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Jamal Mirzaei MD. MPH Infectious disease specialist

Post Gynecologic Surgery Fever. Jamal Mirzaei MD. MPH Infectious disease specialist. Post operative Fever. T >38 oC : common in the first few days Early: inflammatory stimulus of surgery (most)  resolve spontaneousely Manifestation of a serious complication.

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Jamal Mirzaei MD. MPH Infectious disease specialist

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  1. Post Gynecologic Surgery Fever Jamal Mirzaei MD. MPHInfectious disease specialist

  2. Post operative Fever • T>38 oC :common in the first few days • Early: • inflammatory stimulus of surgery (most)  resolve spontaneousely • Manifestation of a serious complication

  3. Pathophysiology of postoperative fever • various stimuli tissue trauma cytokine release (IL1,6,TNF, IFN-gamma)  FEVER • Bacterial endotoxins and exotoxins stimulate cytokines postoperative fever

  4. Causes of postoperative fever

  5. 1. Non infectious causes • Surgical site inflammation without infection (Hematoma,Suture reaction) • Thrombosis (DVT, Pulmonary emboli) • Inflammatory (gout, pancreatitis) • Vascular (cerebral infarction, ICH, SAH,MI, Bowel ischemia/infarction) • Other (medications,transfusion reaction,drug/alcohol withdrawal, cancer/neoplastic fever)

  6. 2. Infectious causes • Surgical site infection • Pneumonia • UTI • Intravascular catheter associated infection • AB associated diarrhea • Sinusitis, Otitis media, parotitis, meningitis, IE, Osteomyelitis • Intra abdominal abscess • Acalculouscholecystitis • Transfusion associated viral infections • Foreign body infection (grafts, stents)

  7. Timing of Fever • Immediate: in the operating room or within hours after surgery • Acute: within the first week after surgery • Subacute: 1-4w after surgery • Delayed:> 1m after surgery

  8. 1-Immediate • Medications or blood products • Trauma (before surgery or as a part of surgery) • Infections before surgery • Malignant hyperthermia (rare) (inhaled anesthetics, succinylcholine)

  9. 2. Acute • Nosocomial infections: • VAP and aspiration pneumonia • UTI • SSI (GAS and Clostridium perfringens) • Catheter exit site infections and bacteremia

  10. 3. Subacute • SSI • CVC infection • AB associated diarrhea • VAP,UTI, Sinusitis • Febrile drug reactions (Beta lactams, sulfa containing products) • Thrombophlebitis, DVT and pulmonary embolism

  11. 4. Delayed • Most of them are due to infection • Viral and parasitic infections from blood products (CMV, Hepatitis viruses, HIV, Toxo, Babesios, Plasmodium Malariae) • SSI due to more indolent MO (CONS) • IE (due to perioperative bacteremia)

  12. Evaluation of patient with postoperative fever

  13. History • Preoperative course and presentation • Operation (emergent or elective, intraoperative complications) • Postoperative course • PMH and comorbidities • Allergies • Medications • Location of catheter and time of placement

  14. History • Ask nurse: • Sputum amount and quality • Diarrhea • Any areas of skin breakdown or rashes • Ask patient: • Cough • pain

  15. Physical examination • VS ( T, HR, RR) • Examine: • Skin(rash, ecchymoses, injection site erythema, hematoma) • Lung • Heart(tachycardia, new murmur) • Abdomen(tenderness, BS) • Operative site and lymphatic drainage • Catheter entry sites • Lower legs (for evidence of DVT)

  16. Laboratory • UA , UC • B/C (peripheral and catheter) • Sputum (smear, culture) • Wound culture • CXR

  17. SURGICAL SITE INFECTION AFTER GYNECOLOGIC SURGERY

  18. SSIs associated with hysterectomy • Vaginal cuff cellulitis • vaginal cuff abscess • pelvic abscess

  19. SSIs associated with hysterectomy • source of pathogens :endogenous microbiota of the vagina • The normal vaginal microbiota: • Lactobacilli:produce both hydrogen peroxide and lactic acid protect against the overgrowth of pathogens in the vagina • Streptococci • G. Vaginalis • Enterobacteriaceae • Anaerobes

  20. SSIs associated with hysterectomy • Excision of the cervix breachedvaginal epithelium MO gain entry to the vaginal cuff, paravaginal tissues, and peritoneal cavity

  21. Cuff Cellulitis

  22. Cuff Cellulitis • inflammatory response at the margins of the vaginal cuff incision • a normal part of the healing process in the early posthysterectomy Period • Host defense mechanisms quickly resolve it in most patients without the need for AB

  23. Cuff Cellulitis • Clinical Findings in patients require AB • present within 10 d after surgery • central lower abdominal and pelvic pain •  vaginal discharge • low-grade fever • Abdominal examination: slight suprapubic tenderness to deep palpation • bimanual examination only the vaginal surgical margin is tender and no masses are palpable

  24. Cuff Cellulitis • Treatment: • OPT with AB regimen that includes coverage for anaerobic MO  • amoxicillin/clavulanic acid • the combination of Metronidazole + • G1 cephalosporin • FQ • trimethoprim/sulfamethoxazole • monitor temperatures at home • clinical reevaluation if improvement in pain and T is not noted by 72 h

  25. vaginal cuff abscess

  26. vaginal cuff abscess • A well-localized collection of pus just above the vaginal cuff • develops in a few patients with cuff cellulitis • CC: fever & sense of fullness (lower abdomen) • PhE: Bimanual pelvic examination vaginal cuff mass • Imaging: ultrasonography confirm the abscess

  27. vaginal cuff abscess • drainagefacilitates cure • simply by dilation of the vaginal cuff in a treatment room • larger collections Sonoor CT guided drainage or in the operating room • culture (aerobic and anaerobic) purulent material • IV AB (Broad-spectrum) until defervescencefor 24 to 36 h

  28. Pelvic Abscess

  29. Pelvic Abscess • Rare but the most serious late postop complication • Involve one or both residual adnexa (tubo-ovarian abscess) • occur almost exclusively in premenopausal women • occur despite prophylactic AB • often have a latent period of many w between surgery and onset of symptoms

  30. Pelvic Abscess • fever (high spike late in the afternoon or early evening) • palpable mass high in the pelvis • WBC: around 20,000/mm • ESR

  31. Pelvic Abscess • Sonoand CT : • confirm the presence of a mass • help to determine whether it is • Loculated • related to an intraperitonealstructure • drainable percutaneously

  32. Pelvic Abscess • Immediate drainage is not mandatory if it is inaccessible  ABtherapy alone may be successful •  isolation of β-lactamase–producing Prevotellaspecies use of clindamycin, metronidazole, or other agents against gram-negative anaerobes

  33. Pelvic Abscess • clindamycin + gentamicin fails to respond drainage • Necrosis+infections  surgical exploration in some cases • aerobic and anaerobic culture of purulent material or tissue

  34. Pelvic Abscess • Duration of AB therapy: • IV AB until • defervescence for 48-72 h • NL leukocyte count • Resolved signs and symptoms • PO AB for 7 d after discharge: • amoxicillin/clavulanate • Metronidazole • reexamine 2 w after discharge  R/Orecurrence or reaccumulation of the abscess

  35. IV AB Regimens for Treating Gynecologic Postoperative Infections

  36. 1. Localized infection with minimal systemic findings • G2: Cefoxitin (2gIV/QID) / Cefotetan (2g/IV/BID) • G3: Cefotaxime(1g/ IV/ TDS) / Ceftriaxone (2g/IV/stat then 1g/IV/D) • Ampi-Sulbactam (3g/IV/QID) • Ticarcilin/Clavulanic acid (3.1g/IV/Q4-6h) • Piperacillin/Tazobactam (3.375g/IV/QID)

  37. 2. Extensive infection with moderate to severe systemic findings • Clinda (900/IV/TDS) + Genta (2mg/kg/stat then 1.5mg/kg/TDS) ± Ampi (2g/IV/stat then 1/IV/Q4h) • Ampi + Genta + Metro (500mg/IV/TDS) • Imipenem or Meropenem or Ertapenem(1g/IV/d) • Levofloxacin (500mg/IV/d) + Metro

  38. Osteomyelitis Pubis

  39. Osteomyelitis Pubis • Past: noninfectious, self-limited inflammatory condition of the symphysis pubis associated with retropubic urologic procedures • Now: It is a rare infection results from: • direct inoculation of the bone at the time of surgery • extension of a contiguous focus of infection • in women : after urethral suspension, radical vulvectomy or pelvic exenteration

  40. Osteomyelitis Pubis • Symptoms and Signs: • suprapubic discomfort • difficulty with ambulation and a wide-based waddling walk • Wound drainage • low-grade fever

  41. Osteomyelitis Pubis • Radiography or MRI: • irregular bony margins and rarefaction and widening of the symphyseal joint spaces • Lab tests: • moderate leukocytosis • ESR • ALP

  42. Osteomyelitis Pubis • Common isolated MO: • gram-negative bacteria • staphylococcal and streptococcal species • Suggestive findings CT guided needle bone Bx histopathology and culture  • recovered MO  AB trial  poor response  debridement • MO not isolated  open surgical Bxwith debridement and culturedirected AB for at least 4 weeks

  43. mirzaei@dr.com

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