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1、SURGICAL INFECTION AND ANTIBIOTICS,OUTLINEIntroduction and overviewDefinitions and SIRSRisk factors for surgical infectionsStrategies for infection preventionPeritonitis and intraabdominal abscessSpecial infectionsInfection risk for the surgeon,SURGICAL INFECTION AND ANTIBIOTICS,Infection The inflam
2、matory response to the presence of microorganisms,SURGICAL INFECTION AND ANTIBIOTICS,SepsisThe systemic inflammatory response syndrome in response to infection,SURGICAL INFECTION AND ANTIBIOTICS,Severe SepsisSepsis associated with organ dysfunction,hypoperfusion or hypotension,SURGICAL INFECTION AND
3、 ANTIBIOTICS,Septic ShockSepsis 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,SURGICAL INFECTION AND ANTIBIOTICS,The Systemic Inflammator
4、y Response SyndromeCaused by the systemic effects of locally released cytokinesCytokine release can be triggered by both infectious and noninfectious insultsProvides a conceptual framework for the understanding of ARDS and MODS in the absence of infection,SURGICAL INFECTION AND ANTIBIOTICS,Systemic
5、Inflammatory Response SyndromeManifested by two or more of the following:Temperature 38 C or 90Respiratory rate 20 or PCO2 12 K 10%bands,SURGICAL INFECTION AND ANTIBIOTICS,Multiple Organ Dysfunction SyndromeThe presence of altered organ function in an acutely ill patient such that homeostasis cannot
6、 be maintained without intervention,SURGICAL INFECTION AND ANTIBIOTICS,Risk Factors for Surgical InfectionSurgical wound classSENIC projectNNISS,SURGICAL INFECTION AND ANTIBIOTICS,Surgical Wound ClassDeveloped by National Research Council in 1964Classifies wounds into one of four classes based on de
7、gree of contaminationCleanClean contaminatedContaminatedDirty,SURGICAL INFECTION AND ANTIBIOTICS,Study on the Efficacy of Nosocomial Infection ControlPublished by Haley in 1985Utilizes four risk factors to stratify riskAbdominal operationOperation longer than 2 hoursContaminated or dirty wound class
8、Having 3 or more medical diagnoses,SURGICAL INFECTION AND ANTIBIOTICS,National Nosocomial Infection Surveillance SystemDeveloped by Centers for Disease ControlUses 3 risk factorsASA score of 3 or greaterOperation classed as contaminated or dirtyOperation of longer than“T”hours with“T”being operation
9、 specific,SURGICAL INFECTION AND ANTIBIOTICS,Antibiotic prophylaxisMust be given pre-incisionNo justification for additional dosingAppropriate pharmacokineticsBenefits outweigh risks,SURGICAL INFECTION AND ANTIBIOTICS,Peritonitis and Intraabdominal AbscessConventional Principles of ManagementControl
10、 source of contaminationIrrigation of peritoneum with salineClosure of the abdomenClose monitoring,SURGICAL INFECTION AND ANTIBIOTICS,Peritonitis and Intraabdominal AbscessAntibiotic TherapyUsually empiricRarely altered by culture dataShould include anaerobic coverage,SURGICAL INFECTION AND ANTIBIOT
11、ICS,Peritonitis and Intraabdominal AbscessDuration of Antibiotic TherapyOften empiric e.g.5,7,10 or 14 daysOften unnecessarily prolongedUsually not based on clinical parameters,SURGICAL INFECTION AND ANTIBIOTIC,Peritonitis and Intraabdominal AbscessDuration of TherapyPatients who are afebrile and wi
12、th normal WBCs rarely develop further infection if antibiotics are stoppedApproximately 30%of patients who are afebrile but with leukocytosis develop further infection when antibiotics are stoppedApproximately 80%of patients who are still febrile at the conclusion of antibiotics will develop further
13、 infection,SURGICAL INFECTION AND ANTIBIOTICS,Peritonitis and Intraabdominal AbscessDuration of TherapySummaryAfebrile patients with normal WBC-stop antibioticsAfebrile patients with leukocytosis-either continue antibiotics or evaluate for residual infectionFebrile patients-evaluate for residual inf
14、ection,SURGICAL INFECTION AND ANTIBIOTICS,Special InfectionsFungal infectionsDiabetic foot infectionsHand infectionsInvasive streptococcal infectionsC.dificile infectionTetanus,SURGICAL INFECTION AND ANTIBIOTICS,Fungal InfectionFungal colonization common in ICUFungal infection less commonRisk factor
15、s for fungal infectionSeverity of illness(APACHE 20 or)Intensity of colonization,SURGICAL INFECTION AND ANTIBIOTICS,Fungal InfectionDiagnosis depends on high index of suspicionCareful culture of blood,urine,sputum,and drain materialEye examination important,SURGICAL INFECTION AND ANTIBIOTICS,Fungal
16、InfectionTherapyAmphotericin B 0.5 mg/kg/day IV for 7-10 daysFluconazole 400 mg/day po for additional 7 daysRemove central venous catheters,SURGICAL INFECTION AND ANTIBIOTICS,Diabetic Foot Infection Risk Factors for Foot ProblemsNeuropathyVascular insufficiencyAltered response to infection,SURGICAL
17、INFECTION AND ANTIBIOTICS,Diabetic Foot Infections Role of AntibioticsAntibiotic therapy is an adjunct to overall surgical careMost infections polymicrobial90%are gram+organisms50%are gram-organisms50%are anaerobes,SURGICAL INFECTION AND ANTIBIOTICS,Hand InfectionsCommonly seen ER condition60%trauma
18、 30%human bites 10%animal bitesMost infections result from neglected injuryAntibiotics given early prevent many complicationsReaction to infection determined by anatomic compartments of hand,SURGICAL INFECTION AND ANTIBIOTICS,Microbiology of Hand InfectionsMicrobiology depends on type of injuryStaph
19、 aureus in 35%Anaerobes in 35%50%of human bites infections are predominantly anaerobic,SURGICAL INFECTION AND ANTIBIOTICS,Antibiotics in Hand InfectionsCoverage should be directed by culture dataIn the absence of culture material use broad spectrum penicillin plus B-lactamase inhibitor(e.g.amoxicill
20、in/clavunanate)Erythromycin a good alternative in penicillin allergic patients,SURGICAL INFECTION AND ANTIBIOTICS,Hand Infections Management PrinciplesImmobilizationSplintingRestElevationSurgical drainageAppropriate antibiotics,SURGICAL INFECTION AND ANTIBIOTICS,Invasive Streptococcal InfectionsIncl
21、ude puerperal sepsis,scarlatina maligna,septic scarlet fever,bacteremia,erysipelas,necrotizing soft tissue and fascia infection,gangrene,and myositisRecent increase in the number and virulence of these infectionsOccur mainly in healthy,immunocompetent patients,SURGICAL INFECTION AND ANTIBIOTICS,Necr
22、otizing Soft Tissue and Fascial InfectionFirst described by Meleney in 1924Preantibiotic era mortality rate 20%Modern era mortality rate 50%Increase in virulence?Decrease in specific immunity?,SURGICAL INFECTION AND ANTIBIOTICS,Necrotizing Soft Tissue and Fascial InfectionPresentation80%follow minor
23、 trauma20%post operativeInitial lesion frequently mild erythemaSwelling,heat,erythema occur rapidly and spread from initial lesionSystemic toxicity early and severe,SURGICAL INFECTION AND ANTIBIOTICS,Necrotizing Soft Tissue and Fascial Infection MicrobiologyGroup A hemolytic strepStaph AureusEnteric
24、 organisms including Clostridia species,SURGICAL INFECTION AND ANTIBIOTICS,Necrotizing Soft Tissue and Fascial InfectionTreatmentAggressive surgical debridementInitial empiric antibiotic coverage for Staph,Strep,Enterics including ClostridiaTailor antibiotic coverage to culture results,SURGICAL INFE
25、CTION AND ANTIBIOTICS,Clostridium Dificile Associated DiarrheaMost common cause of nosocomial diarrhea on surgical unitsVariable manifestations includingNo symptomsPeritonitis,toxic megacolon,perforation,death,SURGICAL INFECTION AND ANTIBIOTICS,Clostridium Dificile Associated Diarrhea Clinical Crite
26、ria for Diagnosis3 or more loose stools per day for 2 days without an obvious causePrevious antibiotic or antineoplastic administration within 6 weeksResponse of the diarrhea to oral vancomycin or metronidazole,SURGICAL INFECTION AND ANTIBIOTICS,Clostridium Dificile Associated DiarrheaLaboratory Cri
27、teria for DiagnosisC.dificile culture-most sensitive testC.dificile toxin assay-most specific testClinical diagnosis plus positive culture adequate to confirm diagnosis,SURGICAL INFECTION AND ANTIBIOTICS,Clostridium Dificile Associated DiarrheaEndoscopic DiagnosisScope optionsRigid proctosigmoidosco
28、pe(25 cm)Flexible sigmoidoscope(60 cm)ColonoscopyIf patients do not have pseudomembranes on limited exam,then colonoscopy indicatedLack of pseudomembranes DO NOT rule out disease,SURGICAL INFECTION AND ANTIBIOTICS,Clostridium Dificile Associated DiarrheaSevere DiseaseUncommon(0.39%of patients with C
29、DAD)Indications for operationSigns of peritonitisSigns of organ failureWorsening CT findingsSurgical procedure of choice-Total abdominal colectomy with ileostomyMortality rate 36%,SURGICAL INFECTION AND ANTIBIOTICS,TetanusPreventable disease100 new cases reported per year in USA,SURGICAL INFECTION A
30、ND ANTIBIOTICS,Tetanus Prophylaxis Guidelines ACS Committee on TraumaGeneral PrinciplesGuidelines for both general and specific preventive measures are availablePrevention depends uponAdequate immunization of general populationGood surgical wound carePassive immunization with tetanus immune globulin
31、-human as indicated,SURGICAL INFECTION AND ANTIBIOTICS,Infection Risk for the SurgeonHIVHepatitis BHepatitis C,SURGICAL INFECTION AND ANTIBIOTICS,HIVRisk of infection relatively low(0.3-0.1%)Universal precautions for all casesAdditional precautions in known or strongly suspected cases,SURGICAL INFEC
32、TION AND ANTIBIOTICS,HIV Postexposure ProphylaxisRecommended for exposure to known HIV infected patients or high risk patientsTherapy within 1-2 hours postexposure and continued for 4 weeks2 drug therapy in all cases,3 drug for“high risk”exposureDrugs:zidovudine,lamivudine,and indinavir,SURGICAL INF
33、ECTION AND ANTIBIOTICS,HIVNo clearly documented case of surgeon to patient transmission reportedUniversal precautions importantNo justification for restriction of HIV+surgeons privileges,SURGICAL INFECTION AND ANTIBIOTICS,Hepatitis12,000 infections with 250 deaths in HCWs per yearMuch more dangerous
34、 than HIVCases equally divided between B&C,SURGICAL INFECTION AND ANTIBIOTICS,Hepatitis PreventionVaccination for hepatitis BUniversal precautions,SURGICAL INFECTION AND ANTIBIOTICS,Hepatitis Transmission by SurgeonsTransmission documented in 18 casesAll HBe Ag positiveRisk if HBe Ag negative is very low,SURGICAL INFECTION AND ANTIBIOTICS,Questions?,
