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1、SURGICAL INFECTION AND ANTIBIOTICSOUTLINElIntroduction and overviewlDefinitions and SIRSlRisk factors for surgical infectionslStrategies for infection preventionlPeritonitis and intraabdominal abscesslSpecial infectionslInfection risk for the surgeonSURGICAL INFECTION AND ANTIBIOTICSInfection The in
2、flammatory response to the presence of microorganismsSURGICAL INFECTION AND ANTIBIOTICSSepsisThe systemic inflammatory response syndrome in response to infectionSURGICAL INFECTION AND ANTIBIOTICSSevere SepsisSepsis associated with organ dysfunction, hypoperfusion or hypotension SURGICAL INFECTION AN
3、D ANTIBIOTICSSeptic 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 stateSURGICAL INFECTION AND ANTIBIOTICSThe Systemic Inflamm
4、atory Response SyndromelCaused by the systemic effects of locally released cytokineslCytokine release can be triggered by both infectious and noninfectious insultslProvides a conceptual framework for the understanding of ARDS and MODS in the absence of infectionSURGICAL INFECTION AND ANTIBIOTICSSyst
5、emic Inflammatory Response SyndromeManifested by two or more of the following:lTemperature 38 C or 90lRespiratory rate 20 or PCO2 12 K 10% bandsSURGICAL INFECTION AND ANTIBIOTICSMultiple Organ Dysfunction SyndromeThe presence of altered organ function in an acutely ill patient such that homeostasis
6、cannot be maintained without interventionSURGICAL INFECTION AND ANTIBIOTICSRisk Factors for Surgical InfectionlSurgical wound classlSENIC projectlNNISSSURGICAL INFECTION AND ANTIBIOTICSSurgical Wound ClasslDeveloped by National Research Council in 1964lClassifies wounds into one of four classes base
7、d on degree of contaminationCleanClean contaminatedContaminatedDirtySURGICAL INFECTION AND ANTIBIOTICSStudy on the Efficacy of Nosocomial Infection ControllPublished by Haley in 1985lUtilizes four risk factors to stratify riskAbdominal operationOperation longer than 2 hoursContaminated or dirty woun
8、d classHaving 3 or more medical diagnosesSURGICAL INFECTION AND ANTIBIOTICSNational Nosocomial Infection Surveillance SystemlDeveloped by Centers for Disease ControllUses 3 risk factorsASA score of 3 or greaterOperation classed as contaminated or dirtyOperation of longer than “T” hours with “T” bein
9、g operation specific SURGICAL INFECTION AND ANTIBIOTICSAntibiotic prophylaxislMust be given pre-incisionlNo justification for additional dosinglAppropriate pharmacokineticslBenefits outweigh risksSURGICAL INFECTION AND ANTIBIOTICSPeritonitis and Intraabdominal AbscessConventional Principles of Manag
10、ementlControl source of contaminationlIrrigation of peritoneum with salinelClosure of the abdomenlClose monitoringSURGICAL INFECTION AND ANTIBIOTICSPeritonitis and Intraabdominal AbscessAntibiotic TherapylUsually empiriclRarely altered by culture datalShould include anaerobic coverageSURGICAL INFECT
11、ION AND ANTIBIOTICSPeritonitis and Intraabdominal AbscessDuration of Antibiotic TherapylOften empiric e.g. 5,7,10 or 14 dayslOften unnecessarily prolongedlUsually not based on clinical parametersSURGICAL INFECTION AND ANTIBIOTICPeritonitis and Intraabdominal AbscessDuration of TherapylPatients who a
12、re afebrile and with normal WBCs rarely develop further infection if antibiotics are stoppedlApproximately 30% of patients who are afebrile but with leukocytosis develop further infection when antibiotics are stoppedlApproximately 80% of patients who are still febrile at the conclusion of antibiotic
13、s will develop further infectionSURGICAL INFECTION AND ANTIBIOTICS Peritonitis and Intraabdominal AbscessDuration of TherapySummarylAfebrile patients with normal WBC-stop antibioticslAfebrile patients with leukocytosis-either continue antibiotics or evaluate for residual infectionlFebrile patients-e
14、valuate for residual infectionSURGICAL INFECTION AND ANTIBIOTICSSpecial InfectionslFungal infectionslDiabetic foot infectionslHand infectionslInvasive streptococcal infectionslC. dificile infectionlTetanusSURGICAL INFECTION AND ANTIBIOTICSFungal InfectionlFungal colonization common in ICUlFungal inf
15、ection less commonlRisk factors for fungal infectionSeverity of illness (APACHE 20 or )Intensity of colonization SURGICAL INFECTION AND ANTIBIOTICSFungal InfectionlDiagnosis depends on high index of suspicionlCareful culture of blood, urine, sputum, and drain materiallEye examination importantSURGIC
16、AL INFECTION AND ANTIBIOTICSFungal InfectionTherapylAmphotericin B 0.5 mg/kg/day IV for 7-10 dayslFluconazole 400 mg/day po for additional 7 dayslRemove central venous cathetersSURGICAL INFECTION AND ANTIBIOTICSDiabetic Foot Infection Risk Factors for Foot ProblemslNeuropathylVascular insufficiencyl
17、Altered response to infectionSURGICAL INFECTION AND ANTIBIOTICSDiabetic Foot Infections Role of AntibioticslAntibiotic therapy is an adjunct to overall surgical carelMost infections polymicrobiall90% are gram + organismsl50% are gram - organismsl50% are anaerobesSURGICAL INFECTION AND ANTIBIOTICS Ha
18、nd InfectionslCommonly seen ER conditionl60% trauma 30% human bites 10% animal biteslMost infections result from neglected injurylAntibiotics given early prevent many complicationslReaction to infection determined by anatomic compartments of handSURGICAL INFECTION AND ANTIBIOTICSMicrobiology of Hand
19、 InfectionslMicrobiology depends on type of injurylStaph aureus in 35%lAnaerobes in 35%l50% of human bites infections are predominantly anaerobicSURGICAL INFECTION AND ANTIBIOTICS Antibiotics in Hand InfectionslCoverage should be directed by culture datalIn the absence of culture material use broad
20、spectrum penicillin plus B-lactamase inhibitor (e.g. amoxicillin/clavunanate)lErythromycin a good alternative in penicillin allergic patientsSURGICAL INFECTION AND ANTIBIOTICS Hand Infections Management PrincipleslImmobilizationlSplintinglRestlElevationlSurgical drainagelAppropriate antibioticsSURGI
21、CAL INFECTION AND ANTIBIOTICSInvasive Streptococcal InfectionslInclude puerperal sepsis, scarlatina maligna, septic scarlet fever, bacteremia, erysipelas, necrotizing soft tissue and fascia infection, gangrene, and myositislRecent increase in the number and virulence of these infectionslOccur mainly
22、 in healthy, immunocompetent patientsSURGICAL INFECTION AND ANTIBIOTICS Necrotizing Soft Tissue and Fascial InfectionlFirst described by Meleney in 1924lPreantibiotic era mortality rate 20%lModern era mortality rate 50%lIncrease in virulence?lDecrease in specific immunity?SURGICAL INFECTION AND ANTI
23、BIOTICS Necrotizing Soft Tissue and Fascial InfectionPresentationl80% follow minor traumal20% post operativelInitial lesion frequently mild erythemalSwelling, heat, erythema occur rapidly and spread from initial lesionlSystemic toxicity early and severeSURGICAL INFECTION AND ANTIBIOTICS Necrotizing
24、Soft Tissue and Fascial Infection MicrobiologylGroup A hemolytic streplStaph AureuslEnteric organisms including Clostridia speciesSURGICAL INFECTION AND ANTIBIOTICSNecrotizing Soft Tissue and Fascial InfectionTreatmentlAggressive surgical debridementlInitial empiric antibiotic coverage for Staph, St
25、rep, Enterics including ClostridialTailor antibiotic coverage to culture resultsSURGICAL INFECTION AND ANTIBIOTICS Clostridium Dificile Associated DiarrhealMost common cause of nosocomial diarrhea on surgical unitslVariable manifestations includingNo symptomsPeritonitis, toxic megacolon, perforation
26、, death SURGICAL INFECTION AND ANTIBIOTICS Clostridium Dificile Associated Diarrhea Clinical Criteria for Diagnosisl3 or more loose stools per day for 2 days without an obvious causelPrevious antibiotic or antineoplastic administration within 6 weekslResponse of the diarrhea to oral vancomycin or me
27、tronidazoleSURGICAL INFECTION AND ANTIBIOTICS Clostridium Dificile Associated DiarrheaLaboratory Criteria for DiagnosislC. dificile culture-most sensitive testlC. dificile toxin assay-most specific testlClinical diagnosis plus positive culture adequate to confirm diagnosis SURGICAL INFECTION AND ANT
28、IBIOTICS Clostridium Dificile Associated DiarrheaEndoscopic DiagnosislScope optionsRigid proctosigmoidoscope (25 cm)Flexible sigmoidoscope (60 cm)ColonoscopylIf patients do not have pseudomembranes on limited exam, then colonoscopy indicatedlLack of pseudomembranes DO NOT rule out disease SURGICAL I
29、NFECTION AND ANTIBIOTICS Clostridium Dificile Associated DiarrheaSevere DiseaselUncommon (0.39% of patients with CDAD)lIndications for operationSigns of peritonitisSigns of organ failureWorsening CT findingslSurgical procedure of choice-Total abdominal colectomy with ileostomylMortality rate 36%SURG
30、ICAL INFECTION AND ANTIBIOTICSTetanuslPreventable diseasel100 new cases reported per year in USASURGICAL INFECTION AND ANTIBIOTICSTetanus Prophylaxis Guidelines ACS Committee on TraumaGeneral PrincipleslGuidelines for both general and specific preventive measures are availablelPrevention depends upo
31、nAdequate immunization of general populationGood surgical wound carePassive immunization with tetanus immune globulin-human as indicatedSURGICAL INFECTION AND ANTIBIOTICSInfection Risk for the SurgeonlHIVlHepatitis BlHepatitis CSURGICAL INFECTION AND ANTIBIOTICS HIVlRisk of infection relatively low
32、(0.3-0.1%)lUniversal precautions for all caseslAdditional precautions in known or strongly suspected cases SURGICAL INFECTION AND ANTIBIOTICS HIV Postexposure ProphylaxislRecommended for exposure to known HIV infected patients or high risk patientslTherapy within 1-2 hours postexposure and continued
33、 for 4 weeksl2 drug therapy in all cases, 3 drug for “high risk” exposurelDrugs: zidovudine, lamivudine, and indinavirSURGICAL INFECTION AND ANTIBIOTICS HIVlNo clearly documented case of surgeon to patient transmission reportedlUniversal precautions importantlNo justification for restriction of HIV+
34、 surgeons privilegesSURGICAL INFECTION AND ANTIBIOTICSHepatitisl12,000 infections with 250 deaths in HCWs per yearlMuch more dangerous than HIVlCases equally divided between B & CSURGICAL INFECTION AND ANTIBIOTICSHepatitis PreventionlVaccination for hepatitis BlUniversal precautionsSURGICAL INFECTION AND ANTIBIOTICSHepatitis Transmission by SurgeonslTransmission documented in 18 caseslAll HBe Ag positivelRisk if HBe Ag negative is very lowSURGICAL INFECTION AND ANTIBIOTICSQuestions?
