ANTIBIOTICS

Severe Sepsis

Sepsis associated with organ dysfunction, hypoperfusion or hypotension


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SURGICAL INFECTION AND ANTIBIOTICS

Septic Shock

Sepsis with hypotension, despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental state


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SURGICAL INFECTION AND ANTIBIOTICS

The Systemic Inflammatory Response Syndrome

  • Caused by the systemic effects of locally released cytokines

  • Cytokine release can be triggered by both infectious and noninfectious insults

  • Provides a conceptual framework for the understanding of ARDS and MODS in the absence of infection


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SURGICAL INFECTION AND ANTIBIOTICS

Systemic Inflammatory Response Syndrome

Manifested by two or more of the following:

  • Temperature > 38 C or < 36 C

  • Heart rate >90

  • Respiratory rate > 20 or PCO2 <32

  • WBC > 12 K < 4K or > 10% bands


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SURGICAL INFECTION AND ANTIBIOTICS

Multiple Organ Dysfunction Syndrome

The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention


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SURGICAL INFECTION AND ANTIBIOTICS

Risk Factors for Surgical Infection

  • Surgical wound class

  • SENIC project

  • NNISS


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SURGICAL INFECTION AND ANTIBIOTICS

Surgical Wound Class

  • Developed by National Research Council in 1964

  • Classifies wounds into one of four classes based on degree of contamination

    • Clean

    • Clean contaminated

    • Contaminated

    • Dirty


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SURGICAL INFECTION AND ANTIBIOTICS

Study on the Efficacy of Nosocomial Infection Control

  • Published by Haley in 1985

  • Utilizes four risk factors to stratify risk

    Abdominal operation

    Operation longer than 2 hours

    Contaminated or dirty wound class

    Having 3 or more medical diagnoses


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SURGICAL INFECTION AND ANTIBIOTICS

National Nosocomial Infection Surveillance System

  • Developed by Centers for Disease Control

  • Uses 3 risk factors

    ASA score of 3 or greater

    Operation classed as contaminated or dirty

    Operation of longer than “T” hours with “T” being operation specific


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SURGICAL INFECTION AND ANTIBIOTICS

Antibiotic prophylaxis

  • Must be given pre-incision

  • No justification for additional dosing

  • Appropriate pharmacokinetics

  • Benefits outweigh risks


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SURGICAL INFECTION AND ANTIBIOTICS

Peritonitis and Intraabdominal Abscess

Conventional Principles of Management

  • Control source of contamination

  • Irrigation of peritoneum with saline

  • Closure of the abdomen

  • Close monitoring


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SURGICAL INFECTION AND ANTIBIOTICS

Peritonitis and Intraabdominal AbscessAntibiotic Therapy

  • Usually empiric

  • Rarely altered by culture data

  • Should include anaerobic coverage


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SURGICAL INFECTION AND ANTIBIOTICS

Peritonitis and Intraabdominal AbscessDuration of Antibiotic Therapy

  • Often empiric e.g. 5,7,10 or 14 days

  • Often unnecessarily prolonged

  • Usually not based on clinical parameters


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SURGICAL INFECTION AND ANTIBIOTIC

Peritonitis and Intraabdominal Abscess

Duration of Therapy

  • Patients who are afebrile and with normal WBC’s rarely develop further infection if antibiotics are stopped

  • Approximately 30% of patients who are afebrile but with leukocytosis develop further infection when antibiotics are stopped

  • Approximately 80% of patients who are still febrile at the conclusion of antibiotics will develop further infection


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SURGICAL INFECTION AND ANTIBIOTICS

Peritonitis and Intraabdominal Abscess

Duration of Therapy

Summary

  • Afebrile patients with normal WBC-stop antibiotics

  • Afebrile patients with leukocytosis-either continue antibiotics or evaluate for residual infection

  • Febrile patients-evaluate for residual infection


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SURGICAL INFECTION AND ANTIBIOTICS

Special Infections

  • Fungal infections

  • Diabetic foot infections

  • Hand infections

  • Invasive streptococcal infections

  • C. dificile infection

  • Tetanus


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SURGICAL INFECTION AND ANTIBIOTICS

Fungal Infection

  • Fungal colonization common in ICU

  • Fungal infection less common

  • Risk factors for fungal infection

    Severity of illness (APACHE 20 or >)

    Intensity of colonization


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SURGICAL INFECTION AND ANTIBIOTICS

Fungal Infection

  • Diagnosis depends on high index of suspicion

  • Careful culture of blood, urine, sputum, and drain material

  • Eye examination important


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SURGICAL INFECTION AND ANTIBIOTICS

Fungal Infection

Therapy

  • Amphotericin B 0.5 mg/kg/day IV for 7-10 days

  • Fluconazole 400 mg/day po for additional 7 days

  • Remove central venous catheters


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SURGICAL INFECTION AND ANTIBIOTICS

Diabetic Foot Infection

Risk Factors for Foot Problems

  • Neuropathy

  • Vascular insufficiency

  • Altered response to infection


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SURGICAL INFECTION AND ANTIBIOTICS

Diabetic Foot Infections

Role of Antibiotics

  • Antibiotic therapy is an adjunct to overall surgical care

  • Most infections polymicrobial

  • 90% are gram + organisms

  • 50% are gram - organisms

  • 50% are anaerobes


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SURGICAL INFECTION AND ANTIBIOTICS

Hand Infections

  • Commonly seen ER condition

  • 60% trauma 30% human bites 10% animal bites

  • Most infections result from neglected injury

  • Antibiotics given early prevent many complications

  • Reaction to infection determined by anatomic compartments of hand


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SURGICAL INFECTION AND ANTIBIOTICS

Microbiology of Hand Infections

  • Microbiology depends on type of injury

  • Staph aureus in 35%

  • Anaerobes in 35%

  • 50% of human bites infections are predominantly anaerobic


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SURGICAL INFECTION AND ANTIBIOTICS

Antibiotics in Hand Infections

  • Coverage should be directed by culture data

  • In the absence of culture material use broad spectrum penicillin plus B-lactamase inhibitor (e.g. amoxicillin/clavunanate)

  • Erythromycin a good alternative in penicillin allergic patients


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SURGICAL INFECTION AND ANTIBIOTICS

Hand Infections

Management Principles

  • Immobilization

  • Splinting

  • Rest

  • Elevation

  • Surgical drainage

  • Appropriate antibiotics


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SURGICAL INFECTION AND ANTIBIOTICS

Invasive Streptococcal Infections

  • Include puerperal sepsis, scarlatina maligna, septic scarlet fever, bacteremia, erysipelas, necrotizing soft tissue and fascia infection, gangrene, and myositis

  • Recent increase in the number and virulence of these infections

  • Occur mainly in healthy, immunocompetent patients


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SURGICAL INFECTION AND ANTIBIOTICS

Necrotizing Soft Tissue and Fascial Infection

  • First described by Meleney in 1924

  • Preantibiotic era mortality rate 20%

  • Modern era mortality rate 50%

  • Increase in virulence?

  • Decrease in specific immunity?


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SURGICAL INFECTION AND ANTIBIOTICS

Necrotizing Soft Tissue and Fascial Infection Presentation

  • 80% follow minor trauma

  • 20% post operative

  • Initial lesion frequently mild erythema

  • Swelling, heat, erythema occur rapidly and spread from initial lesion

  • Systemic toxicity early and severe


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SURGICAL INFECTION AND ANTIBIOTICS

Necrotizing Soft Tissue and Fascial Infection

Microbiology

  • Group A hemolytic strep

  • Staph Aureus

  • Enteric organisms including Clostridia species


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SURGICAL INFECTION AND ANTIBIOTICS

Necrotizing Soft Tissue and Fascial Infection

Treatment

  • Aggressive surgical debridement

  • Initial empiric antibiotic coverage for Staph, Strep, Enterics including Clostridia

  • Tailor antibiotic coverage to culture results


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SURGICAL INFECTION AND ANTIBIOTICS

Clostridium Dificile Associated Diarrhea

  • Most common cause of nosocomial diarrhea on surgical units

  • Variable manifestations including

    • No symptoms

    • Peritonitis, toxic megacolon, perforation, death


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SURGICAL INFECTION AND ANTIBIOTICS

Clostridium Dificile Associated Diarrhea

Clinical Criteria for Diagnosis

  • 3 or more loose stools per day for >2 days without an obvious cause

  • Previous antibiotic or antineoplastic administration within 6 weeks

  • Response of the diarrhea to oral vancomycin or metronidazole


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SURGICAL INFECTION AND ANTIBIOTICS

Clostridium Dificile Associated Diarrhea

Laboratory Criteria for Diagnosis

  • C. dificile culture-most sensitive test

  • C. dificile toxin assay-most specific test

  • Clinical diagnosis plus positive culture adequate to confirm diagnosis


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SURGICAL INFECTION AND ANTIBIOTICS

Clostridium Dificile Associated Diarrhea

Endoscopic Diagnosis

  • Scope options

    Rigid proctosigmoidoscope (25 cm)

    Flexible sigmoidoscope (60 cm)

    Colonoscopy

  • If patients do not have pseudomembranes on limited exam, then colonoscopy indicated

  • Lack of pseudomembranes DO NOT rule out disease


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SURGICAL INFECTION AND ANTIBIOTICS

Clostridium Dificile Associated Diarrhea

Severe Disease

  • Uncommon (0.39% of patients with CDAD)

  • Indications for operation

    Signs of peritonitis

    Signs of organ failure

    Worsening CT findings

  • Surgical procedure of choice-Total abdominal colectomy with ileostomy

  • Mortality rate 36%


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SURGICAL INFECTION AND ANTIBIOTICS

Tetanus

  • Preventable disease

  • 100 new cases reported per year in USA


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SURGICAL INFECTION AND ANTIBIOTICS

Tetanus Prophylaxis Guidelines

ACS Committee on Trauma

General Principles

  • Guidelines for both general and specific preventive measures are available

  • Prevention depends upon

    Adequate immunization of general population

    Good surgical wound care

    Passive immunization with tetanus immune globulin-human as indicated


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SURGICAL INFECTION AND ANTIBIOTICS

Infection Risk for the Surgeon

  • HIV

  • Hepatitis B

  • Hepatitis C


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SURGICAL INFECTION AND ANTIBIOTICS

HIV

  • Risk of infection relatively low (0.3-0.1%)

  • Universal precautions for all cases

  • Additional precautions in known or strongly suspected cases


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SURGICAL INFECTION AND ANTIBIOTICS

HIV

Postexposure Prophylaxis

  • Recommended for exposure to known HIV infected patients or high risk patients

  • Therapy within 1-2 hours postexposure and continued for 4 weeks

  • 2 drug therapy in all cases, 3 drug for “high risk” exposure

  • Drugs: zidovudine, lamivudine, and indinavir


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SURGICAL INFECTION AND ANTIBIOTICS

HIV

  • No clearly documented case of surgeon to patient transmission reported

  • Universal precautions important

  • No justification for restriction of HIV+ surgeon’s privileges


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SURGICAL INFECTION AND ANTIBIOTICS

Hepatitis

  • 12,000 infections with 250 deaths in HCWs per year

  • Much more dangerous than HIV

  • Cases equally divided between B & C


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SURGICAL INFECTION AND ANTIBIOTICS

Hepatitis

Prevention

  • Vaccination for hepatitis B

  • Universal precautions


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SURGICAL INFECTION AND ANTIBIOTICS

Hepatitis

Transmission by Surgeons

  • Transmission documented in 18 cases

  • All HBe Ag positive

  • Risk if HBe Ag negative is very low



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