Surgical Infections
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Surgical Infections ~group A, surgery~
TYPES • Superficial • Deep • Organ/space
Soft tissue/wound • Most common surgical patient nosocomial infection • 2/3 involved surgical incision, 1/3 deep structures accessed by incision • Deaths in patients with nosocomial infections— 77% related to infection.
Risk factors for SSI • • • • • • •
Diabetes Nicotine Steroids Malnutrition Length of preoperative hospitalization Nares colonization Staph Aureus Perioperative transfusion
PREOP PREPARATION OF PATIENT • Scrub • Skin prep ▫ Iodophors, chlorahexadine,betadine
• Hair removal(shaving off for surgical purpose) • Antiseptic showering ▫ Reduce skin flora only
ANTIMICROBIAL PROPHYLAXIS • Clean/contaminated procedures ▫ Vascular cases ▫ Cardiac cases ▫ Orthopedic prosthetic cases
• Second generation cephalosporin for distal intestinal tract
Necrotizing Soft Tissue Infection • Debridement/Resuscitation • Antibiotics • Nutrition ▫ 1.5 to 2 times basal requirements
• Treatment delays are predictive of adverse outcome
Necrotizing Soft Tissue Infection(NSTI) • Mortality rate as high as 40% • Impaired immune system • Compromised tissue blood supply , anticipate TISSUE ISCHEMIA…GANGRENE • Microorganisms (Polymicrobial) • “skin poppin’” or “muscling” • 1/3 diabetics involved • 90% with comorbid conditions
Antibiotic therapy for NSTI • • • •
Penicillin and aminoglycoside Clindamycin or metronidazole +/- Vancomycin Alternative: unasyn/zosyn
Hydradenitis suppurativa • • • • •
Infection of apocrine sweat glands axilla, groin, perineum, any skin fold Single abscess treated by I&D Doxycycline 100mg BID Excision with STSG (15%)
50 y/o diabetic with 2 & 3 degree burns • Develops full thickness necrosis of second degree areas a few days later • Third degree burn eschar unexpectedly separated, revealing hemorrhagic discoloration of the sub eschar fat.
Burn Infections • Necrotic tissue readily colonized • High bacteria counts are NOT a reliable indication of an infected burn • Histological examination to determine invasiveness • TREATMENT: debridement and antibiotics
50 y/o diabetic BELOW KNEE AMPUTATION • presents with rust colored fluid draining from stump. Extremity is edematous and has some associated erythema.
Gas gangrene • • • •
Beta hemolytic strept Clostridium perfringes (gram pos rods)rare 50% polymicrobial Rapid lyses of tissues w/ relatively little response from host • Endotoxin release by microorganisms.
Gas gangrene • Treatment:Aggressive debridement & antibiotics • Repeat antibiotics if wound healing not satisfactory
Catheter Sepsis • 80% of cases, colonized catheters had been inserted by inexperienced and experienced residents • Key is to identify infection before sepsis develops • Stapylococcus epidermis, S. Aureus, yeast
Gram-Negative Sepsis • E.coli, pseudomonas, klebsiella, Enterobacter • >30% mortality • Hypotension, hypoxia, acidosis, compliment and coagulation cascade activation • Lipopolysaccharide (LPS)/ endotoxin
Gram-Negative Sepsis • • • • • •
6ml/kg, plateau <30, good oxygen delivery Resuscitation SPO2 Daily breathing trials(spirometry, chest physio) Sedation protocol DVT prophylaxis
A LITTLE BIT ON ANTIBIOTICS…
Inhibits cell wall synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Inhibits cell wall synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Impairment of bacterial DNA synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Impairment of bacterial DNA synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of membrane barrier function • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of membrane barrier function • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of ribosomal protein synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of ribosomal protein synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
TYPES • Superficial • Deep • Organ/space
Soft tissue/wound • Most common surgical patient nosocomial infection • 2/3 involved surgical incision, 1/3 deep structures accessed by incision • Deaths in patients with nosocomial infections— 77% related to infection.
Risk factors for SSI • • • • • • •
Diabetes Nicotine Steroids Malnutrition Length of preoperative hospitalization Nares colonization Staph Aureus Perioperative transfusion
PREOP PREPARATION OF PATIENT • Scrub • Skin prep ▫ Iodophors, chlorahexadine,betadine
• Hair removal(shaving off for surgical purpose) • Antiseptic showering ▫ Reduce skin flora only
ANTIMICROBIAL PROPHYLAXIS • Clean/contaminated procedures ▫ Vascular cases ▫ Cardiac cases ▫ Orthopedic prosthetic cases
• Second generation cephalosporin for distal intestinal tract
Necrotizing Soft Tissue Infection • Debridement/Resuscitation • Antibiotics • Nutrition ▫ 1.5 to 2 times basal requirements
• Treatment delays are predictive of adverse outcome
Necrotizing Soft Tissue Infection(NSTI) • Mortality rate as high as 40% • Impaired immune system • Compromised tissue blood supply , anticipate TISSUE ISCHEMIA…GANGRENE • Microorganisms (Polymicrobial) • “skin poppin’” or “muscling” • 1/3 diabetics involved • 90% with comorbid conditions
Antibiotic therapy for NSTI • • • •
Penicillin and aminoglycoside Clindamycin or metronidazole +/- Vancomycin Alternative: unasyn/zosyn
Hydradenitis suppurativa • • • • •
Infection of apocrine sweat glands axilla, groin, perineum, any skin fold Single abscess treated by I&D Doxycycline 100mg BID Excision with STSG (15%)
50 y/o diabetic with 2 & 3 degree burns • Develops full thickness necrosis of second degree areas a few days later • Third degree burn eschar unexpectedly separated, revealing hemorrhagic discoloration of the sub eschar fat.
Burn Infections • Necrotic tissue readily colonized • High bacteria counts are NOT a reliable indication of an infected burn • Histological examination to determine invasiveness • TREATMENT: debridement and antibiotics
50 y/o diabetic BELOW KNEE AMPUTATION • presents with rust colored fluid draining from stump. Extremity is edematous and has some associated erythema.
Gas gangrene • • • •
Beta hemolytic strept Clostridium perfringes (gram pos rods)rare 50% polymicrobial Rapid lyses of tissues w/ relatively little response from host • Endotoxin release by microorganisms.
Gas gangrene • Treatment:Aggressive debridement & antibiotics • Repeat antibiotics if wound healing not satisfactory
Catheter Sepsis • 80% of cases, colonized catheters had been inserted by inexperienced and experienced residents • Key is to identify infection before sepsis develops • Stapylococcus epidermis, S. Aureus, yeast
Gram-Negative Sepsis • E.coli, pseudomonas, klebsiella, Enterobacter • >30% mortality • Hypotension, hypoxia, acidosis, compliment and coagulation cascade activation • Lipopolysaccharide (LPS)/ endotoxin
Gram-Negative Sepsis • • • • • •
6ml/kg, plateau <30, good oxygen delivery Resuscitation SPO2 Daily breathing trials(spirometry, chest physio) Sedation protocol DVT prophylaxis
A LITTLE BIT ON ANTIBIOTICS…
Inhibits cell wall synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Inhibits cell wall synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Impairment of bacterial DNA synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Impairment of bacterial DNA synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of membrane barrier function • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of membrane barrier function • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of ribosomal protein synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
Disruption of ribosomal protein synthesis • • • • •
A. Amphotericin B B. Penicillin C. Cephalosporins D. Aminoglycosides E. Quinolones
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